Research shows innovative approach serves health care consumers over long term

Mailing yearly stool kits—an alternative to the often-dreaded colonoscopy—has helped Group Health to boost rates of lifesaving screening for colon cancer, according to new research from Group Health Research Institute.

Group Health researchers mailed an easy-to-use at-home stool kit to test more than 1,000 for signs of cancers of the colon and rectum. This boosted the screening rate from less than four in 10, to more than half of these hard-to-reach patients, who had never had a colonoscopy and were overdue for screening.

"Once again, Group Health is proving that preventive medicine is the best approach to keeping members healthy," said study leader Beverly B. Green, MD, MPH, a family physician at Group Health and an associate investigator at Group Health Research Institute. "By offering patients of average risk a choice of the stool kit or colonoscopy, we keep narrowing the gap to achieve better colorectal cancer screening rates." Group Health's overall rate of screening for (72 percent) already exceeds Washington state's (59 percent), but "we keep trying to boost ours further," she said.

Group Health care providers discuss the pros and cons of both colonoscopy and stool tests with patients in "shared decision making." Screening colonoscopy is done once a decade and can remove polyps if present, but it often requires time off work—and an unpleasant bowel-clearing preparation the night before. It involves a procedure in which a doctor uses a flexible scope to visually inspect the inside of the colon. The stool test is less expensive and done quickly at home, but it should be done every year. And if it finds blood in the stool, which suggests cancer, a follow-up colonoscopy is still needed.

"Screening has been proven to reduce deaths from colorectal cancer, but only if people are screened regularly, as advised for 50- to 75-year-olds of average risk—but too often not done," Dr. Green said. "What matters most is maximizing how many people are screened regularly. The best test is the one that gets done."

Higher screening rates, lower costs

Dr. Green's team had previously proven the effectiveness—and cost-effectiveness—of the approach used in the Systems of Support to Increase Colon Cancer Screening and Follow-up (SOS) randomized controlled trial. Over the first two years of the 10-year study, it doubled the colorectal rates for Group Health patients who'd previously been overdue for screening—while significantly lowering health care costs. It used electronic health records to identify patients who weren't screened regularly for colon cancer, to encourage these patients with automated reminders to be screened, and to mail them at-home stool kits. And nurse navigators helped the patients to get needed follow-up care after positive screening tests.

Now the researchers report that this approach continued to be effective in the third year in patients who hadn't already opted for colonoscopy. Of the more than 1,000 Group Health patients included in the third year of the centralized electronic health record-linked program, 53 percent were screened for colorectal cancer—versus 37 percent in those receiving usual care during that year. This difference was entirely due to greater completion of stool tests, rather than colonoscopy, which was also offered as an option.

Dr. Green called the study's results "striking, because usual care at Group Health is intensive and already offers patients so many other chances to get screened." Based in part on her prior findings, usual care at Group Health now includes electronic health record reminders of overdue and providing stool kits at primary care visits and outreach calls.

"Ours is the first randomized controlled trial to test the effectiveness of such a program in a health care setting over three years," Dr. Green said. This kind of long-term evidence is important for health systems seeking to maintain high screening levels over the long haul. Cancer published "Impact of Continued Mailed Fecal Tests in the Patient-Centered Medical Home: Year 3 of the Systems of Support to Increase Colon Cancer Screening and Follow-Up Randomized Trial," by Group Health researchers.

How to reach nonscreeners?

The benefit of increased screening was confined to those patients who had responded by doing stool tests in at least one of the first two years. Third-year screening rates were highest in patients completing a stool test in both the first and second years (77 percent), followed by patients doing a test in one of the two years (45 percent), with low in patients who hadn't taken any stool test in the first two years (18 percent).

"It's important for us to reach the people who are didn't respond to this intervention at all over three years," Dr. Green said. This study may provide some hints about who these patients might be: They tended to report their own health as "fair to poor"—and not to have made any primary care or preventive visits in the three years. There was also a statistically insignificant trend toward less in African American and Latino patients—but no differences seen by age, sex, education, marriage, or smoking.

How can they best be reached? Different types of interventions may be needed for those people who consistently refuse a mailed stool kit program. For example, a physician recommendation may be particularly important for this group of patients. Studies testing this and other strategies should be the focus of future research, she said.

The researchers will continue to follow up with the same patients for up to 10 years to see whether the regular screenings—and cost savings—persist. They have also shown that systematically mailing stool tests to patients each year is a promising way to help prevent disparities in .

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