An innovative program in community health centers to mail free colorectal cancer screening tests to patients' homes led to a nearly 4 percentage point increase in CRC screening, compared to clinics without the program, according to a Kaiser Permanente study published today in JAMA Internal Medicine.
According to the National Association of Community Health Centers, approximately 24 million people in the United States receive care at federally qualified health centers, often called community health or safety net clinics. These underserved patients historically have low rates of CRC screening compared to the general population.
"With such a large number of individuals receiving care in the safety-net setting, an improvement in CRC screening rates of even a few percentage points can have a major impact in terms of cancers detected and lives saved," said lead author Gloria Coronado, Ph.D., an investigator at the Kaiser Permanente Center for Health Research in Portland, Oregon.
The study, "Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC)," took place in 26 clinics representing eight health centers in Oregon and California. More than 41,000 adults aged 50-64 met the study criteria of being due for CRC screening between February 2014 and February 2015.
Half of the clinics were randomized to implement the program after receiving training and support, and the other half continued to deliver usual care without the program. For clinics implementing the program, the process began with customization of their electronic health record systems to identify patients who were due for CRC screening. The clinics then mailed an introductory letter to these patients, explaining they would soon be receiving a screening test in the mail.
Next, clinics mailed the screening tests to eligible patients' homes. The clinics used the fecal immunochemical test (or FIT), a simple test that detects small amounts of blood in the stool and can be done easily at home. Individuals with a positive FIT result were encouraged to get a follow-up colonoscopy to look for cancer or pre-cancerous polyps. Finally, as the last step of the program, clinics mailed a reminder letter to patients' homes, encouraging them to complete and return their FIT kits.
Compared to the control group clinics, clinics that delivered the intervention had a significantly higher proportion of patients who were screened for CRC. The percentage of patients who completed a FIT kit was 3.4 points higher, and the percentage of patients who received any type of CRC screening was 3.8 points higher in intervention clinics compared to control clinics.
The clinical effectiveness of mailing FIT kits to patients' homes had already been established in previous research, including a pilot study by Coronado and her team. But this new, much larger study showed the program can also work well when clinic staff—not researchers—are responsible for implementing it.
"This was a real-world, pragmatic trial, which is quite a bit different from a carefully controlled research environment," explained Coronado. "Our team provided clinics with the EHR tools needed to identify and contact patients who were due for screening; we trained clinic staff to use the tools; we provided letter templates, pictographic instructions and other materials; and we used a collaborative learning model to offer ongoing support. But ultimately, clinic staff were responsible for integrating the intervention into their care processes."
The study team observed significant variation across health centers in successful implementation of the program. The proportion of eligible patients who were mailed a FIT kit ranged from 6.5 percent to 68.2 percent. Of eligible patients who did receive a FIT kit in the mail, reminder letters had a major impact on return rates. Clinics that consistently sent out reminder letters after sending FIT kits had a return rate of 25 percent, compared to clinics that did so inconsistently (14 percent) or not at all (6 percent).
"Community health centers are very busy places with many competing priorities," said senior author Beverly Green, MD, MPH, of the Kaiser Permanente Washington Health Research Institute. "Our study showed that while FIT outreach programs can be a great way to increase colorectal cancer screening rates in this underserved population, we need to identify additional strategies to support program implementation in health centers with limited resources."
Coronado and her team are building on this research with a new study, "Participatory Research to Advance Colon Cancer Prevention." The researchers are working with community advisors to adapt and spread a direct-mail FIT kit and reminder program, with the ultimate goal of increasing the effectiveness of reminders by ensuring they meet the specific needs of diverse population subgroups.
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Gloria D. Coronado et al, Effectiveness of a Mailed Colorectal Cancer Screening Outreach Program in Community Health Clinics, JAMA Internal Medicine (2018). DOI: 10.1001/jamainternmed.2018.3629