Mailed Kits Can Up Colorectal Screening at Community Health Clinics

Mailed fecal immunochemical test kits (FIT) and outreach can raise rates of colorectal cancer (CRC) screening among low-income patients seen at community clinics, according to a study published Aug. 6 in JAMA Internal Medicine. These increases in CRC screening occurred despite relatively low implementation of the program, suggesting that additional strategies may be needed to support program implementation in low-resource health centers.

Despite recommendations from professional groups and the U.S. Preventive Screening Task Force, CRC screening rates remain low nationally, particularly among underserved groups, including the 24 million Americans seen at federally qualified health centers where screening rates are estimated at 40 percent for eligible adults. FIT is a convenient CRC screening tool because it does not require a clinical visit, taking time off from work, or a chaperon, like colonoscopy.

The present study was conducted in 26 federally qualified health center clinics, representing eight health centers in Oregon and California, randomized to intervention (n = 13 clinics; 21,134 patients) or usual care (n = 13; 20,059 patients). Electronic health records (EHRs) identified participants (aged 50 to 74 years) who were overdue for colorectal cancer screening during the accrual interval (February 2014 to February 2015). FIT follow-up extended to August 2015. EHR-embedded tools enabled the mailed intervention that included an introductory letter, a mailed FIT, and a reminder letter. Clinic staff received training and facilitation through a practice improvement process. Clinic staff could choose the mailing schedule (e.g., monthly, quarterly, one-time).

The researchers found that the 2014 baseline CRC screening rate was 34 percent in both the intervention and usual care clinics, while baseline fecal testing rates in the past year were 13.0 percent in the intervention and 12.6 percent in usual care clinics. Intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (3.4 percentage points) and any colorectal cancer screening (3.8 percentage points), compared to usual care clinics. When accounting for implementation delays, difference in adjusted FIT completion was even higher (4.7 percentage points).

There was large variation across health centers in implementation (proportion who were mailed a FIT range, 6.5 to 68.2 percent) and effectiveness of the program (FIT completion differences range, −7.4 percentage points to 17.6 percentage points). Of patients who were mailed a FIT test, the overall FIT return rate was 21 percent (1304 of 6308). As expected, completion rates were higher in clinics that consistently delivered a reminder letter (25 percent) versus clinics that did so inconsistently (14 percent) or not at all (6 percent).

Overall, the number needed to mail to achieve a completed FIT was 4.8 and 4.0 in clinics that mailed a FIT reminder. Clinics reported primary implementation challenges included time burden on clinic staff, limited organizational capacity, and EHR issues.

"Across health centers, levels of implementation were strongly correlated with net differences in FIT completion," write the authors led by Gloria Coronado, Ph.D., from Kaiser Permanente Center for Health Research in Oregon. "Our pilot FIT outreach program resulted in a 38 percent boost in FIT completion rates. The smaller effect in this full trial may reflect the efficacy-effectiveness gap, where the ideal effect of an intervention is attenuated by conditions in the actual health care system."

Takeaway: Mailed FIT kits and outreach can raise rates of CRC screening among low-income patients seen at community clinics. However, additional support in health systems may be needed to implement such programs as the standard of care.