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

Barriers to stool specimen collection during foodborne and enteric illness outbreak investigations in Arizona and Colorado

Stool specimen collection during a foodborne or enteric illness outbreak investigation is essential for determining the outbreak etiology and for advancing the epidemiologic understanding of the pathogens and food vehicles causing illness. However, public health professionals face multifaceted barriers when trying to collect stool specimens from ill person during an outbreak investigation. The Colorado Integrated Food Safety Center of Excellence (Colorado IFS CoE) and the Arizona Department of Health Services surveyed local public health agencies (LPHAs) to identify barriers to collecting ≥2 clinical specimens in foodborne and enteric illness outbreaks. The most commonly selected patient-related barrier was that the patient did not think it is important to provide a stool sample because they are well by the time the LPHA follows-up (61%). The most frequently selected outbreak-related barrier was the LPHA did not learn about the outbreak until after symptoms had resolved (61%). Time/personnel not being available for stool collection was the most frequently chosen health department-related barrier (51%). Timing of the outbreak (e.g., on a weekend or holiday) was the most frequently selected transportation-related barrier (51%) to collecting ≥2 stool specimens. Many of the frequently cited barriers in this survey were similar to those previously reported, such as workforce capacity and patient privacy concerns, indicating that these barriers are ongoing. Reducing barriers to stool collection during outbreaks will require efforts led at the national and state levels, such as increased enteric illness program funding, educating public health staff on the importance of specimen collection during every enteric illness outbreak, and providing specimen collection resources to LPHA staff.

Results of an African American-targeted norm-based colorectal cancer screening intervention: a pilot study

Lower colorectal cancer screening rates among African Americans contribute to higher colorectal cancer incidence and mortality. We tested the effects of a racially-targeted messaging intervention that used favorable behavioral norm information to increase uptake of at-home Fecal Immunochemical Test (FIT) Kits. We expected stronger intervention effects among African Americans with stronger racial identity. Eligible African Americans were randomized to one of four intervention conditions: injunctive norm message, descriptive norm message, both messages, neither message. The norm-based messages were delivered via an animated video health message. Background variables, constructs defined by the theory of planned behavior, racial identity, screening modality preferences, and uptake and return of FIT Kits were assessed. Of 205 participants, 111(54%) requested FIT Kits. Contrary to hypotheses, multigroup path analyses indicated stronger effects of targeted messages among African Americans with weaker racial identity. Findings highlight the importance of within-race heterogeneity in the receptivity to racially-targeted health messages.

A hands-free stool sampling system for monitoring intestinal health and disease

Analysis of stool offers simple, non-invasive monitoring for many gastrointestinal (GI) diseases and access to the gut microbiome, however adherence to stool sampling protocols remains a major challenge because of the prevalent dislike of handling one's feces. We present a technology that enables individual stool specimen collection from toilet wastewater for fecal protein and molecular assay. Human stool specimens and a benchtop test platform integrated with a commercial toilet were used to demonstrate reliable specimen collection over a wide range of stool consistencies by solid/liquid separation followed by spray-erosion. The obtained fecal suspensions were used to perform occult blood tests for GI cancer screening and for microbiome 16S rRNA analysis. Using occult blood home test kits, we found overall 90% agreement with standard sampling, 96% sensitivity and 86% specificity. Microbiome analysis revealed no significant difference in within-sample species diversity compared to standard sampling and specimen cross-contamination was below the detection limit of the assay. Furthermore, we report on the use of an analogue turbidity sensor to assess in real time loose stools for tracking of diarrhea. Implementation of this technology in residential settings will improve the quality of GI healthcare by facilitating increased adherence to routine stool monitoring.

A Centralized Program with Stepped Support Increases Adherence to Colorectal Cancer Screening Over 9 Years: a Randomized Trial

BACKGROUND

Screening over many years is required to optimize colorectal cancer (CRC) outcomes.

OBJECTIVE

To evaluate the effect of a CRC screening intervention on adherence to CRC screening over 9 years.

DESIGN

Randomized trial.

SETTING

Integrated health care system in Washington state.

PARTICIPANTS

Between August 2008 and November 2009, 4653 adults in a Washington state integrated health care system aged 50-74 due for CRC screening were randomized to usual care (UC; N =1163) or UC plus study interventions (interventions: N = 3490).

INTERVENTIONS

Years 1 and 2: (arm 1) UC or this plus study interventions; (arm 2) mailed fecal tests or information on scheduling colonoscopy; (arm 3) mailings plus brief telephone assistance; or (arm 4) mailings and assistance plus nurse navigation. In year 3, stepped-intensity participants (arms 2, 3, and 4 combined) still eligible for screening were randomized to either stopped or continued interventions in years 3 and 5-9.

MAIN MEASURES

Time in adherence to CRC testing over 9 years (covered time, primary outcome), and percent with no CRC testing in participants assigned to any intervention compared to UC only. Poisson regression models estimated incidence rate ratios for covered time, adjusting for patient characteristics and accounting for variable follow-up time.

KEY RESULTS

Compared to UC, intervention participants had 21% more covered time over 9 years (57.5% vs. 69.1%; adjusted incidence rate ratio 1.21, 95% confidence interval 1.16-1.25, P<0.001). Fecal testing accounted for almost all additional covered time among intervention patients. Compared to UC, intervention participants were also more likely to have completed at least one CRC screening test over 9 years or until censorship (88.6% vs. 80.6%, P<0.001).

CONCLUSIONS

An outreach program that included mailed fecal tests and phone follow-up led to increased adherence to CRC testing and fewer age-eligible individuals without any CRC testing over 9 years.

TRIAL REGISTRATION

Systems of Support (SOS) to Increase Colon Cancer Screening and Follow-up (SOS), NCT00697047, clinicaltrials.gov/ct2/show/NCT00697047.

What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%?

Screening reduces colorectal cancer mortality; however, this remains the second leading cause of cancer deaths in the United States and adherence to colorectal cancer screening falls far short of the National Colorectal Cancer Roundtable goal of 80%. Numerous studies have examined the effectiveness of interventions to increase colorectal cancer screening uptake. Outreach is the active dissemination of screening outside of the primary care setting, such as mailing fecal blood tests to individuals' homes. Navigation uses trained personnel to assist individuals through the screening process. Patient education may take the form of brochures, videos, or websites. Provider education can include feedback about screening rates of patient panels. Reminders to healthcare providers can be provided by dashboards of patients due for screening. Financial incentives provide monetary compensation to individuals when they complete screening tests, either as fixed payments or via a lottery. Individual preference for specific screening strategies has also been examined in several trials, with a choice of screening strategies yielding higher adherence than recommendation of a single strategy.

Proven Strategies for Increasing Adherence to Colorectal Cancer Screening

Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.

Making FIT Count: Maximizing Appropriate Use of the Fecal Immunochemical Test for Colorectal Cancer Screening Programs

Colorectal cancer (CRC) remains one of the most common and deadly malignancies despite advancements in screening, diagnostic capabilities, and treatment. The ability to detect and remove precancerous and cancerous lesions via screening has altered the epidemiology of the disease, decreasing incidence, mortality, and late-stage disease presentation. The fecal immunochemical test (FIT) is a screening test that aims to detect human hemoglobin in the stool. FIT is the most common CRC screening modality worldwide and second most common in the United States. Its use in screening programs has been shown to increase screening uptake and improve CRC outcomes. However, FIT-based screening programs vary widely in quality and effectiveness. In health systems with high-quality FIT screening programs, only superior FIT formats are used, providers order FIT appropriately, annual patient participation is high, and diagnostic follow-up after an abnormal result is achieved in a timely manner. Proper utilization of FIT involves multiple steps beyond provider recommendation of the test. In this commentary, we aim to highlight ongoing challenges in FIT screening and suggest interventions to maximize FIT effectiveness. Through active engagement of patients and providers, health systems can use FIT to help optimize CRC screening rates and improve CRC outcomes.

Directly Mailing gFOBT Kits to Previous Responders Being Recalled for Colorectal Cancer Screening Increases Participation

Background

Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces CRC-related death. Average risk individuals should be recalled for screening with gFOBT every 2 years in order to maximize effectiveness. However, adherence with repeated testing is often suboptimal. Our aim was to evaluate whether adding a gFOBT kit to a mailed recall letter improves participation compared with a mailed recall letter alone, among previous responders to a mailed invitation.

Methods

We conducted a cluster randomized controlled trial, with the primary care provider as the unit of randomization. Eligible patients had completed a gFOBT and tested negative in an earlier pilot study and were now due for recall. The intervention group received a mailed CRC screening recall letter from their primary care provider plus a gFOBT kit (n = 431) while the control group received a mailed CRC screening mailed recall letter alone (n = 452). The primary outcome was the uptake of gFOBT or colonoscopy within 6 months.

Results

gFOBT uptake was higher in the intervention group (61.3%, n = 264) compared with the control group (50.4%, n = 228) with an absolute difference between the two groups of 10.8% (95% confidence interval [CI]: 1.4 to 20.2%, P = <0.01). Patients in the intervention group were more likely to complete the gFOBT compared with the control group (odds ratio [OR] = 1.4; 95% CI: 1.1 to 1.9).

Conclusion

Our findings show that adding gFOBT kits to the mailed recall letter increased participation among persons recalled for screening. Nine gFOBT kits would have to be sent by mail in order to screen one additional person.

Factors Affecting Adherence in a Pragmatic Trial of Annual Fecal Immunochemical Testing for Colorectal Cancer

BACKGROUND

Colorectal cancer screening by fecal immunochemical test (FIT) reduces the burden of colorectal cancer. However, effectiveness relies on annual adherence, which presents challenges for clinic staff and patients.

OBJECTIVE

Describe FIT return rates and identify factors associated with FIT adherence over 2 years in a mailed FIT outreach program in federally qualified health centers.

DESIGN

Observational study nested in the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) trial. Five thousand one hundred ninety-five patients had an initial FIT order and were followed for ≥ 2 years (3574 also had a FIT order in the second year).

MAIN MEASURES

FIT return percent in each year and patient- and neighborhood-level characteristics associated with FIT adherence.

KEY RESULTS

Overall, the proportion of FIT orders that were completed was 46% in the patients' first year and 41% in the patients' second year. Of the 5195 patients with a FIT order in year 1, 3574 (69%) also had a FIT order in year 2 (71% of year 1 adherers and 67% of year 1 non-adherers, p = 0.009). Among those with a FIT order in the second year, the FIT return rate was about twice as high among those who were adherent in the first year (952/1674, or 57%) as among those who were not (531/1900, or 28%, p < 0.0001). Patient-level characteristics associated with higher odds of FIT return were a history of FIT screening at baseline, age over 65 (vs 50-65), no current tobacco use, recent receipt of a mammogram or flu vaccine, Asian ancestry (compared to non-Hispanic white), and non-English preference. The only neighborhood factor associated with lower FIT return rate was patient's larger residential city size.

CONCLUSION

Our findings can inform the customization of programs to promote FIT return among patients who receive care at federally qualified health centers.

TRIAL REGISTRATION

http://www.clinicaltrials.gov.

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

IMPORTANCE

Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

OBJECTIVE

To identify interventions associated with increasing CRC screening rates and their effect sizes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

STUDY SELECTION

Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

DATA EXTRACTION AND SYNTHESIS

At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

MAIN OUTCOMES AND MEASURES

The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

RESULTS

The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

CONCLUSIONS AND RELEVANCE

Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

Barriers to Colorectal Cancer Screening in a Primary Care Setting in Turkey

Colorectal cancer (CRC) is the third most common form of cancer in men worldwide and the second most common in women. The purpose of this study was to determine both barriers established by primary health care providers (PHCPs) and barriers perceived by them and to produce solutions for achieving the desired results. A four-part questionnaire was administered to family physicians (FPs) and family health personnels (FHPs) in Samsun, Turkey on 01-15 May, 2016. Sixty-six percent of PHCPs were contacted. Data were evaluated as numbers and percentages, and statistical significance was analyzed using the Chi square and t tests. 478 PHCPs participated; 49.4 % were FPs and 50.6 % FHPs. Of the participants, 86.6 % stated that they performed CRC screening on patients. The level of participants knowing that screening should start at age 50 and conclude at age 70 was 49.7 %. The level of subjects requesting the fecal occult blood test (FOBT) at the correct intervals was 29.7 %, but only 6.9 % recommended colonoscopy at the correct intervals. Additionally, 18.2 % of subjects knew that the test used is immunochemical FOBT, and 60.5 % reported not using reminders. PHCPs' low levels of knowledge, awareness and advice compatible with guidelines concerning CRC screening may represent an obstacle to such screening. Barriers perceived by PHCPs include patients' inability to access definite medical information, deficiencies in the reminder system and patients' lack of interest in CRC screening. Additions to the screening program will be useful in overcoming barriers.

Evaluating the Effectiveness of One-on-One Conversations to Increase Colorectal Cancer Screening in a Community-Based Clinical Setting

Context

The American Cancer Society's 80% by 2018 initiative aims to increase at-home colorectal cancer (CRC) screening.

Objective

To assess the effectiveness of one-on-one conversations with patients about CRC screening on compliance with at-home fecal immunochemical tests (FITs).

Setting

Federally funded health care center serving a largely minority, urban, underserved population in Vallejo, California.

Methods

Patients aged 50 to 75 years were divided into 3 main intervention arms: (1) patients who received a one-on-one in-person consultation to discuss the need for CRC screening and the screening process, as well as a FIT; (2) patients who received a telephone call to discuss the need for CRC screening and the screening process before receiving a FIT in the mail; and (3) patients who were mailed a FIT with a letter explaining the importance of completing the FIT and instructions. The FITs were tracked to see if they were returned to the laboratory for processing, and the rates of return were compared in bivariate analyses using t and χ2 tests and in adjusted analyses using logistic regression with bootstrapping.

Results

A total of 3415 patients were included in the study. One-on-one conversations either in person (OR, 24.63; 95% CI, 19.28-31.46) or via telephone (OR, 14.74; 95% CI, 10.96-19.82) were more effective at getting patients to complete the at-home CRC screening than not having one-on-one conversations before receiving the FIT.

Conclusion

Patients may be more likely to complete at-home FITs to screen for CRC if they are first able to discuss the need for screening and the screening process with a health care professional.

A centralized mailed program with stepped increases of support increases time in compliance with colorectal cancer screening guidelines over 5 years: A randomized trial

BACKGROUND

Screening over many years is required to optimize reductions in colorectal cancer (CRC) mortality. However, no prior trials have compared strategies for obtaining long-term adherence.

METHODS

Systems of Support to Increase Colorectal Cancer Screening and Follow-Up was implemented in an integrated health care organization in Washington State. Between 2008 and 2009, 4675 individuals aged 50 to 74 years were randomized to receive the usual care (UC), which included clinic-based strategies to increase CRC screening (arm 1), or, in years 1 and 2, mailings with a call-in number for colonoscopy and mailed fecal tests (arm 2), mailings plus brief telephone assistance (arm 3), or mailings and assistance plus nurse navigation (arm 4). Active-intervention subjects (those in arms 2, 3, and 4 combined) who were still eligible for CRC screening were randomized to mailings being stopped or continued in years 3 and 5. The time in compliance with CRC screening over 5 years was compared for persons assigned to any intervention and persons assigned to UC. Screening tests contributed time on the basis of national guidelines for screening intervals (fecal tests annually, sigmoidoscopy every 5 years, and colonoscopy every 10 years).

RESULTS

All participants contributed data, but they were censored at disenrollment, death, the age of 76 years, or a diagnosis of CRC. Compared with UC participants, intervention participants had 31% more adjusted covered time over 5 years (incidence rate ratio, 1.31; 95% confidence interval, 1.25-1.37; covered time, 47.5% vs 62.1%). Fecal testing accounted for almost all additional covered time.

CONCLUSIONS

In a health care organization with clinic-based activities to increase CRC screening, a centralized program led to increased CRC screening adherence over 5 years. Longer term data on screening adherence and its impact on CRC outcomes are needed. Cancer 2017;123:4472-80. © 2017 American Cancer Society.

Reasons for never and intermittent completion of colorectal cancer screening after receiving multiple rounds of mailed fecal tests

Background

Long-term adherence to colorectal cancer (CRC) screening is particularly important for fecal testing. Some U.S. studies report that only 25% of individuals repeat fecal testing annually. The purpose of this qualitative study was to identify barriers and facilitators reported by patients with suboptimal screening adherence to refine interventions for starting ongoing adherence to CRC screening. We also explored whether participants, particularly never screeners, would be willing to do a CRC screening blood test.

Methods

Forty-one patients who previously enrolled in the Systems of Support to Increase CRC Screening (SOS) trial were interviewed 4–5 years later. Participants were purposively selected to include men and women with diverse race/ethnicities who had either been inconsistent screeners or had never screened during the first three years of SOS despite receiving at least two rounds of mailed fecal tests. Two interviewers conducted 30-min telephone interviews using a semi-structured interview guide. An iterative thematic analysis approach was used.

Results

Themes related to screening barriers were more pervasive among never screeners including: (1) Avoidance (inattention, procrastination) (2) Concerns about handling stool; (3) Health concerns; (4) Fear of a cancer diagnosis or positive test results. Themes related to screening facilitators were more often mentioned by participants who screened at least once including: (1) Use of a simpler 1-sample fecal test; (2) Convenience of mailings and doing the test at home; (3) Salience of prevention, especially as one got older; and (4) Influence of recommendations from providers, family and friends. Participants had diverse preferences for the number (3 on average) and types (phone, mail, text) of screening reminders. Some participants did not prefer e-mail links to the patient shared electronic health record because of difficulties remembering their password. It was acceptable for a nurse or medical assistant not from their clinic to call them as long as that person was knowledgeable about their records and could communicate with their physician. Participants, especially never screeners, were generally very enthusiastic about the potential option of a CRC screening blood test.

Conclusion

Future CRC screening programs should be designed to minimize these barriers and maximize facilitators to improve long-term screening adherence.

Trial registration

Primary Funding Agency: The National Cancer Institute of the National Institutes of Health (R01CA121125). Registered at clinicaltrials.govNCT00697047.

A Quality Improvement Initiative to Increase Colorectal Cancer (CRC) Screening: Collaboration between a Primary Care Clinic and Research Team

BACKGROUND

Multiple randomized controlled trials have demonstrated that mailed fecal testing programs are effective in increasing colorectal cancer screening participation. However, few healthcare organization in the US have Implemented such programs.

METHODS

Stakeholders from one clinic in an integrated healthcare system in Washington State initiated collaboration with researchers with expertise in CRC screening, aiming to increase screening rates at their clinic. Age-eligible individuals who were overdue for CRC screening and had previously completed a fecal test were randomized to receive mailed fecal immunochemical test kits (FIT) at the start of the project (Early) or 6 months later (Late). Outcomes included comparing FIT completion at 6 months by randomization group, and overall CRC screening rates at 12 months. We also assessed implementation facilitators and challenges.

RESULTS

Overall 2,421 FIT tests were mailed at a cost of $10,739. At 6 months, FIT completion was significantly higher among the Early compared to the Late group (62% vs.47%, p <0.001). By 12 months, after both groups had received mailings, 71% in each group had completed a FIT. The clinic's overall CRC screening rate was 75.1% at baseline and 78.0% 12 months later. Key constructs associated with successful program implementation included strong stakeholder involvement, use of evidence-based strategies, simplicity, and low cost. Challenges included lack of a plan for maintaining the program.

DISCUSSION

Collaboration between clinic stakeholders and researchers led to a successful project that rapidly increased CRC screening rates. However, institutional normalization of the program would be required to maintain it.