Outreach for Annual Colorectal Cancer Screening: A Budget Impact Analysis for Community Health Centers

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.

METHODS

SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.

DISCUSSION

Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Extending analytic methods for economic evaluation in implementation science

Background

Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation.

Main body

We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the “boundaries” of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection—particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs.

Conclusion

Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Cost-effectiveness of Leveraging Social Determinants of Health to Improve Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review

Importance

Screening for breast, cervical, and colorectal cancers in the United States has remained below the Healthy People 2020 goals, with evidence indicating that persistent screening disparities still exist. The US Department of Health and Human Services has emphasized cross-sectoral collaboration in aligning social determinants of health with public health and medical services. Examining the economics of intervening through these novel methods in the realm of cancer screening can inform program planners, health care providers, implementers, and policy makers.

Objective

To conduct a systematic review of economic evaluations of interventions leveraging social determinants of health to improve screening for breast, cervical, and colorectal cancer to guide implementation.

Evidence Review

A systematic literature search for economic evidence was performed in MEDLINE, Embase, PsycINFO, Cochrane Library, Global Health, Scopus, Academic Search Complete, Business Source Complete, EconLit, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resources Information Center), and Sociological Abstracts from January 1, 2004, to November 25, 2019. Included studies intervened on social determinants of health to improve breast, cervical, and colorectal cancer screening in the United States and reported intervention cost, incremental cost per additional person screened, and/or incremental cost per quality-adjusted life-year (QALY). Risk of bias was assessed along with qualitative assessment of quality to ensure complete reporting of economic measures, data sources, and analytic methods. In addition, included studies with modeled outcomes had to define structural elements and sources for input parameters, distinguish between programmatic and literature-derived data, and assess uncertainty.

Findings

Thirty unique articles with 94 706 real and 4.21 million simulated participants satisfied our inclusion criteria and were included in the analysis. The median intervention cost per participant was $123.87 (interquartile interval [IQI], $24.44-$313.19; 34 estimates). The median incremental cost per additional person screened was $250.37 (IQI, $44.67-$609.38; 17 estimates). Studies that modeled final economic outcomes had a median incremental cost per person of $122.96 (IQI, $46.96-$124.80; 5 estimates), a median incremental screening rate of 15% (IQI, 14%-20%; 5 estimates), and a median incremental QALY per person of 0.04 years (IQI, 0.006-0.06 year; 5 estimates). The median incremental cost per QALY gained of $3120.00 (IQI, $782.59-$33 600.00; 5 estimates) was lower than $50 000, an established, conservative threshold of cost-effectiveness.

Conclusions and Relevance

Interventions focused on social determinants of health to improve breast, cervical, and colorectal cancer screening appear to be cost-effective for underserved, vulnerable populations in the United States. The increased screening rates were associated with earlier diagnosis and treatment and in improved health outcomes with significant gains in QALYs. These findings represent the latest economic evidence to guide implementation of these interventions, which serve the dual purpose of enhancing health equity and economic efficiency.

Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods

BACKGROUND

Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors.

OBJECTIVES

As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program.

DESIGN

Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program.

MAIN MEASURES

We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model.

KEY RESULTS

FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present.

CONCLUSIONS

Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.

Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia

The purpose of this study is to evaluate the effectiveness of the West Virginia Program to Increase Colorectal Cancer Screening in implementing patient reminders to increase fecal immunochemical test (FIT) kit return rates in nine federally qualified health centers (FQHCs). Using process measures and cost data collected, the authors examined the differences in the intensity of the phone calls across FQHCs and compared them with the return rates achieved. They also reported the cost per kit successfully returned as a result of the intervention. Across all FQHCs, 5,041 FIT kits were ordered, and the initial return rate (without a reminder) was 41.1%. A total of 2,201 patients received reminder phone calls; on average, patients received 1.61 reminder calls each. The reminder interventions increased the average FIT kit return rate to 60.7%. The average total cost per FIT kit returned across all FQHCs was $60.18, and the average cost of only the reminders was $11.20 per FIT kit returned. FQHCs achieved an average increase of 19.6 percentage points in FIT kit return rates, and costs across clinics varied. Clinics with high-quality health information systems that enabled tracking of patients with minimal effort were able to implement lower cost reminder interventions.

Examining the Effectiveness of Provider Incentives to Increase CRC Screening Uptake in Neighborhood Healthcare: A California Federally Qualified Health Center

As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened.

Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

BACKGROUND

Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care.

METHODS

Patients age 50-75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided.

RESULTS

A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care.

CONCLUSION

Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Improving Colorectal Cancer Screening in a Rural Setting: A Randomized Study

INTRODUCTION

Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.

STUDY DESIGN

RCT.

SETTING/PARTICIPANTS

Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.

INTERVENTION

A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.

MAIN OUTCOME MEASURES

Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.

RESULTS

Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p<0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.

CONCLUSIONS

A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members

BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.

Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review

CONTEXT

The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions.

EVIDENCE ACQUISITION

A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018.

EVIDENCE SYNTHESIS

Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817.

CONCLUSIONS

Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review

BACKGROUND & AIMS

Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions.

METHODS

We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2.

RESULTS

Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening.

CONCLUSIONS

In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.

Budget Impact Analysis of Cancer Screening: A Methodological Review

BACKGROUND

Budget impact analyses (BIAs) describe changes in intervention- and disease-related costs of new technologies. Evidence on the quality of BIAs for cancer screening is lacking.

OBJECTIVES

We systematically reviewed the literature and methods to assess how closely BIA guidelines are followed when BIAs are performed for cancer-screening programs.

DATA SOURCES

Systematic searches were conducted in MEDLINE, EMBASE, EconLit, CRD (Centre for Reviews and Dissemination, University of York), and CEA registry of the Tufts Medical Center.

STUDY ELIGIBILITY CRITERIA

Eligible studies were BIAs evaluating cancer-screening programs published in English, 2010-2018.

SYNTHESIS METHODS

Standardized evidence tables were generated to extract and compare study characteristics outlined by the ISPOR BIA Task Force.

RESULTS

Nineteen studies were identified evaluating screening for breast (5), colorectal (6), cervical (3), lung (1), prostate (3), and skin (1) cancers. Model designs included decision-analytic models (13) and simple cost calculators (6). From all studies, only 53% reported costs for a minimum of 3 years, 58% compared to a mix of screening options, 42% reported model validation, and 37% reported uncertainty analysis for participation rates. The quality of studies appeared to be independent of cancer site.

LIMITATIONS

"Gray" literature was not searched, misinterpretation is possible due to limited information in publications, and focus was on international methodological guidelines rather than regional guidelines.

CONCLUSIONS

Our review highlights considerable variability in the extent to which BIAs evaluating cancer-screening programs followed recommended guidelines. The annual budget impact at least over the next 3-5 years should be estimated. Validation and uncertainty analysis should always be conducted. Continued dissemination efforts of existing best-practice guidelines are necessary to ensure high-quality analyses.

A cost-effectiveness analysis of a colorectal cancer screening program in safety net clinics

STOP CRC is a cluster-randomized pragmatic study of a colorectal cancer (CRC) screening program within eight federally-qualified health centers (FQHCs) in Oregon and California promoting fecal immunochemical testing (FIT) with appropriate colonoscopy follow-up. Results are presented of a cost-effectiveness analysis of STOP CRC. Organization staff completed activity-based costing spreadsheets, assigning labor hours by intervention activity and job-specific wage rates. Non-labor costs were from study data. Data were collected over February 2014-February 2016; analyses were performed in 2016-2017. Incremental cost-effectiveness ratios (ICERs) using completed FITs adjusted for number of screening-eligible patients (SEPs), as the effectiveness measure were calculated overall and by organization. Intervention delivery costs totaled $305 K across eight organizations (range: $10.2 K-$110 K). Overall delivery cost per SEP was $14.43 (range: $10.37-$19.10). The largest cost category across organizations was implementation, specifically mailing preparation. The overall ICER was $483 per SEP-adjusted completed FIT (range: $96-$1021 among organizations with positive effectiveness). Lagged data accounting for implementation delay produced comparable results. The costs of colonoscopies following abnormal FITs decreased the overall ICER to S409 because usual care clinics generated more such colonoscopies than intervention clinics. Using lagged data, follow-up colonoscopies increase the ICER by 4.3% to $460. Results indicate the complex implications for cost-effectiveness of implementing standard CRC screening within a pragmatic setting involving FQHCs with varied patient populations, clinical structures, and resources. Performance variation across organizations emphasizes the need for future evaluations that inform the introduction of efficient CRC screening to underserved populations.

Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness

BACKGROUND

The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment's Clinic Quality Improvement for Population Health initiative.

METHODS

Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems.

RESULTS

CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened.

CONCLUSIONS

In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

Effectiveness and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in Washington State

BACKGROUND

It has been demonstrated that fecal immunochemical test (FIT) mailing programs are effective for increasing colorectal cancer (CRC) screening. The objectives of the current study were to assess the magnitude of uptake that could be achieved with a mailed FIT program in a federally qualified health center and whether such a program can be implemented at a reasonable cost to support sustainability.

METHODS

The Washington State Department of Health's partner HealthPoint implemented a direct-mail FIT program at 9 medical clinics, along with a follow-up reminder letter and automated telephone calls to those not up-to-date with recommended screening. Supplemental outreach events at selected medical clinics and a 50th birthday card screening reminder program also were implemented. The authors collected and analyzed process, effectiveness, and cost measures and conducted a systematic assessment of the short-term cost effectiveness of the interventions.

RESULTS

Overall, 5178 FIT kits were mailed with 4009 follow-up reminder letters, and 8454 automated reminder telephone calls were made over 12 months. In total, 1607 FIT kits were returned within 3 months of the end of the implementation period: an overall return rate of 31% for the mailed FIT program. The average total intervention cost per FIT kit returned was $39.81, and the intervention implementation cost per kit returned was $18.76.

CONCLUSIONS

The mailed FIT intervention improved CRC screening uptake among HealthPoint's patient population. This intervention was implemented for less than $40 per individual successfully screened. The findings and lessons learned can assist other clinics that serve disadvantaged populations to increase their CRC screening adherence.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

OBJECTIVE

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

INTERVENTIONS

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

RESULTS

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

CONCLUSIONS AND RELEVANCE

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02054598.

Budget Impact Analysis of Against Colorectal Cancer In Our Neighborhoods (ACCION): A Successful Community-Based Colorectal Cancer Screening Program for a Medically Underserved Minority Population

OBJECTIVES

Given the uncertain cost of delivering community-based cancer screening programs, we developed a Markov simulation model to project the budget impact of implementing a comprehensive colorectal cancer (CRC) prevention program compared with the status quo.

METHODS

The study modeled the impacts on the costs of clinical services, materials, and staff expenditures for recruitment, education, fecal immunochemical testing (FIT), colonoscopy, follow-up, navigation, and initial treatment. We used data from the Against Colorectal Cancer In Our Neighborhoods comprehensive CRC prevention program implemented in El Paso, Texas, since 2012. We projected the 3-year financial consequences of the presence and absence of the CRC prevention program for a hypothetical population cohort of 10,000 Hispanic medically underserved individuals.

RESULTS

The intervention cohort experienced a 23.4% higher test completion rate for CRC prevention, 8 additional CRC diagnoses, and 84 adenomas. The incremental 3-year cost was $1.74 million compared with the status quo. The program cost per person was $261 compared with $86 for the status quo. The costs were sensitive to the proportion of high-risk participants and the frequency of colonoscopy screening and diagnostic procedures.

CONCLUSIONS

The budget impact mainly derived from colonoscopy-related costs incurred for the high-risk group. The effectiveness of FIT to detect CRC was critically dependent on follow-up after positive FIT. Community cancer prevention programs need reliable estimates of the cost of CRC screening promotion and the added budget impact of screening with colonoscopy.