Parts greater than their sum: randomized controlled trial testing partitioned incentives to increase cancer screening

Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis?

Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.

Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis

IMPORTANCE

Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening.

OBJECTIVE

To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening.

DATA SOURCES

PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies.

STUDY SELECTION

Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded.

DATA EXTRACTION AND SYNTHESIS

The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised.

MAIN OUTCOMES AND MEASURES

The primary outcome was CRC screening completion within 12 months of receiving the intervention.

RESULTS

A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18).

CONCLUSIONS AND RELEVANCE

Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.

Effect of Behavioral Economic Incentives for Colorectal Cancer Screening in a Randomized Trial

BACKGROUND & AIMS

Financial incentives might increase participation in prevention such as screening colonoscopy. We studied whether incentives informed by behavioral economics increase participation in risk assessment for colorectal cancer (CRC) and completion of colonoscopy for eligible adults.

METHODS

Employees of a large academic health system (50-64 y old; n = 1977) were randomly assigned to groups that underwent risk assessment for CRC screening and direct access colonoscopy scheduling (control), or risk assessment, direct access colonoscopy scheduling, a $10 loss-framed incentive to complete risk assessment, and a $25 unconditional incentive for colonoscopy completion (incentive). The primary outcome was the percentage of participants who completed screening colonoscopy within 3 months of initial outreach. Secondary outcomes included the percentage of participants who scheduled colonoscopy and the percentage who completed the risk assessment.

RESULTS

At 3 months, risk assessment was completed by 19.5% of participants in the control group (95% CI, 17.0-21.9%) and 31.9% of participants in the incentive group (95% CI, 29.0-34.8%) (P < .001). At 3 months, 0.7% of controls had completed a colonoscopy (95% CI, .2%-1.2%) compared with 1.2% of subjects in the incentive group (95% CI, .5%-1.9%) (P = .25).

CONCLUSIONS

In a randomized trial of participants who underwent risk assessment for CRC with vs without financial incentive, the financial incentive increased CRC risk assessment completion but did not result in a greater completion of screening colonoscopy. Clinicaltrials.gov no: NCT03068052.

The Effects of Different Invitation Schemes on the Use of Fecal Occult Blood Tests for Colorectal Cancer Screening: Systematic Review of Randomized Controlled Trials

Simple Summary

There is large heterogeneity in invitation schemes and participation rates in colorectal cancer screening programs offering fecal occult blood tests (nowadays mostly fecal immunochemical tests). It is unclear what the most effective invitation strategies are for fecal occult blood tests. In this systematic review, advance notification, mailed fecal occult blood test, and reminders had major, consistent, and complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening. Our findings show that the effectiveness of invitations for fecal occult blood test-based colorectal cancer screening can be substantially increased across several settings by the implementation of comprehensive invitation strategies.

Abstract

Personal invitations for fecal occult blood tests (nowadays mostly fecal immunochemical tests) are increasingly used to raise their usage for colorectal cancer screening. However, there is a large heterogeneity in applied invitation schemes. We aimed to review evidence for the effectiveness of various invitation schemes. The main outcome was the fecal occult blood test usage rate. A systematic search was performed in Medline and Web of Science (up to 9 July 2020). Randomized controlled trials or cluster-randomized controlled trials were eligible, which reported on general invitations for fecal occult blood test-based colorectal cancer screening sent to the general population at average colorectal cancer risk. (PROSPERO 2020 CRD42020169409). Overall, 34 studies were included. Invitations with an attached, i.e., mailed fecal occult blood test consistently increased test usage by 4–19.7% points, compared to other methods of test provision. Likewise, the introduction of advance notification consistently led to a higher usage rate, with an increase of 3.3–10.8% points. Reminders showed positive but varying effects by method. With an increase of 8.5–15.8% points, letter or email reminders were more effective than reminders by phone call or text message (0.6–6.5% points). Inconsistent results were found for financial incentives ((−8.4)–20% points) and for added or changed invitation material ((−3.5)–11.8% points). With 3.5–24.7% points, the strongest increases in use were achieved by multifaceted invitation, implementing multiple components. Any invitation scheme was superior over no invitation. Advance notification, mailing of fecal occult blood test, and reminders were consistently shown to have major, complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening settings.