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

Differential impact of test performance characteristics on burden-to-benefit tradeoffs for blood-based colorectal cancer screening: A microsimulation analysis

OBJECTIVES

To inform the development and evaluation of new blood-based colorectal cancer (CRC) screening tests satisfying minimum United States (US) coverage criteria, we estimated the impact of the different test performance characteristics on long-term testing benefits and burdens.

METHODS

A novel CRC-Microsimulation of Adenoma Progression and Screening (CRC-MAPS) model was developed, validated, then used to assess different screening tests for CRC. We compared multiple, hypothetical blood-based CRC screening tests satisfying minimum coverage criteria of 74% CRC sensitivity and 90% specificity, to measure how changes in a test's CRC sensitivity, specificity, and adenoma sensitivity (sizes 1-5 mm, 6-9 mm, ≥10 mm) affect total number of colonoscopies (COL), CRC incidence reduction (IR), CRC mortality reduction (MR), and burden-to-benefit ratios (incremental COLs per percentage-point increase in IR or MR).

RESULTS

A blood test meeting minimum US coverage criteria for performance characteristics resulted in 1576 lifetime COLs per 1000 individuals, 46.7% IR and 59.2% MR compared to no screening. Tests with increased CRC sensitivity of 99% ( + 25%) vs. increased ≥10 mm adenoma sensitivity of 13.6% ( + 3.6%) both yielded the same MR, 62.7%. Test benefits improved the most with increases in all-size adenoma sensitivity, then size-specific adenoma sensitivities, then specificity and CRC sensitivity, while increases in specificity or ≥10 mm adenoma sensitivity resulted in the most favorable burden-to-benefit tradeoffs (ratios <11.5).

CONCLUSIONS

Burden-to-benefit ratios for blood-based CRC screening tests differ by performance characteristic, with the most favorable tradeoffs resulting from improvements in specificity and ≥10 mm adenoma sensitivity.

A patient reminder to improve colorectal cancer screenings

BACKGROUND

Colorectal cancer screenings detect the early, treatable, and often curable stages of the disease. Screenings are now recommended beginning at 45 years of age. Health care providers are expected to have patient's complete screenings, and reimbursement rates can be affected if results are not documented.

LOCAL PROBLEM

An independent review of expected organizational core measures revealed inadequate colorectal cancer screenings completed and no formal patient outreach program for patients who had not completed ordered screenings. The lack of a formal reminder to patients resulted in a cumulative completion rate of 19%.

METHODS

A phone call intervention was designed to notify patients of the need to complete colorectal cancer screenings. A preimplementation and postimplementation design was used to compare completed colorectal cancer screenings.

INTERVENTION

Patients with ordered colorectal cancer screenings received one reminder phone call to complete the screening. Preintervention and postintervention completion rates were evaluated using data from the electronic medical record.

RESULTS

Results revealed a colorectal cancer screening rate of 19% preimplementation and 43% postimplementation and reflected a 61.9% increase in cumulative completion rates over a 12-week intervention period.

CONCLUSION

The colorectal cancer patient reminder intervention showed clinical significance in improving completion rates of colorectal cancer screenings. The intervention was a successful method to improve patient compliance with the expected screening and helped improve provider core measure expectations.

Self-Reported Reasons for Inconsistent Participation in Colorectal Cancer Screening Using FIT in Flanders, Belgium

Background: In Flanders, the uptake in the population-based colorectal cancer (CRC) screening program (using fecal immunochemical test, FIT) is suboptimal (~50%). This study explored the reasons for inconsistent participation in FIT screening among irregular participants in Flanders. Methods: An online survey with both open questions and fixed statements was sent to irregular participants (2016–2018) in the Flemish CRC screening program. A reminder email followed eight weeks after the first email. Data analysis used both qualitative and quantitative approaches. Post-stratification weights based on gender, age group, and the first two digits of the postcode were employed to reduce non-response bias. Results: In total, 5328 out of 19,592 irregular participants responded to the survey. While the main reasons not to participate were related to ‘postponing participation’ and ‘having other priorities’, the main reasons to participate were related to the importance of (preventive) health checks. The role of general practitioners (GPs) in promoting CRC screening also emerged as an important theme among the respondents’ answers (based on fixed statements). Conclusions: The study reported the main reasons for inconsistent participation in FIT screening for CRC in Flanders. The findings are helpful in guiding tailored interventions to increase FIT screening uptake in the region.

The impact of pre-notifications and reminders on participation in colorectal cancer screening - A randomised controlled trial

This study aimed to test whether participation in colorectal cancer (CRC) screening can be increased by combining the standard invitation procedure with a pre-notification and/or an extra reminder. In a non-blinded randomised controlled trial nested in a population-based CRC screening programme employing the faecal immunochemical test, Group I received a three-staged invitation procedure (pre-notification, invitation and one reminder), Group II received a three-staged invitation procedure (invitation and two reminders) and Group III received a four-staged invitation procedure (pre-notification, invitation and two reminders). The control group received the invitation and one reminder (usual procedure). A total of 59,041 participants were included in the analyses. Overall participation rates increased from 66.9% in the control group to 69.8% in the four-staged invitation procedure corresponding to an increase in overall participation rate of 2.9% (95% CI: 1.8 to 4.0). In the age group 50-59 years, the four-staged invitation procedure increased the participation rate by 4.0% (95% CI: 2.4 to 5.6). An extra reminder increased participation with 2.7% (95% CI: 1.1; 4.2) for males compared to 1.1% (95% CI: -0.3; 2.5) for females. In conclusion, the four-staged invitation procedure was the most effective invitation procedure indicating that multiple invitation procedures are most effective, especially in the youngest age group. If a three-staged invitation procedure is applied, a second reminder should be preferred over a pre-notification. Trial registration The project was registered at ClinicalTrials.gov on 26 February 2020 and patient enrolment began in August 2020. ClinicalTrials.gov Identifier: NCT04292366.

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.

Financial Literacy, Financial Education, and Cancer Screening Behavior: Evidence from Japan

Although Japan has a well-established cancer screening program and has implemented several initiatives to increase screening rates, levels of cancer screening can be further improved. Based on a rational decision-making framework, this study examines the role of financial literacy and financial education, which measure peoples' knowledge about investment and savings, respectively, in improving cancer screening rates in Japan. The main data were extracted from Osaka University's Preference Parameters Study for 2011. The dependent variable was the number of cancer screenings while the two main independent variables were financial literacy and financial education. Ordered probit regression models were run to test the association between financial literacy, financial education, and the number of cancer screenings. The results showed a positive relationship between financial education and cancer screening behavior in Japan, while no significant association was observed between financial literacy and screening behavior. Furthermore, according to findings stratified by three age groups, the positive association between financial education and cancer screening behavior was particularly evident in 50- to 59-year-olds, while the effects of other demographic, socioeconomic, and risky health behavior variables were not consistent. It is imperative that implementation of more financial education programs is an effective intervention to encourage cancer screening behavior in Japanese populations.

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.

Barriers and facilitators to participate in the colorectal cancer screening programme in Flanders (Belgium): a focus group study

OBJECTIVE

In Flanders (Belgium), a population-based colorectal cancer (CRC) screening programme offers a faecal immunochemical test (FIT) biennially to Flemish citizens aged 50-74 years. A FIT uptake of only 51,5% in 2018 is significantly lower among men, lower income groups and among people with other than the Belgian nationality.The objective of this study was to identify attitudes, barriers and facilitators to participate in the Flemish CRC screening programme.

METHODS

Qualitative study using focus group discussions (FGDs) with non-participants in the Flemish CRC screening programme. Four FGDs were held with non-migrant Flemish population groups, and four were held with Turkish migrants (41 participants).

RESULTS

Feeling healthy, fear of cancer and embarrassment to talk about CRC screening emerged as common barriers in all FGDs. Having other priorities (non-migrant group) and a lack of understanding mainly due to a language barrier (Turkish migrants) differed between the two groups. Providing face-to-face information, information in group and GP recommendation were perceived as important facilitators to CRC screening in both groups. More publicity and making CRC screening more of a routine (non-migrant group) and offering translated information (Turkish migrants) were the suggested facilitators that differed between the groups.

CONCLUSIONS

Several common and some group-specific barriers and facilitators appeared to play a role in the decision to participate in the CRC screening programme. In order to improve informed decision making and participation in the CRC screening programme in Flanders, the options of more GP involvement, targeted information events, and adapted reminder letters are currently being explored.

The effect of deadlines on cancer screening completion: a randomized controlled trial

Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low—particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines—both with and without monetary incentives tied to them—increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines—especially short ones—can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.

Computer-tailored intervention increases colorectal cancer screening among low-income African Americans in primary care: Results of a randomized trial

INTRODUCTION

Although African Americans have the highest colorectal cancer (CRC) incidence and mortality rates of any racial group, their screening rates remain low.

STUDY DESIGN/PURPOSE

This randomized controlled trial compared efficacy of two clinic-based interventions for increasing CRC screening among African American primary care patients.

METHODS

African American patients from 11 clinics who were not current with CRC screening were randomized to receive a computer-tailored intervention (n = 335) or a non-tailored brochure (n = 358) designed to promote adherence to CRC screening. Interventions were delivered in clinic immediately prior to a provider visit. Univariate and multivariable logistic regression models analyzed predictors of screening test completion. Moderators and mediators were determined using multivariable linear and logistic regression analyses.

RESULTS

Significant effects of the computer-tailored intervention were observed for completion of a stool blood test (SBT) and completion of any CRC screening test (SBT or colonoscopy). The colonoscopy screening rate was higher among those receiving the computer-tailored intervention group compared to the nontailored brochure but the difference was not significant. Predictors of SBT completion were: receipt of the computer-tailored intervention; being seen at a Veterans Affairs Medical Center clinic; baseline stage of adoption; and reason for visit. Mediators of intervention effects were changes in perceived SBT barriers, changes in perceived colonoscopy benefits, changes in CRC knowledge, and patient-provider discussion. Moderators of intervention effects were age, employment, and family/friend recommendation of screening.

CONCLUSION

This one-time computer-tailored intervention significantly improved CRC screening rates among low-income African American patients. This finding was largely driven by increasing SBT but the impact of the intervention on colonoscopy screening was strong. Implementation of a CRC screening quality improvement program in the VA site that included provision of stool blood test kits and follow-up likely contributed to the strong intervention effect observed at that site. The trial is registered at ClinicalTrials.gov as NCT00672828.

A Qualitative Analysis of Barriers to Colorectal Cancer Screening among Korean Americans

Colorectal cancer (CRC) is the second most-commonly diagnosed cancer among Korean Americans after breast cancer, with incidence rates exceeding that of lung, prostate, and stomach cancers. However, CRC screening rates are lower among Korean Americans than the general U.S. population. To understand barriers to screening in this population, we conducted 11 focus groups with 51 Korean Americans ages 40+ in the Washington, DC, metropolitan area between 2011 and 2016. Our analysis used the Health Belief Model as a framework. Motivators to seek screening include a family or personal history of cancer or gastrointestinal disease (high perceived susceptibility), knowing people with CRC (high severity), favorable test results reducing worry (high benefits), and physician recommendations (cues to action). Barriers to screening include the common misperception that Korean lifestyles prevent CRC (low susceptibility), the belief that cancer is normal for older adults (low severity), the assumption that screening only benefits symptomatic people (low benefits), the costs and potential risks of testing along with a preference for traditional Korean approaches to wellness (high barriers), and lack of health insurance (low self-efficacy). Interventions seeking to increase the rate of cancer screening in the Korean American community will benefit from emphasizing the burden from CRC among Korean Americans (increasing perceived susceptibility to CRC), explaining that colonoscopies can prevent CRC rather than just diagnosing it (increasing perceived benefits of screening), reducing anxieties about test procedures and embarrassment (reducing perceived barriers to screening), and improving clinical communication (improving cues to action and self-efficacy).

Patients' Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis

PURPOSE

To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening.

APPROACH

We used qualitative methods to describe patients' attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS.

SETTING

Kaiser Permanente Washington (KPWA).

PARTICIPANTS

KPWA patients who were due or overdue for CRCS.

METHOD

We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach.

RESULTS

Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening.

CONCLUSIONS

Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.

Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

Background

Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality.

Methods

We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including 30 lay people at average risk for CRC, 13 health care personnel from a local public clinic, and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the social ecological model (SEM), the PRECEDE-PROCEED model, and the health belief model.

Results

We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels were as follows: (1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; (2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; and (3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.

Conclusions

This study's findings suggest that multi-level CRC screening programs in middle-income countries such as Mexico should incorporate complementary strategies to address barriers and facilitators, such as (1) provision of free screening tests, (2) education of primary healthcare personnel, and (3) promotion of non-fear-based CRC screening messages to the target population, tailored to address common lay beliefs.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Understanding those overdue for cancer screening by five years or more: A retrospective cohort study in Ontario, Canada

Populations that are more than just slightly overdue for breast, cervical and colorectal screening should likely be targeted for policy and practice interventions. We used provincial-level administrative data to describe the Ontario population who are screen-eligible for breast, cervical and colorectal cancers but overdue by at least five years. For each cancer screening type, we created three cohorts and a binary outcome: screened at least once in the previous five years or not, using March 31, 2017 as our index date. We conducted simple descriptive analyses as well as multivariable logistic regression, where age category, immigrant status, neighbourhood income quintile, region, urban/suburban/rural status, primary care model type, and healthcare utilization were included in the models. More than 20% of Ontarians eligible for each of breast, cervical and colorectal cancer screening respectively had no history of screening in the previous five years. In multivariable analyses, people were significantly more likely to have no recent screening history if they lived in lower-income neighbourhoods (e.g. adjusted odds ratio [95% confidence interval]: 0.59 [0.58-0.59] for cervical screening), were recent immigrants, did not have a primary care provider, had a provider who practiced in a traditional fee-for-service model. Despite the presence of three provincial organized screening programs, we have found that more than one-fifth of Ontarians who are eligible for each of breast, cervical and colorectal screening respectively have not been screened for five years or more. Ensuring that all Ontarians have access to high-quality primary care, may be crucial to increasing screening uptake.

Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial

Importance

Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups.

Objective

To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates.

Design, Setting, and Participants

This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled.

Interventions

Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion).

Main Outcomes and Measures

The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures.

Results

A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03).

Conclusions and Relevance

Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups.

Trial Registration

ClinicalTrials.gov identifier: NCT00697047.

Using a continuum of hybrid effectiveness-implementation studies to put research-tested colorectal screening interventions into practice

Background

Few previous studies have applied the hybrid effectiveness-implementation design framework to illustrate the way in which an intervention was progressively implemented and evaluated across multiple studies in diverse settings.

Methods

We describe the design components and methodologies of three studies that sought to improve rates of colorectal cancer (CRC) screening using mailed outreach, and apply domains put forth by Curran et al.: research aims, research questions, comparison conditions, sample, evaluation methods, measures, and potential challenges.

The Hybrid 1 study (emphasis on effectiveness) was a patient-level randomized trial of a mailed fecal test and stepped phone-outreach intervention program delivered in an integrated healthcare system (21 clinics, 4673 patients). The primary outcome was effectiveness (CRC screening uptake). Implementation outcomes included cost-effectiveness and acceptability.

The Hybrid 2 study (shared emphasis on effectiveness and implementation) was a pragmatic cluster-randomized trial of mailed fecal immunochemical test (FIT) outreach implemented at safety net clinics (26 clinics, 41,000 patients). The intervention used electronic health record tools (adapted from Hybrid 1) and clinic personnel to deliver the intervention. Outcomes included effectiveness (FIT completion) and implementation (FIT kits delivered, clinic barriers and facilitators, cost-effectiveness).

Hybrid 3 study (emphasis on implementation) is a demonstration project being conducted by two Medicaid/Medicare insurance plans (2 states, 12,000 patients) comparing two strategies for implementing mailed FIT programs that addressed Hybrid 2 implementation barriers. Outcomes include implementation (activities delivered, barriers) and effectiveness (FIT completion).

Results

The effectiveness-implementation typology successfully identified a number of distinguishing features between the three studies. Two additional features, program design and program delivery, varied across our studies, and we propose adding them to the current typology. Program design and program delivery reflect the process by which and by whom a program is designed and delivered (e.g., research staff vs. clinic/health plan staff).

Conclusions

We describe three studies that demonstrate the hybrid effectiveness to implementation continuum and make recommendations for expanding the hybrid typology to include new descriptive features. Additional comparisons of Hybrid 1, 2, and 3 studies may help confirm whether our hybrid typology refinements are generalizable markers of the pipeline from research to practice.

Population health interventions to improve colorectal cancer screening by fecal immunochemical tests: A systematic review

Despite clear evidence that colorectal cancer (CRC) screening reduces mortality, screening, including fecal immunochemical tests (FIT), is underutilized. We conducted a systematic review to determine the evidence of efficacy of interventions to improve FIT completion that could be scaled and utilized in population health management. We systematically searched publication databases for studies evaluating provider- or system-level interventions to improve CRC screening by FIT between 1 January 1996 and 13 December 2017 without language restrictions. Twenty articles describing 25 studies were included, 23 were randomized controlled trials with 1 quasi-experimental and 1 observational study. Ten studies discussed mailed FIT outreach, 4 pre-FIT patient reminders, 3 tailored patient messages, 2 post-FIT reminders, 2 paired FIT with influenza vaccinations, 2 provider alerts and 1 study each described the use of high-quality small media and patient financial incentives. Mailed FIT outreach was consistently effective with median improvement in CRC screening of 21.5% (interquartile range (IQR) 13.6%-29.0%). FIT paired with vaccinations led to a median 15.9% (IQR 15.6%-16.3%) improvement, while pre-FIT and post-FIT reminders demonstrated modest efficacy with median 4.1% (IQR 3.6%-6.7%) and 3.1% (IQR 2.9%-3.3%) improvement in CRC screening, respectively. More than half the studies were at high or unclear risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. FIT-based CRC screening programs utilizing multilevel interventions (e.g. mailed FIT outreach, FIT paired with other preventative services, and provider alerts) have the potential to significantly increase screening participation. However, such programs must also follow-up patients with abnormal FIT results.

Bowel cancer screening for women at midlife

In Australia one in 15 women will be diagnosed with colorectal cancer in their lifetime because of the high incidences of lifestyle risk factors. The risk could be reduced by taking aspirin. Evidence-based Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer produced by Cancer Council Australia and approved by the National Health and Medical Research Council recommended that 'population screening in Australia, directed at those at average risk of colorectal cancer and without relevant symptoms, is immunochemical fecal occult blood testing every 2 years, starting at age 50 years and continuing to age 74 years.' Women at high risk because of family history will need more intense screening. At the current 40% participation rate, it is estimated that biennial screening with fecal immunohistochemical tests (FIT) reduces colorectal cancer incidence by 23% and mortality by 36%. The major adverse effects of screening are the psychological impact of a positive FIT that does not prove to be cancer, or adenomas on colonoscopy (47.7%), and the rare side-effects of colonoscopy of hemorrhage, bleeding or even death. A range of factors that could increase a woman's participation rate includes advice to screen from her general practitioner and more information about the nature of the screening tests.