A large-scale study funded by the National Institutes of Health and published this week in JAMA Internal Medicine found mailing fecal immunochemical test (FIT) kits to socioeconomically underserved patients at risk for colorectal cancer (CRC) led to a nearly 4 percent increase in CRC screening.
The study, headed by Kaiser Permanente investigator Gloria Coronado, PhD, and known as “STOP CRC," explored how the practice of mailing FIT kits—an initiative proven to be successful in a handful of recent studies—applied to actual clinical practice. Coronado and her team at Kaiser focused on community health centers, or “safety net” clinics, which aim to provide care for 24 million Americans whose access to quality health services is limited.
“This was a real-world, pragmatic trial, which is quite a bit different from a carefully controlled research environment,” Coronado said in a release from Kaiser Permanente. “With such a large number of individuals receiving care in the safety net setting, an improvement in CRC screening rates of even a few percentage points can have a major impact in terms of cancers detected and lives saved.”
For their research, Coronado and colleagues randomized 26 clinics representing eight health centers in Oregon and California to either implement the FIT kit mailing program or continue to deliver standard care. Centers randomized to the FIT kit cohort had their electronic health record (EHR) systems customized to identify patients who were due for colorectal cancer screening.
Those clinics then mailed eligible patients an explanatory introductory letter before sending a FIT kit and follow-up letter to remind them of the at-home exams. Patients whose FIT kit results were positive were encouraged to schedule a colonoscopy.
Coronado said other studies have shown mailing FIT kits can be an effective way of boosting colorectal screening numbers, but her team’s was unique in that it gave clinics full autonomy over their actions.
“Our team provided clinics with the EHR tools needed to identify and contact patients who were due for screening,” she said. “We trained clinic staff to use the tools, we provided letter templates, pictographic instructions and other materials, and we used a collaborative learning model to offer ongoing support. But ultimately, clinic staff were responsible for integrating the intervention into their care process.”
The portion of eligible patients who actually received a screening test in the mail varied across the board, from anywhere as low as 6.5 percent to as high as 68.2 percent, Coronado said. But, compared to the control group clinics, clinics that implemented to program saw a 3.4 percent increase in the number of kits completed and a 3.8 percent increase across all types of CRC screening.
Clinics that followed protocol and sent reminder letters to their eligible patients saw a 25 percent return rate, too, compared to 14 percent in inconsistent clinics and 6 percent in those who failed to send return letters altogether.
“Community health centers are very busy places with many competing priorities,” senior author Beverly Green, MD, MPH, said in the release. “Our study showed that while FIT outreach programs can be a great way to increase colorectal cancer screening rates in this underserved population, we need to identify additional strategies to support program implementation in health centers with limited resources.”