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Original Investigation | Health Care Reform

Comparative Effectiveness of a Multifaceted Intervention to Improve Adherence to Annual Colorectal Cancer Screening in Community Health Centers:  A Randomized Clinical Trial

David W. Baker, MD, MPH1,2,3; Tiffany Brown, MPH1,2; David R. Buchanan, MD, MS1,4; Jordan Weil, BA4; Kate Balsley, MPH4; Lauren Ranalli, MPH4; Ji Young Lee, MS1; Kenzie A. Cameron, PhD, MPH1,2,3; M. Rosario Ferreira, MD5; Quinn Stephens, BA1; Shira N. Goldman, MPH1,2; Alred Rademaker, PhD3,6; Michael S. Wolf, PhD1,2,3
[+] Author Affiliations
1Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
2Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
3Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
4Erie Family Health Center, Chicago, Illinois
5Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
6Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Intern Med. 2014;174(8):1235-1241. doi:10.1001/jamainternmed.2014.2352.
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Importance  Colorectal cancer (CRC) screening rates are lower among Latinos and people living in poverty. Fecal occult blood testing (FOBT) is one recommended screening modality that may overcome cost and access barriers. However, the ability of FOBT to reduce CRC mortality depends on high rates of adherence to annual screening.

Objective  To determine whether a multifaceted intervention increases adherence to annual FOBT compared with usual care.

Design, Setting, and Participants  Patient-level randomized controlled trial conducted in a network of community health centers. Included were 450 patients who had previously completed a home FOBT from March 2011 through February 2012 and had a negative test result: 72% of participants were women; 87% were Latino; 83% stated that Spanish was their preferred language; and 77% were uninsured.

Interventions  Usual care at participating health centers included computerized reminders, standing orders for medical assistants to give patients home fecal immunochemical tests (FIT), and clinician feedback on CRC screening rates. The intervention group also received (1) a mailed reminder letter, a free FIT with low-literacy instructions, and a postage-paid return envelope; (2) an automated telephone and text message reminding them that they were due for screening and that a FIT was being mailed to them; (3) an automated telephone and text reminder 2 weeks later for those who did not return the FIT; and (4) personal telephone outreach by a CRC screening navigator after 3 months.

Main Outcomes and Measures  Completion of FOBT within 6 months of the date the patient was due for annual screening.

Results  Intervention patients were much more likely than those in usual care to complete FOBT (82.2% vs 37.3%; P < .001). Of the 185 intervention patients completing screening, 10.2% completed prior to their due date (intervention was not given), 39.6% within 2 weeks (after initial intervention), 24.0% within 2 to 13 weeks (after automated call/text reminder), and 8.4% between 13 and 26 weeks (after personal call).

Conclusions and Relevance  This intervention greatly increased adherence to annual CRC screening; most screenings were achieved without personal calls. It is possible to improve annual CRC screening for vulnerable populations with relatively low-cost strategies that are facilitated by health information technologies.

Trial Registration  clinicaltrials.gov Identifier: NCT01453894

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Trial Flow Diagram

FIT indicates fecal immunochemical test.

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