By Beverly Green, MD, MPH, associate investigator at Kaiser Permanente Washington Health Research Institute and physician at Kaiser Permanente Washington
Far too many people die needlessly from colon cancer. Most cases can be prevented by being screening regularly from age 50 to 75, but too many people don’t get the screening they need, especially those in disadvantaged groups: nonwhite ethnic groups and people living in poverty and/or without health insurance. We have done research at Kaiser Permanente Washington and Kaiser Permanente Northwest that demonstrated that mailing stool tests to our system’s own patients can improve colon cancer screening rates.
But my Kaiser Permanente Northwest colleague Dr. Gloria Coronado and I feel strongly that everyone deserves good care, so we wanted to help spread this work beyond Kaiser Permanente to people who receive care in federally qualified health centers that care for those with Medicaid or no health insurance. So we began a new research study in California, Oregon, and Washington to see if we could implement a program similar to Kaiser Permanente’s in federally subsidized clinic systems, which care for low-income and uninsured people and have low rates of screening for colorectal cancer (CRC), with only 40 percent of eligible people current for screening.
Directly mailing fecal tests to patients has been shown to be an effective strategy for increasing screening uptake. These tests can detect small amounts of blood in stool, which can be a sign of this cancer. A study done at Kaiser Permanente Washington showed that a mailed fecal test program, linked to electronic health records, increased screening uptake by 30 percent, doubling the number of people current for screening. But mailed fecal test programs have not been broadly implemented, particularly in community clinics that care for disadvantaged populations.
Trying to make it easy
Called “STOP Colon Cancer in Priority Populations in Priority Populations (STOP CRC),” the program was designed to make it easy to implement direct mailing fecal testing in federally qualified health centers. The researchers and the clinics worked together to design a screening program embedded in the electronic health record, which could be used to identify eligible adults and implement a stepwise mailed intervention involving an introductory letter, a mailed fecal kit, and a reminder letter — and training, collaborative learning, and facilitation through a practice-improvement process.
The study was large, with 26 clinics and more than 40,000 unscreened individuals included. Although the program significantly increased screening uptake, the net increase was small, with only 4 percent more individuals in the 13 intervention clinics screened compared to the 13 usual-care clinics. Some clinics were much more successful than other clinics and increased screening uptake by almost 18 percent, mainly because they mailed 70 percent of the fecal kits, compared to 7 percent in lower-performing clinics. In a separate analysis, we found that screening uptake was just as high among Spanish speakers and people with incomes below the poverty level than in groups without these potential disadvantages. These findings suggest that if a mailed program is implemented as intended, disparities in screening rates and cancer outcomes might be decreased.
STOP CRC demonstrated that mailing fecal tests directly to patients can increase CRC screening, but additional strategies may be needed for clinics that had more difficulties in completing the mailings.
We published “Mailed Colorectal Cancer Screening Outreach Program in Federally Qualified Health Centers: The STOP CRC Cluster Randomized Pragmatic Clinical Trial ” in JAMA Internal Medicine. (See bilingual poster used to promote screening in the study population.)
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