Automated Phone and Mail Population Outreach to Promote Colorectal Cancer Screening

Automated phone and mail population outreach resulted in an almost 4-fold increase in the rate of screening for colorectal cancer even without an office visit.
Published Online: July 12, 2012
Karin L. Kempe, MD, MPH; Susan M. Shetterly, MS; Eric K. France, MD, MSPH; and Theodore R. Levin, MD
Objectives: To evaluate a population outreach program to promote screening for colorectal cancer (CRC) among average-risk insured men and women.

Study Design: In 2008, 58,440 Kaiser Permanente Colorado members unscreened for CRC received an interactive voice response (IVR) call followed by mailed fecal immunochemical test (FIT), or colonoscopy if requested. We used a quasi-experimental design with staged implementation, in which a random subset of eligible members was selected each week to receive the intervention. This design allowed the entire group to ultimately receive the intervention.

Methods: Survival models summarized timespecific comparisons of screening behaviors for members who received immediate outreach compared with those who had not yet received it.

Results: A total of 26,003 (45%) of the unscreened population completed screening, predominately due to the mailed kits. The unadjusted hazard ratio (HR) for the outreach effect on screening completion was 4.08 (95% confi dence interval: 3.93-4.25) and adjusted HR was 3.75 (3.60-3.91). Lower levels of screening were seen in African Americans (HR 0.83; 0.77-0.90) and Hispanics (HR 0.84; 0.80-0.88) compared with whites, and in smokers (HR 0.77; 0.74-0.80) compared with nonsmokers. The outreach had greater impact among those without a primary care (HR 4.5 vs 3.0, P <.0001) or specialty care (HR 5.2 vs 3.5, P <.0001) visit compared with those with 1 or more visits.

Conclusions: The rate of colorectal cancer screening in members after mailed FIT with IVR was almost 4 times higher than usual care, particularly in those without an office visit. Targeted approaches are needed for groups at risk for not screening.

(Am J Manag Care. 2012;18(7):370-378)
We used a quasi-experimental design to evaluate a large outreach program in an insured population to promote colorectal cancer screening by stool testing or colonoscopy.

  •  Unscreened members received an educational automated call and mailed immunochemical stool test.

  •  Forty-five percent of unscreened members completed screening within the study period.

  •  The outreach had even greater impact among members without a primary care visit (HR 4.5 vs 3.0, P <.0001) or specialty care visit (HR 5.2 vs 3.5, P <.0001) compared with those with 1 or more visits.

  •  Targeted approaches are additionally needed for groups at risk for not screening.
Mortality from colorectal cancer (CRC) is declining, yet it remains the second-leading cause of cancer death in the United States and the leading cause among nonsmokers. Screening of average-risk men and women aged 50 to 75 years is recommended by the US Preventive Services Task Force (USPSTF) as well as specialty organizations because early detection of high-risk adenomas and cancers is associated with decreased CRC incidence and mortality.1-7 Screening with fecal occult blood testing and sigmoidoscopy have been shown in clinical trials to decrease CRC mortality. 6-8 Evidence of effectiveness for screening colonoscopy remains indirect,9 though 1 recent case-control study did show a signifi cant benefit.10 Screening rates for CRC lag behind rates for breast and cervical cancer and vary by socioeconomic status, insured status, and ethnicity.7,11

The age-adjusted prevalence for screening (fecal occult blood test [FOBT] within a year or lower endoscopy within 10 years) in 2010 was 65.4% for adults aged 50 to 75 years, up from 52.3% in 2002.12 The ability to screen large numbers of individuals for CRC in a cost-effective manner is critical as states and large health plans assume more responsibility for aging populations. The fecal immunochemical test (FIT) offers increased sensitivity for cancer and specifi city compared with standard guaiac FOBTs. Thus FIT is a non-invasive low-cost option which may achieve higher levels of population acceptance than primary colonoscopy. 3,13-19 The ability to process large numbers of samples by machine facilitates mass screening. This paper describes our quasi-experimental evaluation of a large outreach program using an interactive voice response (IVR) call followed by mailed FIT, or colonoscopy if requested, to increase screening among average-risk men and women in a nonprofit integrated care delivery system.


Study Setting and Data Sources

Kaiser Permanente Colorado (KPCO) is a not-for-profit integrated care delivery system with over 530,000 members. KPCO uses an electronic medical record (EMR) and multiple population registries for prevention and chronic disease management programs. The CRC registry includes family history, diagnoses, procedures, and pathology dating back to 1994. For this study, the registry was used to determine eligibility in April 2008 for CRC screening in members who had continuous enrollment until April 2009, the end of the study period. The study protocol was approved by the Institutional Review Board and Research Review Committees of KPCO. The need for individual signed consent was waived.

Outreach Protocol

In fall 2007, KPCO replaced the 3 sample guaiac FOBTs with the 1 sample FIT from Polymedco (Cortland Manor, New York). From April through mid-September 2008, a systematic outreach program targeted all unscreened average-risk men and women at a rate of 3000 IVR calls a week (Figure 1). The call lasted approximately 5 minutes and included options for education about screening modalities. Members could clarify risk status and, if eligible, request a mailed FIT kit as well as rank their perception of barriers to screening. The registry was updated with new information regarding high-risk status, and the member’s provider was notifi ed for colonoscopy referral if requested. Average-risk members who completed the call and requested stool testing were mailed a kit within 2 weeks. Kits included an invitational letter with information about stool testing, an FIT kit with instructions, and a prepaid return envelope. A section in Spanish gave a phone number to call for assistance in Spanish. Members who did not complete the IVR call were mailed the FIT kit 30 days later. If the kit was not returned, a reminder letter was sent at 4 weeks. Members with negative FIT results were notified by mail; positive results were sent electronically through the medical record to the primary care provider for referral. Members with positive studies who did not complete diagnostic evaluation received a reminder letter at 8 weeks followed by a certifi ed letter at 16 weeks. The program sent yearly FIT tests on the anniversary date of initial testing for members who chose to screen by FIT and remained eligible.

Both the IVR and outreach letter also offered colonoscopy as a screening option. Members were informed that not all cancers are found by stool testing and that colonoscopy would be required if their FIT test was positive. Members who chose colonoscopy for screening were asked to contact their provider for a referral and the outreach program notifi ed the provider through the EMR.

Usual Care

Efforts to increase screening began before 2008 and included provider and staff education, new promotional materials for members, panel screening reports, and quality incentive programs. The CRC registry prompted in-reach alerts printed on individual check-in sheets in primary care visits for all ageand risk-eligible members, stating “colorectal screening may be due” and providing a phone number for members to report prior screening or risk status. This in-reach alert continued until there was documentation of screening refusal, a completed FIT, or colonoscopy pathology.

Participant Selection for Outreach

A summary of study exclusions and the flow of the outreach for FIT testing is shown in Figure 1. Initial exclusions included high-risk status, removal from the registry by personal physician due to comorbidities, or evidence of completed screening. High-risk status included personal history of CRC or polyps, family history (first-degree relative) of CRC, infl ammatory bowel disease, and genetic syndromes. Average-risk members were assumed to be unscreened if they did not have a completed FOBT or FIT within 12 months or a colonoscopy within 10 years. Members who had had barium enema or fl exible sigmoidoscopy within 5 years were eligible for FIT outreach, as the combination of FIT with either was judged to improve screening effectiveness.2 The CRC registry tracked members according to their risk status and most recent screening modality. All average-risk members who were unscreened in April 2008 and were continuously enrolled until April 2009 were used for the analysis reported here (N = 58,440).

Study Design and Statistical Analysis

We used a quasi-experimental design with staged implementation, in which a random subset of eligible members was selected each week to receive the intervention. This design allowed the entire group to ultimately receive the intervention, while not exceeding the capacity of providers and systems during any single time period. The timing of outreach was randomized by medical record number. Survival models summarized time-specifi c comparisons of screening behaviors for members, comparing exposed and unexposed person-time, with each individual contributing a variable amount to the immediate to the delayed intervention control groups. This analytic

strategy isolated the effect of the outreach from the effects of usual care received by all members during the study period. While all members received the outreach between April and September 2008, the follow-up period extended an additional 6 months until April 2009. All members eligible at the start of outreach were included and analyzed by intention to treat.

The analysis was done in 2010 and used SAS 9.13 (SAS Institute, Cary, North Carolina). The primary outcome was a 2-category variable: screened by FIT or colonoscopy versus remaining unscreened April 2008 through April 2009. Analysis variables included age, gender, race/ethnicity, smoking status, body mass index (BMI), enrollment in a chronic disease registry, and visit history within the past year. Cox proportional hazards models estimated the time to screening completion using the time of the IVR call, which initiated the outreach, as a time-varying covariate.20 In addition to main effects, interaction terms examined whether the outreach effectiveness varied across race/ethnic subgroups and by evidence of having had a visit in primary care, obstetrics/gynecology (Ob/Gyn), or specialty care during the past year.

We also conducted secondary univariate analyses to compare characteristics of those choosing FIT versus colonoscopy during the study period. To evaluate sustainability, a descriptive analysis identifi ed members who completed FIT screening after the initial outreach, were still enrolled and eligible on their year 2 anniversary date, and completed a second FIT.


Participant Characteristics

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