Automated Phone and Mail Population Outreach to Promote Colorectal Cancer 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.

METHODS

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