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The American Journal of Managed Care April 2019
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Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
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Time to Fecal Immunochemical Test Completion for Colorectal Cancer

Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
Targeted interventions by patient characteristics to improve fecal immunochemical test completion could reduce disparities in colorectal cancer screening and improve overall compliance with screening recommendations.

Objectives: Fecal immunochemical tests (FITs) can efficiently screen for colorectal cancer (CRC), but little is known on the timing to their completion. We investigate the time to return of a FIT following an order and describe patient characteristics associated with FIT return.

Study Design: Retrospective cohort study.

Methods: We identified 63,478 members of Kaiser Permanente Washington, aged 50 to 74 years, who received a FIT order from 2011 through 2012. Patient characteristics were ascertained through administrative and electronic health record data sources. We compared time from FIT order to return by patient characteristics using Kaplan-Meier and Cox regression methods.

Results: About half (53.7%) of members completed a FIT. Median time from order to return was 13 days (mean, 44.5 days; interquartile range, 6-42 days). There was higher completion of FITs among Asian patients (hazard ratio [HR], 1.43; 95% CI, 1.38-1.48), black patients (HR, 1.13; 95% CI, 1.08-1.19), and Hispanic patients (HR, 1.10; 95% CI, 1.04-1.16) compared with white patients; among patients with recent CRC testing (vs no testing in past 2 years; HR, 1.90; 95% CI, 1.86-1.95); and among patients with Medicare insurance (vs commercial; HR, 1.30; 95% CI, 1.24-1.37). Factors associated with decreased FIT completion included younger age (50-54 years vs 70-74 years; HR, 0.87; 95% CI, 0.82-0.92), obesity (vs normal body mass index; HR, 0.88; 95% CI, 0.86-0.91), and higher Charlson Comorbidity Index score (≥3 vs 0; HR, 0.82; 95% CI, 0.79-0.87).

Conclusions: Time to return of FIT varies by patient characteristics. We observed greater FIT completion among people of color, suggesting that racial disparities in CRC may not be due to patient completion of the test after an order is received.

Am J Manag Care. 2019;25(4):174-180
Takeaway Points
  • Fecal immunochemical tests (FITs) are efficient and cost-effective means of colorectal cancer screening if completed in a timely manner.
  • About half (53.7%) of patients in our study sample returned their annual FIT within 1 year of clinician order.
  • Among completed FITs, more than half were returned within 2 weeks from the time of clinician order.
  • We did not observe disparities in FIT return by race, but younger age and higher body mass index were significantly associated with lower FIT completion.
The US Preventive Services Task Force (USPSTF) recommends several colorectal cancer (CRC) screening strategies for average-risk adults aged 50 to 75 years.1 These screening options received the highest grade by the USPSTF, reflecting the strength of evidence that shows high certainty of substantial benefit from CRC screening.2-4

One option is an annual high-sensitivity guaiac-based fecal occult blood test (gFOBT); another option is an annual fecal immunochemical test (FIT).1 FITs are consistently a preferred screening tool among patients at average risk for CRC.5 Compared with colonoscopy, FIT use is less invasive, is less expensive, and carries less risk of adverse events, giving it the potential to translate into increased CRC screening participation by underscreened groups and a lower overall cost to screening programs.6-9 As stool-based screening tests, FITs are an improvement over previous stool tests due to a higher sensitivity in detection of CRC and reduced burden on patients (ie, FIT requires only 1 stool test, whereas gFOBT requires 3).10-17 However, no previous research has investigated the overall completion of FIT orders in a community-based setting and assessed the time to completion for this modality.

The process of cancer screening completion consists of several steps, from identification of the eligible population to completion of the test and follow-up of testing results.18 Understanding where failures in the screening process occur (ie, uptake, longitudinal adherence, follow-up of positive tests) is critical for improving the process. Previous research has highlighted the deficits in overall compliance with CRC screening recommendations without identifying failures at specific steps in the screening process.19 In a previous study among members of Kaiser Permanente Washington (KPWA), we noted the prominent use of stool tests (either gFOBT or FIT) among first-time screenees, with 72% of study participants using a stool-based test for their first CRC screening after age 50 years.19 Further, the retrospective cohort showed that important patient characteristics, including higher body mass index (BMI) and female gender, were associated with lower uptake of any CRC screening tests when considering all screening methods combined. Other studies have shown disparities in general CRC screening for all modalities in socioeconomically disadvantaged populations.20 Such findings encompass 2 critical aspects in the cancer care continuum: (1) the administration of screening options to patients by clinicians as part of regular primary care, resulting in CRC screening order; and (2) the follow-through of screening on the part of the patient once given a screening order.21

Here we focus on understanding factors associated with time to completion of FIT orders, as this step is required for FIT use to be effective. Building on previous findings regarding the acceptability and performance of FIT use,22 we characterized patterns of return of a FIT following clinician order and identified patient characteristics associated with lower rates of FIT screening completion within an integrated healthcare delivery system.


Study Population and Setting

The Population-based Research to Optimize the Screening Process (PROSPR) consortium was created by the National Cancer Institute to allow multiple study sites to coordinate research for the improvement of screening practices for breast, cervical, and colorectal cancers in community settings.23 One aim of the consortium is to understand screening processes and potential failures and successes of the screening process to improve overall patient health. The collection of data throughout the screening process can further inform comparative effectiveness research for CRC screening.21 KPWA, a mixed-model health insurance and care delivery system in Washington state, is a member of the PROSPR consortium. KPWA data were extracted in 2016 from the Virtual Data Warehouse (VDW), which houses patient information in separate content areas: enrollment/demographics, utilization, laboratory, pharmacy, census, tumor registry, vital signs, and social history (tobacco, alcohol, sexual activity, etc).24

The study protocol received institutional review board approval through the KPWA Human Subjects Division for waiver of consent to enroll participants, link study data, and perform statistical analyses.

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