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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.
RESULTS

We identified 63,478 men and women aged 50 to 74 years who were members of KPWA in 2011-2012 and received a FIT order for inclusion in our final study population. Among those with a FIT order, about half (54%) of the sample population returned a FIT to the laboratory within 1 year of the order date. In our sample population, nearly 60% of FIT order recipients were female and approximately 75% were white (Table 1). There was an even distribution of subjects in each age group. Among those with a recorded BMI (71.0%), nearly 40% were obese. Approximately 25% of our patients had a CCI score of 1 or greater.

The proportion of patients who returned a completed FIT varied by patient race/ethnicity, age, and BMI (Table 1). Among patients who completed a FIT, the median return time of the FIT was 13 days. There was little variation in the median time to completion by patient characteristics (Table 2), with a few exceptions. On average, members of Asian race/ethnicity completed a FIT 4 days earlier than white members. Older adults (70-74 years) returned a FIT 4 days earlier than those in the youngest categories (50-54 and 55-59 years). The substantial difference between the mean and median across groups, along with the difference between the median and third quartile, suggests a heavily right-skewed distribution of time to return (Table 2). The Kaplan-Meier curves display the time-to-completion experience comparing member groups, namely age groups, race/ethnicity, BMI, and CCI score (Figure).

In multivariate adjusted models (Table 3), patient factors statistically significantly associated with decrease in FIT completion included being a woman, younger age compared with oldest age (70-74 years), being overweight, CCI score (≥1), and, more specifically, diagnosis with diabetes, chronic pulmonary disease, and myocardial infarction. Compared with white race/ethnicity, Asian, black, and Hispanic race/ethnicity were statistically significantly associated with improvements in FIT completion (Asian: adjusted HR, 1.43; 95% CI, 1.38-1.48; black: adjusted HR, 1.13; 95% CI, 1.07-1.19; Hispanic: adjusted HR, 1.10; 95% CI, 1.04-1.16).

A sensitivity analysis in which time was censored at 6 months, rather than 1 year, showed near-identical results, with very small attenuations of HRs (data not shown).

DISCUSSION

In our study, adults with the intention to return a FIT kit did so within 2 to 3 weeks from order date; otherwise, the FIT kit was more likely to not be returned. These results provide important evidence on the timing of return, which has not been previously reported and can support outreach interventions to improve FIT return. Further, we identify some differences by patient characteristics that indicate which patients might need additional support for stool-based CRC screening.

Our observation that women who receive a FIT order are less likely to return a completed FIT compared with men is consistent with previous study findings, suggesting gender-specific factors that influence completion of CRC screening, such as prior breast cancer screening.33 Women have been shown to be less likely to participate in CRC screening, possibly due to the additional need to participate in screening programs for breast and cervical cancers.24,34

We saw a consistent linear trend with improved rates of FIT return with increasing age. Interventions aimed at improving initiation of CRC screening through referrals, tracking of patient outcomes, and mitigating patient barriers have been shown to be effective at increasing CRC screening among adults younger than 65 years and may help to attenuate the observed differences in FIT completion by age.35 Being insured by Medicare remained significantly associated with return in the adjusted model accounting for age, which is appropriate with increasing risk of CRC.

Across all variables, missing data were associated with slow return and overall incompletion of FITs. The attenuated HR in the adjusted models compared with that in the unadjusted models was likely a result of correlated missingness across variables. Although there are a variety of reasons for which members could have missing capture of data variables, the most probable case is that it reflects overall healthcare engagement. Thus, the observation that those patients who are missing data for a given variable less commonly returned their FIT or did so over more time is not surprising. For cases in which missing data are a reflection of lower healthcare engagement, additional support to understand and overcome barriers for such patients may prove to be challenging but could result in the greatest return on investment.

Higher BMI has been associated with less engagement with healthy behaviors, particularly in women,36 and it is associated with reduced participation in CRC screening compared with patients with normal BMI.35,37 CRC is particularly relevant to overweight and obese adults, as increased weight is a strong risk factor for CRC.38 In a subanalysis using a Cox proportional hazards model, we did see a marginally significant interaction (P = .04) between gender and obesity on time to FIT completion (results not shown). The presence of comorbidities overall was associated with a slight reduction in completion of a FIT. We did not specifically evaluate interactions between patient characteristics, but important subgroups, such as overweight women with diabetes, could be potential target populations for screening follow-up.


 
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