Effectiveness and Cost-effectiveness of Mailed FIT in a Safety Net Clinic Population

Abstract

BACKGROUND: Mailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its costeffectiveness is unclear. OBJECTIVE: We sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas. DESIGN: Single group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening. INTERVENTION: The program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders. MAIN MEASURES:We measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate. KEY RESULTS: Of the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing.

Understanding the role of access in Hispanic cancer screening disparities

“…Finally, we note the promise of new screening methods for improving the accessibility of screening. Mailed delivery of noninvasive fecal immunochemical testing has shown promise for not only improving screening rates, but doing so in an equitable manner, 53,54 potentially contributing to some resilience of colorectal cancer screening rates during the COVID‐19 pandemic and some decline in screening disparities by Hispanic ethnicity over the past decade 9,55,56 . Though not yet approved by the Food and Drug Administration, self‐collected human papillomavirus DNA testing has shown promise in trials and may offer the same equitable approach to improving screening uptake in the future 57 …”

Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic

“…FIT is an annual stool-based test that can be completed at home [ 37 ] and the kits have traditionally been offered to patients during in-person primary care visits. Mailed FIT outreach programs have been shown to increase CRC screening rates and to be cost-effective [ 38 – 41 ], but were not widely adopted in primary care clinics prior to the COVID-19 pandemic [ 42 ]. This public health emergency served as a catalyst for primary care clinics to adopt mailed FIT outreach as a means to continue promoting CRC screening while addressing patient hesitancy to attend in-person appointments, reducing patient risk for COVID-19 exposure and addressing the issue of postponed or missed non-urgent procedures (including screening colonoscopies) during periods of high infection rates [ 10 , 15 , 16 , 43 ].…”

Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot

“…While a growing body of work emphasizes how reminder calls or alerts for mailed FIT programs can increase completion rates and lead to cost savings overall—these tasks may be challenging for individual clinics to complete 71 . Pignone and colleagues estimate the direct costs of mailed FIT at $55‐$73 per patient screened, 72 but Medicare reimburses FIT at an average of $21 73 . Therefore, FIT reimbursement rates do not adequately cover the actual costs of mailing and promoting FIT completion by clinic‐level staff.…”