Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

Abstract

Background Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care. Methods Patients age 50–75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided. Results A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care. Conclusion Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Effectiveness of a mailed fecal immunochemical test outreach: a Medicare Advantage pilot study

“…Our prior research demonstrated that the cost to perform outreach for one individual was $23 and the cost per additional patient screened was $112; both acceptable costs on face value given the established benefit of CRC screening. 23 …”

“…Despite these limitations, mailed outreach remains cost effective even with suboptimal follow-up colonoscopy rates. 23 …”

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention–sponsored Summit

“…A microcosting and long-term modeling study from a San Francisco safetynet health system reported a cost of $23 per patient for outreach delivery and a cost of $112 per patient screened for a program that included an informational postcard, FIT kit, and reminder telephone calls. 65 Another modeling study evaluated the cost-effectiveness of extending a FIT outreach strategy on a national level. 66 The authors reported that this strategy would provide CRC screening to approximately 9.4 million people, preventing 3100 CRC-related deaths, at a cost of $277.9 million.…”

Colorectal Cancer Screening and COVID-19

“…Electronic medical records and registries can identify patients not up to date with screening, use of at-home FIT kits mailed directly to patients can be expanded, and positive tests can be followed up with automated calls and text prompts from direct patient messaging platforms—all strategies that have proven effective at increasing screening rates and follow-up. Increased utilization of FIT would triage higher-risk patients to colonoscopy, allowing endoscopy units to better manage procedure backlog volume and limit unnecessary patient exposures ( 5 ).…”