Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities

Abstract

IMPORTANCEColorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups.OBJECTIVETo examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates.DESIGN, SETTING, AND PARTICIPANTSThis parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled.INTERVENTIONSInterventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion).MAIN OUTCOMES AND MEASURESThe primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures.RESULTSA total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%–15.1%) in the mail and monetary group and 7.1% (95% CI, −0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%–64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, −0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03).CONCLUSIONS AND RELEVANCEFinancial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups.TRIAL REGISTRATIONClinicalTrials.gov identifier:

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

“…The literature in this area is evolving, as currently available randomized trials have had mixed results. [74][75][76][77] Future research is likely to clarify whether and how financial incentives may augment FIT completion in response to mailed outreach. We did not include a formal key question focused on the cost-effectiveness of patient navigation for abnormal FIT follow-up; however, evidence regarding the costeffectiveness of patient navigation across the cancer continuum for multiple cancers recently has been summarized.…”

Patients’ Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis

“…8,14,15 In contrast to these findings, the quantitative analysis of our trial found that both a guaranteed incentive of $10 and probabilistic incentive of a 1 in 10 chance of winning $50 were effective at increasing FIT testing, but not colonoscopy. 16 Our qualitative findings help explain the difference found in this trial, in that participants often had strong feelings about colonoscopy based on their own or their loved ones’ prior experiences. Thus, they stated that small financial incentives would not compel them to complete a colonoscopy.…”

“…These qualitative findings provide context to the results from our parent, quantitative study, in which financial incentives were found to significantly increase FIT uptake among individuals who reported making decisions based on how easy they were to do as well as among patients with high opt-out defensive processing (e.g., “if I feel healthy I don’t go the doctor”). 16…”

“…We conducted semi-structured telephone interviews with a subset of participants who were part of a 3-arm randomized controlled trial to test 2 types of financial incentives for completion of CRCS within 6 months. Trial details are described elsewhere 16 (ClinicalTrials.gov: NCT00697047).…”

What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%?

“…20 A mailed FIT plus a $10 reward for screening completion, or mailed FIT plus entry into a lottery for a 1 in 10 chance of receiving $50 on screening completion achieved a higher proportion of FIT return compared with a mailed FIT alone. 21 However, when colonoscopy adherence was included with FIT, overall CRC screening was not significantly improved with either financial incentive. Another study reported that sending an email with the phone number to schedule a colonoscopy with a $100 incentive to undergo colonoscopy increased screening compared with the email alone, although the absolute increase in screening was less than 5%.…”