A Randomized Controlled Trial of Financial Incentives to Increase Colorectal Cancer Screening: Presidential Poster Award

Abstract

Introduction: Mailing fecal immunochemical test (FIT) kits to patients’ homes has been shown to boost colorectal cancer (CRC) screening rates, but response rates remain limited, and organized programs typically require repeated outreach attempts. Behavioral economics has shown that offering salient financial incentives to patients may increase participation in preventive health. We compare the impact of different financial incentives for mailed FIT outreach. Methods: This is a four-arm pragmatic randomized controlled trial conducted between December 2015 and February 2018 at urban primary care practices at an academic health system (clinicaltrials.gov NCT02594150). Patients aged 50-75 were included who had an established primary care provider, at least 2 visits in the prior two years, and were eligible for CRC screening. Through automated data extraction and chart review, patients were excluded if they were up-to-date with screening or had a history of CRC, polyps, inflammatory bowel disease, symptoms of gastrointestinal bleeding, a family history of CRC, or advanced illness that may compromise life expectancy. Eligible patients received a letter from their primary care provider that included a mailed FIT kit and instructions for use. They were randomized in a 1:1:1:1 ratio to receive: (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) a conditional lottery with a 1-in-10 chance of winning $100 after FIT completion. The primary outcome was FIT completion within 2 months of initial outreach, and the secondary outcome was FIT completion within 6 months. Results: 897 patients were included in the intent-to-treat analysis with a median age (IQR) of 56 (52-63) years and average household income of $40,817; 56% were female and 69% were black (Table 1). The overall completion rate across all arms was 23.4% at 2 months and 28.5% at 6 months. No incentive arm was statistically superior to the arm without incentive (Table 2). The completion rate also did not differ across arms at 6 months. We found no difference in completion across arms based on sex or race. Conclusion: Mailed FIT was effective at increasing CRC screening rates in this population, but different forms of financial incentives of the same expected value ($10) did not increase FIT completion rates. The incentive value may be too small or financial incentives may not be effective in this context.250_A Figure 1. Demographic characteristics by group assignment250_B Figure 2. Response to outreach and completion of FIT