Abstract
Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%. To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program. In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis. Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group). The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate. The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004). Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems. ClinicalTrials.gov Identifier: NCT05115916.
Highlights
Implementation of an electronic patient portal primer message in a mailed fecal immunochemical test (FIT) outreach program led to a significant increase in Colorectal cancer (CRC) screening and improvement in
After adjusting for patient demographic characteristics, we found that the intervention group had significantly increased odds of completing CRC screening compared with the control group
We found that the addition of an electronic primer message sent through patients’ electronic health record (EHR) portal significantly increased the CRC screening completion rate by 5.5% for patients in our mailed FIT outreach program
Summary
The fecal immunochemical test (FIT) is an effective screening modality for CRC.[9,10,11,12,13] the US Preventive Services Task Force does indicate individuals complete screening via FIT, fecal occult blood test, stool DNA test, colonoscopy, computed tomography colonography, and flexible sigmoidoscopy, it does not recommend any one of the screening modality over another.[7] The US Multi-Society Task Force, recommended FIT and colonoscopy as first-line screening modalities for CRC in 2017.14 This guidance has practical implications because FIT can be mailed to patients and completed at home, reaching patients who do not have access to colonoscopy or who have reservations about more invasive screening modalities. In light of decreasing CRC screening rates and patient hesitancy for in-person health visits during the COVID-19 pandemic, multiple medical and professional societies have emphasized the use of a mailed FIT outreach program.[15,16,17]
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