Annual Fecal Occult Blood Testing Research Articles

Projected Colorectal Cancer Incidence and Mortality Based on Observed Adherence to Colonoscopy and Sequential Stool-Based Screening.

Modeling supporting recommendations for colonoscopy and stool-based colorectal cancer (CRC) screening tests assumes 100% sequential participant adherence. The impact of observed adherence on the long-term effectiveness of screening is unknown. We evaluated the effectiveness of a program of screening colonoscopy every 10 years vs annual high-sensitivity guaiac-based fecal occult blood testing (HSgFOBT) using observed sequential adherence data. The MIcrosimulation SCreening ANalysis (MISCAN) model used observed sequential screening adherence, HSgFOBT positivity, and diagnostic colonoscopy adherence in HSgFOBT-positive individuals from the National Colonoscopy Study (single-screening colonoscopy vs ≥4 HSgFOBT sequential rounds). We compared CRC incidence and mortality over 15 years with no screening or 10 yearly screening colonoscopy vs annual HSgFOBT with 100% and differential observed adherence from the trial. Without screening, simulated incidence and mortality over 15 years were 20.9 (95% probability interval 15.8-26.9) and 6.9 (5.0-9.2) per 1,000 participants, respectively. In the case of 100% adherence, only screening colonoscopy was predicted to result in lower incidence; however, both tests lowered simulated mortality to a similar level (2.1 [1.6-2.9] for screening colonoscopy and 2.5 [1.8-3.4] for HSgFOBT). Observed adherence for screening colonoscopy (83.6%) was higher than observed sequential HSgFOBT adherence (73.1% first round; 49.1% by round 4), resulting in lower simulated incidence and mortality for screening colonoscopy (14.4 [10.8-18.5] and 2.9 [2.1-3.9], respectively) than HSgFOBT (20.8 [15.8-28.1] and 3.9 [2.9-5.4], respectively), despite a 91% adherence to diagnostic colonoscopy with FOBT positivity. The relative risk of CRC mortality for screening colonoscopy vs HSgFOBT was 0.75 (95% probability interval 0.68-0.80). Findings were similar in sensitivity analyses with alternative assumptions for repeat colonoscopy, test performance, risk, age, and projection horizon. Where sequential adherence to stool-based screening is suboptimal and colonoscopy is accessible and acceptable-as observed in the national colonoscopy study, microsimulation, comparative effectiveness, screening recommendations.

The cost-effectiveness of non-invasive stool-based colorectal cancer screening offerings from age 45 for a commercial and medicare population

AimThe United States Preventive Services Taskforce (USPSTF) recently recommended lowering the age for average-risk colorectal cancer (CRC) screening from 50 to 45 years. While initiating screening at age 45 versus 50 provides a greater opportunity for CRC early detection and prevention, the full profile of benefits, risks, and cost-effectiveness of expanding the screen-eligible population requires further evaluation.Materials and methodsThe costs and clinical outcomes for screening at age 45 for triennial multi-target stool DNA [mt-sDNA], and other non-invasive stool-based modalities (annual fecal immunochemical test [FIT] and annual fecal-occult blood test [FOBT]), were estimated using the validated CRC-AIM microsimulation model over a lifetime horizon. Test sensitivity and specificity inputs were based on 2021 USPSTF modeling analyses; adherence rates were based on published real-world data and the costs of the screening test, follow-up colonoscopies, complications, and CRC care were included. Outcomes are reported from the perspective of a United States payer as clinical, life-years gained (LYG), and incremental cost-effectiveness ratio (ICER); stool-based and follow-up colonoscopy adherence ranges were explored in one-way, probabilistic and threshold analyses.ResultsWhen compared to initiation of CRC screening at age 45 versus 50, all modalities reduced both the incidence of and mortality from CRC and increased LYG. Initiating CRC screening at age 45 was cost-effective with an ICER of $59,816 and $35,857 per quality-adjusted life year (QALY) for mt-sDNA versus FIT and FOBT, respectively. In the threshold analyses, at equivalent rates to stool-based screening, mt-sDNA was always cost-effective at a willingness-to-pay threshold of $100,000 per QALY versus FIT and FOBT.ConclusionsInitiating average-risk CRC screening at age 45 instead of age 50 increases the estimated clinical benefit by reducing disease burden while remaining cost-effective. Among stool-based screening modalities, mt-sDNA provides the most clinical benefit in a Commercial and Medicare population.

Comparison of Simulated Outcomes Between Stool- and Blood-Based Colorectal Cancer Screening Tests.

The Centers for Medicare & Medicaid Services (CMS) recommend covering blood-based tests meeting proposed minimum performance thresholds for colorectal cancer (CRC) screening. Outcomes were compared between currently available stool-based screening tests and a hypothetical blood-based test meeting CMS minimum thresholds. Using the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM), outcomes were simulated for average-risk individuals screened between ages 45 and 75 years with triennial multitarget stool DNA (mt-sDNA), annual fecal immunochemical test (FIT), and annual fecal occult blood test (FOBT). Per CMS guidance, blood-based CRC screening was modeled triennially, with 74% CRC sensitivity and 90% specificity. Although not specified by CMS, adenoma sensitivity was set between 10% and 20%. Published adenoma and CRC sensitivity and specificity were used for stool-based tests. Adherence was set at (1) 100%, (2) 30%-70%, in 10% increments, and (3) real-world rates for stool-based tests (mt-sDNA = 65.6%; FIT = 42.6%; FOBT = 34.4%). Assuming perfect adherence, a blood-based test produced ≥19 lower life-years gained (LYG) than stool-based strategies. At the best-case scenario for blood-based tests (100% adherence and 20% adenoma sensitivity), mt-sDNA at real-world adherence achieved more LYG (287.2 vs. 297.1, respectively) with 14% fewer colonoscopies. At 100% blood-based test adherence and real-world mt-sDNA and FIT adherence, the blood-based test would require advanced adenoma sensitivity of 30% to reach the LYG of mt-sDNA (297.1) and ∼15% sensitivity to reach the LYG of FIT (258.9). This model suggests that blood-based tests with CMS minimally acceptable CRC sensitivity and low advanced adenoma sensitivity will frequently yield inferior outcomes to stool-based testing across a wide range of adherence assumptions.

Does National Colorectal Cancer Screening Program Represent Good Value for Money? Results from a Return-on-Investment Model in Vietnam.

To provide important evidence for the resource allocation process in Vietnam, this research was conducted to explore the return on investment (ROI) of the national colorectal cancer (CRC) screening program. A decision tree model was designed to estimate the cost and cost savings of a national screening program (ie, providing annual fecal occult blood test [FOBT], following with colonoscopy in case of FOBT positive for the medium-risk group over 50 years old) compared to no screening scenario. This was the first attempt in estimating the ROI of a public health program in Vietnam. Although there was a wide variation due to the uncertainty of the input parameters, especially regarding the coverage of the colorectal cancer screening program in the community, the calculated ROI rates in all different cases were positive, demonstrating that the national colorectal cancer screening program brought benefits to the investment. With a modest coverage of 30% of the population over the age of 50, the corresponding ROI value was 325.4% (95%UI: 321.0; 329.9). The results of this study could be used to advocate for the implementation of a national colorectal cancer screening program in terms of the monetary benefits of investing in the program.

Real-world cost-effectiveness of stool-based colorectal cancer screening in a Medicare population

Aim Multiple screening strategies are guideline-endorsed for average-risk colorectal cancer (CRC). The impact of real-world adherence rates on the cost-effectiveness of non-invasive stool-based CRC screening strategies remains undefined. Methods This cost-effectiveness analysis from the perspective of Medicare as a primary payer used the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC–AIM) to estimate cost and clinical outcomes for triennial multi-target stool DNA (mt-sDNA), annual fecal immunochemical test (FIT) and annual fecal occult blood test (FOBT) screening strategies in a simulated cohort of US adults aged 65 years, who were assumed to either be previously unscreened or initiating screening upon entry to Medicare. Reported real-world adherence rates for initial stool-based screening and colonoscopy follow up (after a positive stool test result) were defined as 71.1% and 73.0% for mt-sDNA, 42.6% and 47.0% for FIT, and 33.4% and 47.0% for FOBT, respectively. The incremental cost-effectiveness ratio using quality-adjusted life years (QALY) was defined as the primary outcome of interest; other cost and clinical outcomes were also reported in secondary analyses. Multiple sensitivity and scenario analyses were conducted. Results When reported real-world adherence rates were included only for initial stool-based screening, mt-sDNA was cost-effective versus FIT ($62,814/QALY) and FOBT ($39,171/QALY); mt-sDNA also yielded improved clinical outcomes. When reported real-world adherence rates were included for both initial stool-based screening and follow-up colonoscopy (when indicated), mt-sDNA was increasingly cost-effective compared to FIT and FOBT ($31,725/QALY and $28,465/QALY, respectively), with further improved clinical outcomes. Limitations Results are based on real-world cross-sectional adherence rates and may vary in the context of other types of settings. Only guideline-recommended stool-based strategies were considered in this analysis. Conclusion Comparisons of the effectiveness and benefits of specific CRC screening strategies should include both test-specific performance characteristics and real-world adherence to screening tests and, when indicated, follow-up colonoscopy.

Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records.

To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel. Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program. Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models. The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence. Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.

Is annual fecal occult blood testing as effective as flexible sigmoidoscopy for colon cancer screening?

Southern Illinois University School of Medicine FMR, Springfield, IL The authors declare no conflicts of interest.

Effectiveness, benefit harm and cost effectiveness of colorectal cancer screening in Austria

BackgroundClear evidence on the benefit-harm balance and cost effectiveness of population-based screening for colorectal cancer (CRC) is missing. We aim to systematically evaluate the long-term effectiveness, harms and cost effectiveness of different organized CRC screening strategies in Austria.MethodsA decision-analytic cohort simulation model for colorectal adenoma and cancer with a lifelong time horizon was developed, calibrated to the Austrian epidemiological setting and validated against observed data. We compared four strategies: 1) No Screening, 2) FIT: annual immunochemical fecal occult blood test age 40–75 years, 3) gFOBT: annual guaiac-based fecal occult blood test age 40–75 years, and 4) COL: 10-yearly colonoscopy age 50–70 years. Predicted outcomes included: benefits expressed as life-years gained [LYG], CRC-related deaths avoided and CRC cases avoided; harms as additional complications due to colonoscopy (physical harm) and positive test results (psychological harm); and lifetime costs. Tradeoffs were expressed as incremental harm-benefit ratios (IHBR, incremental positive test results per LYG) and incremental cost-effectiveness ratios [ICER]. The perspective of the Austrian public health care system was adopted. Comprehensive sensitivity analyses were performed to assess uncertainty.ResultsThe most effective strategies were FIT and COL. gFOBT was less effective and more costly than FIT. Moving from COL to FIT results in an incremental unintended psychological harm of 16 additional positive test results to gain one life-year. COL was cost saving compared to No Screening. Moving from COL to FIT has an ICER of 15,000 EUR per LYG.ConclusionsOrganized CRC-screening with annual FIT or 10-yearly colonoscopy is most effective. The choice between these two options depends on the individual preferences and benefit-harm tradeoffs of screening candidates.

Cost-Effectiveness of Colorectal Cancer Screening Strategies—A Systematic Review

Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions. We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question2. Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening. In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.

Is the patient activation measure associated with adherence to colonoscopy after a positive fecal occult blood test result?

BackgroundColorectal cancer (CRC) is a major cause of morbidity and mortality worldwide, but these can be reduced significantly with population screening using annual fecal occult blood tests (FOBT)A positive FOBT requires timely follow-up with colonoscopy to maximize screening benefits.. Several barriers to follow-up have been identified, with patient health behaviors and choices comprising a significant part of these. The Patient Activation Measure (PAM) assesses knowledge, skills, beliefs, and confidence in managing health. Increased patient activation is related to positive health outcomes. The aim of this study is to examine the association between patient empowerment, as reflected in the PAM, and follow-up colonoscopy within 90 days of a positive FOBT result.MethodsThis case-control study included 429 patients with a positive FOBT, 174 who had a colonoscopy within 90 days, and 255 who did not.. Participants completed a PAM telephone questionnaire (Cronbach’s α = 0.785). We used both univariate and multivariate analyses to examine the effect of the PAM score as on the likelihood of undergoing colonoscopy, after adjusting for the independent variables.ResultsIn this study we did not find a significant association between PAM and adherence to colonoscopy, using both univariate and multivariate analyses (p = .334 and p = .697, whether PAM was defined as a continuous or as categorical, respectively).ConclusionsThis study was the first to examine the association between patient empowerment, as reflected in the patient activation measure, and adherence to colonoscopy after a positive FOBT. The findings did not support such an association. Further examination is required to clarify the relation between patient empowerment and activation and personal healthcare in general, and in the Israeli population in particular. Future policy should include specific, technical interventions to improve FOBT follow-up among all groups, until the patient-related barriers are better understood.Trial registrationClinicalTrials.gov Identifier: NCT02534142 https://clinicaltrials.gov/ct2/show/NCT02534142

Patterns and predictors of repeat fecal immunochemical and occult blood test screening in four large health care systems in the United States

Effectiveness of fecal occult blood test (FOBT) for colorectal cancer (CRC) screening depends on annual testing, but little is known about patterns of repeat stool-based screening within different settings. Our study's objective was to characterize screening patterns and identify factors associated with repeat screening among patients who completed an index guaiac FOBT (gFOBT) or fecal immunochemical test (FIT). We performed a multi-center retrospective cohort study among people who completed a FOBT between January 2010 and December 2011 to characterize repeat screening patterns over the subsequent 3 years. We studied at 4 large health care delivery systems in the United States. Logistic regression analyses were used to identify factors associated with repeat screening patterns. We included individuals aged 50-71 years who completed an index FOBT and had at least 3 years of follow-up. We excluded people with a history of CRC, colonoscopy within 10 years or flexible sigmoidoscopy within 5 years before the index test, or positive index stool test. Consistent screening was defined as repeat FOBT within every 15 months and inconsistent screening as repeat testing at least once during follow-up but less than consistent screening. Among 959,857 eligible patients who completed an index FIT or gFOBT, 344,103 had three years of follow-up and met inclusion criteria. Of these, 46.6% had consistent screening, 43.4% inconsistent screening, and 10% had no repeat screening during follow-up. Screening patterns varied substantially across healthcare systems, with consistent screening proportions ranging from 1 to 54.3% and no repeat screening proportions ranging from 6.9 to 42.8%. Higher consistent screening proportions were observed in health systems with screening outreach and in-reach programs, whereas the safety-net health system, which uses opportunistic clinic-based screening, had the lowest consistent screening. Consistent screening increased with older age but was less common among racial/ethnic minorities and patients with more comorbidities. Adherence with annual FOBT screening is highly variable across healthcare delivery systems. Settings with more organized screening programs performed better than those with opportunistic screening, but evidence-based interventions are needed to improve CRC screening adherence in all settings.

Koreans’ Awareness and Preventive Behaviors Regarding Colorectal Cancer Screening

Background:Koreans in the Republic of Korea had high incidence and mortality rates of colorectal cancer (CRC), late stage of CRC diagnosis, and low CRC screening. The purpose of this study was to gain a more thorough understanding of CRC awareness, preventive behaviors, and preferred strategies to improve CRC screening behaviors among Koreans.Methods:Individual interviews with 33 Koreans aged 50 and older were conducted using semi-structured, open-ended questions. All interview data were recorded and analyzed using direct content analysis.Results:To prevent CRC, all participants focused on primary prevention including healthy lifestyle more than secondary prevention such as screening. Motivators of CRC screening were (a) symptoms, (b) being scared by acquaintances with CRC, (c) being healthy for the family, (d) others’ recommendations, and (f) annual fecal occult blood test (FOBT) in the National Cancer Screening Program. Barriers to CRC screening were (a) no symptom, (b) discomfort on test procedure, (c) lack of knowledge, (d) low perceived risk of developing CRC, (e) mistrust in CRC screening tests or health care providers, (f) fear of CRC diagnosis, (g) embarrassment, and (h) colonoscopy was a follow-up test in the National Cancer Screening Program. Participants suggested preferred strategies using various information delivery methods.Conclusions:This study suggests that we should provide accurate knowledge, emphasize importance of secondary prevention, enhance motivators and decrease barriers, and use multilevel approach incorporating preferred strategies to improve CRC screening behaviors among Koreans.

Measuring Beliefs Related to Colorectal Cancer Screening Behavior among Iranian Middle-Aged and Elderly: a Psychometric Study

The annual fecal occult blood test is a very important method for colorectal cancer early detection through screening. Our aim was to assess psychometrics of instrument measuring beliefs related to fecal occult blood test uptake among Iranian middle-aged and elderly, based on the theory of planned behavior. This cross-sectional study was performed on 150 middle-aged and elderly who were randomly selected to participate voluntarily in Kermanshah, in the west of Iran. The studied constructs included attitude, subjective norms, perceived behavior control, and behavior intention. Data were analyzed with SPSS software (ver. 21.0). The mean age of the respondents was 59.1 years [SD: 6.73], in the range from 50 to 73. All of the loads of the exploratory factorial analysis were larger than 0.4. KMO was calculated as 0.756. Overall, four factors under investigation accounted for 82% of the variance in the hypothesized model. Cronbach’s alpha for the measured constructs of attitude, subjective norms, perceived behavior control, and behavior intention were 0.92, 0.88, 0.70 and 0.88, respectively. Our findings indicated the final scale to be adequately reliable and valid for measurement of these constructs for prediction of fecal occult blood test uptake among Iranian middle-aged and elderly.

Wide Under- and Over-Estimation by PCPs Regarding Bleeding and Perforation Rates of Screening Colonoscopy

Introduction: Only about 62% of patients 50 years or older get Screening for Colorectal Cancer (SCRC). We surveyed Primary Care Physicians (PCPs) who are medical school faculty to find if they know how useful or harmful colonoscopy is, the estimates of survival they give to patients if colorectal cancer is found without screening, and what they think of newer Stool Based Methods (SBMs) for SCRC. Methods: An online anonymous Google survey was sent by email to PCPs at Family Medicine (FM) and Internal Medicine residency programs at Baylor College of Medicine and to a FM residency program at Eastern Virginia Medical School. Results: Of the 42 responses received, 60% were from FM; the setting was academic in 68%; 63% had been PCPs for over 10 years; and 65% estimated that their rate of SCRC was at national average. Their most common estimates respectively for annual Fecal Occult Blood Testing (FOBT), annual Fecal Immunnochemical Test (FIT), Cologuard every 3 years and colonoscopy every 10 years were 50-75%, 75-90%, 75-90% and >90% for sensitivity for SCRC, <50%, 50-75%, 75-90%, and >90% for sensitivity for screening for advanced adenomas, and 50-75%, 50-75%, 75-90% and >90% for specificity for SCRC. Although 44% of PCPs correctly estimated that rates of perforation and bleeding in screening colonoscopy are 4 in 10,000 and 8 in 10,000, 21% PCPs estimated them to be 4 in 1000 and 8 in 1000 and 30% PCPs estimated them to be 20 in 10,000 and 40 in 10,000 respectively. Although 56% of PCPs correctly estimated 5-year survival to be 90%, 70% and 10% respectively for screen-detected (stages 1 and 2), regional (stage 3) and distant (stage 4) cancer, 37% PCPs estimated this to be 90%, 50% and 5%. 38% PCPs thought colonoscopy was the same or only slightly better than SBMs, only 52% agreed that SBM should only be done if patients decline colonoscopy, and 19% did not prefer colonoscopy for SCRC. Conclusion: The estimates of PCPs regarding sensitivity and specificity of SCRC methods were similar to data reported by the US Preventive Task Force in 2016 except that PCPs under-estimated specificity of FOBT and FIT for SCRC and over-estimated specificity of Cologuard for screening of advanced adenomas. 37% PCPs under-estimated survival in advanced cancer. Although colonoscopy is recommended as the preferred modality of screening, 19% of PCPs did not prefer it. The most significant finding was that 21% PCPs underestimated perforation and bleeding rates during screening colonoscopy by 5 times, and 31% overestimated the rates by 5 times.

Cancer Screening of Older Adults in Israel According to Life Expectancy: Cross Sectional Study.

To examine over-screening of older Israelis for colon and breast cancer. Cross sectional. Clalit Health Services (CHS), Israel's largest health maintenance organization (HMO), provides care for more than half of the country's population and operates a national age-based programs for cancer screening. All community-dwelling members aged 65 to 79 in 2014 (N=370,876). We used CHS data warehouse to evaluate cancer screening during 2014. Life expectancy (LE) was estimated using the validated Schonberg index. Almost one-quarter (23.1%; 15.6% of adults aged 65-74, 42.7% of adults aged 75-79) of the study population had an estimated LE of less than 10years. Annual fecal occult blood test and biannual mammography rates among adults aged 65 to 74 with a LE of 10years or longer were 37.1% and 70.0%, respectively. Rates dropped after age 75 (4.0%, 19.5%) and to a lesser extent with a LE of less than 10years (31.6%, 56.4%). Prostate-specific antigen testing is not part of the national screening program, and the proportion of people tested (42.6%), did not vary similarly with age of 75 and older (43.2%) or LE of less than 10years (38.1%). The cancer screening inclusion criteria of the national referral system have a strong effect on receipt of screening; LE considerations are less influential. Some method of estimating LE could be incorporated into algorithms to improve individualized cancer screening to reduce over- and underscreening of older adults.

Abstract IA14: Decision analysis for colorectal cancer screening recommendations

Abstract IA14: Decision analysis for colorectal cancer screening recommendations

Third Annual Fecal Occult Blood Testing in Community Health Clinics.

Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention. Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT. Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy. All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

Mo1715 Comparison of Resources and Adherence for Annual Fecal Occult Blood Test versus Colonoscopy (CRAFT) Study: Analysis from the National Colonoscopy Study

Mo1715 Comparison of Resources and Adherence for Annual Fecal Occult Blood Test versus Colonoscopy (CRAFT) Study: Analysis from the National Colonoscopy Study

Final Results of a 3-Year Literacy-Informed Intervention to Promote Annual Fecal Occult Blood Test Screening.

This three arm study was designed to make CRC screening with FOBTs more accessible, understandable and actionable for patients cared for in predominantly rural Federally Qualified Health Centers. Patients in an enhanced version of usual care received an annual CRC recommendation and FOBT kit; those in the education arm additionally received brief literacy and culturally appropriate education and those in the nurse arm received the education by a nurse manager who followed up by telephone. Baseline FOBT rates in this population were 3%. We evaluated if FOBT rates could be sustained over 3years. A three-arm, quasi-experimental evaluation was conducted among eight clinics in Louisiana. Screening efforts included: (1) enhanced usual care, (2) literacy-informed education of patients, and (3) education plus nurse support. Overall, 961 average-risk patients, ages 50-85, eligible for routine CRC screenings were recruited. The primary outcome was completing three annual FOBT tests. Of 961 patients enrolled, 381 (39.6%) participants did not complete a single FOBT, 60.4% completed at least one FOBT of which 318 (33.1%) completed only one, 162 (16.9%) completed two and 100 (10.4%) completed three FOBTs over the 3-year period (the primary study outcome). The primary outcome, return of three FOBT kits over the 3-year period, was achieved by 4.7% in enhanced care, 11.4% in education and 13.6% in the nurse arm (p=0.005). Overall 3-year FOBT screening rates were not sustained with any of the three interventions, despite reports of promising interim results at years 1 and 2. New strategies for sustaining FOBT screening over several years must be developed.

Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers.

We previously found that a multifaceted outreach intervention achieved 82 % annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT). This study assessed adherence to FOBT after a second outreach. We followed 225 patients in community health centers in Chicago, Illinois, who were randomized to the intervention group. Our primary analysis focused on 124 patients who completed FOBT during the first outreach and were due again for annual FOBT; 90% were Latino, 87% preferred to speak Spanish, and 77% were uninsured. Second outreach consisted of (1) a mailed reminder letter, a free fecal immunochemical test (FIT) with postage-paid return envelope, (2) automated phone and text messages, (3) automated reminders 2 weeks later if the FIT was not returned, and (4) a telephone call after 3 months. Our main outcome was completion of FIT within 6 months of the due date. We also analyzed the proportion of the original 225 patients who were fully screened for CRC over the 2-year study period. A total of 88.7% of patients completed a FIT within 6 months of their second outreach. Over the 2 years since the first outreach, 71.6% of the 225 patients assigned to the intervention group were fully up to date on CRC screening, another 11.1% had been screened suboptimally, and 17.3% were inadequately screened or not screened. It is possible to achieve high rates of CRC screening over a 2-year period for vulnerable populations using outreach with FIT as a primary strategy.