Program Components and Results From an Organized Colorectal Cancer Screening Program Using Annual Fecal Immunochemical Testing

Abstract

Background and aims: Programmatic colorectal cancer (CRC) screening increases uptake, but the design and resources utilized for such models are not well known. We characterized program components and participation at each step in a large program that used mailed fecal immunochemical testing (FIT) with opportunistic colonoscopy.

Methods: Mixed-methods with site visits and retrospective cohort analysis of 51-75-year-old adults during 2017 in the Kaiser Permanente Northern California integrated health system.

Results: Among 1,023,415 screening-eligible individuals, 405,963 (40%) were up to date with screening at baseline, and 507,401 of the 617,452 not up-to-date were mailed a FIT kit. Of the entire cohort (n = 1,023,415), 206,481 (20%) completed FIT within 28 days of mailing, another 61,644 (6%) after a robocall at week 4, and 40,438 others (4%) after a mailed reminder letter at week 6. There were over 800,000 medical record screening alerts generated and about 295,000 FIT kits distributed during patient office visits. About 100,000 FIT kits were ordered during direct-to-patient calls by medical assistants and 111,377 people (11%) completed FIT outside of the automated outreach period. Another 13,560 (1.3%) completed a colonoscopy, sigmoidoscopy, or fecal occult blood test unrelated to FIT. Cumulatively, 839,463 (82%) of those eligible were up to date with screening at the end of the year and 12,091 of 14,450 patients (83.7%) with positive FIT had diagnostic colonoscopy.

Conclusions: The >82% screening participation achieved in this program resulted from a combination of prior endoscopy (40%), large initial response to mailed FIT kits (20%), followed by smaller responses to automated reminders (10%) and personal contact (12%).

Keywords: Colorectal Cancer Screening; Fecal Immunochemical Tests; Mailed Fecal Tests.

Figure 1

Delivery of centralized, automated FIT outreach, local outreach, and local in-reach in 2017. Eligible people are identified by the Patient Reminder, Outreach Management, Population Tracking (PROMPT) system. At 56 days after the FIT kit mailing, the names of nonresponders are transferred to responsible primary care practices for local outreach. Local outreach occurs primarily within 5 weeks of transfer. All FIT completed in 2017 that were not within 91 days of a FIT mailing were assumed to be caused by local FIT in-reach.

Figure 2

Central processing and analysis of completed FIT. QC, quality control.

Figure 3

Follow-up of FIT results, stratified by normal or “negative” results ≤20 μg/mL and abnormal or “positive” results >20 μg/mL. GI, gastroenterology.