Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort

Abstract

Importance: Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known.

Objective: To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach.

Design, setting, and participants: This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023.

Exposures: Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT.

Main outcomes and measures: The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test.

Results: This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process.

Conclusions and relevance: In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.

Figure 1.. Kaiser Permanente Northern California Colorectal Cancer Screening Program Process via Automated and Personalized Components and Corresponding Measures of Screening Completion

FIT indicates fecal immunochemical test.

Figure 2.. Colorectal Cancer (CRC) Screening Completion via Automated and Personalized Components by Race and Ethnicity Among Kaiser Permanente Northern California Members in 2019

Up to date indicates the proportion of members not eligible for a fecal immunochemical test (FIT) that year because, as of January 1, they had completed a colonoscopy within the last 9 years or sigmoidoscopy within the last 5 years. Automated indicates the proportion of members who completed a FIT within 56 days of FIT kit mailing; they received a prescreening notification postcard by mail (7 days prior), FIT kit by mail, robocall (28 days after kit mailing), and postcard reminder (42 days after kit mailing). Personalized indicates the proportion of members who completed a FIT, colonoscopy, or sigmoidoscopy outside of the 56-day window after FIT kit mailing, presumably linked to a telephone call, electronic message, in-clinic reminder, or contact with a health care professional.