Implementing an enhanced mailed FIT program to improve CRC screening at a federally qualified health center: experiences of patients and staff

Colorectal cancer (CRC) is a leading cause of cancer death in the USA. Screening programs in federally qualified health centers (FQHCs) are essential to reducing CRC-related mortality and morbidity among underserved populations. Centralized, population-based mailed fecal immunochemical test (FIT) programs can improve CRC screening rates, but barriers to implementation remain. We qualitatively explored barriers and facilitators to implementation of a mailed FIT program at a large, urban FQHC that employed advance notification "primers" (live calls and texts) and automated reminders. We interviewed 25 patients and 45 FQHC staff by telephone about their experience with the program. Interviews were transcribed, coded, and content analyzed using NVivo.12. Patients and staff found advance notifications conveyed through live phone calls or text messages to be acceptable and motivational for FIT completion. Live phone primers were helpful in addressing patients' questions and misconceptions about screening, particularly for patients new to screening. Advance notifications sent by text were considered timely and useful in preparing patients for receipt of the FIT. Barriers to implementation included lack of receipt of primers, reminders, or the mailed FIT itself due to inaccurate patient contact information within the FQHC medical record; lack of systems for documenting mailed FIT outreach to coordinate with clinical care; and lack of local caller identification for primers and reminders. Our findings demonstrate that an enhanced mailed FIT program using primers and reminders was acceptable. Our findings can help other FQHCs implement and optimize their mailed FIT programs.

Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.

Predictors of Colorectal Cancer Knowledge and Screening Among Asian Americans Aged 50-75 years old

Colorectal cancer, the second leading cause of mortality in the USA, can be prevented with colorectal cancer screening. However, many people who should receive the screening do not get screened. To learn more, this study estimated the prevalence of up-to-date colorectal cancer (CRC) screening and examined the relationship between CRC knowledge and screening compliance among Asian Americans living in the Baltimore-Washington Metropolitan area. The study included a cross-sectional sample of 274 Chinese, Korean, and Vietnamese Americans aged 50-75 years old. Participants completed a questionnaire regarding CRC knowledge in either their preferred native language or in English, and data were collected in person. The percentage of total participants with up-to-date overall CRC screening was 52.9%. Up-to-date fecal occult blood test (FOBT) screening was 15.0% and colonoscopy was 50.7%. The average CRC knowledge score was 6.10 out of 9 (SD = 2.91). Those with high education, high English proficiency, married, health insurance, and good physical health ratings had higher CRC knowledge. In multivariate analysis, CRC knowledge was significantly correlated with increasing up-to-date colonoscopy (aOR = 2.74, 1.13-6.64). Having health insurance (aOR = 4.40, 2.33-8.32) was another predictor of up-to-date colonoscopy. These findings suggest that CRC knowledge is a strong predictor of CRC screening behavior in Asian American populations. Lack of CRC screening knowledge still remains an important barrier to screening, and increased public awareness is necessary to achieve greater screening compliance.