Which factors affect completion of stool-based screening and what is their impact?
Having available funding for EHR system optimization increases EHR system automation,[[11]] which allows clinics to generate patient reminders and perform patient tracking.[[3, 13, 16, 17]] Both strategies increase the number of stool-based screens completed.[[90, 146, 277]] An automated EHR system also allows a clinic to track completed FIT kits, which increases a clinic’s capacity to implement mailed FIT kits as an intervention.[[1, 3]]
Other factors that increase a clinic’s capacity to implement mailed FIT kits include the availability of contactless return options for FIT kits and support from clinic leadership for the intervention.[[2, 8, 13, 27]] Offering mailed FIT kits increases the number of stool-based tests completed, especially for patients who reside in rural or sparsely populated areas or who prefer at-home testing.[[24, 158-161]]
One challenge that clinics prioritizing the use of FIT kits reported facing was having providers who strongly preferred recommending colonoscopy over stool-based testing.[[1, 7, 147, 293]] To mitigate this challenge, clinic champions helped increase provider and staff prioritization of CRC screening and stool-based screening in general.[[19]] Clinic champions also helped garner support for mailed FIT kits from clinic leadership.[[5]]
There is a small balancing loop between the number of patients due for CRC screening and the number of stool-based screens completed. The relationships were highlighted during COVID but are true across the board.
Cited references for this diagram
Challenges included insufficient capacity in existing systems to track distribution and return of FIT kits and reluctance from clinicians to support use of a screening tool other than colonoscopy.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Third, support from clinic leadership is essential for continuing CRC screening promotion efforts and exploring innovative solutions to emergent challenges, especially when faced with limited clinic resources and staff capacity.[[42, 59]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Consistent with previous studies,[[42]] we found that mailed FIT outreach is challenging without adequate staff capacity and systems for tracking FIT kit dissemination and return and follow-up to ensure patients with positive test results complete a timely colonoscopy. Developing stand-alone tracking databases and/or increasing use of automated systems embedded within clinic EMRs may improve FIT kit tracking and facilitate dissemination of patient reminders to complete and return their kits.[[42]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
In these cases, participants noted that clinic champions were essential to fostering clinician and leadership buy-in for using mailed FIT kits as well as supporting improved tracking systems that would reduce burden on staff.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Participants also reported reluctance among some clinicians to embrace increased use of FIT kits vs. continued promotion of screening colonoscopies, even temporarily[[44–46]] as a challenge.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Interview respondents discussed increasing use of mailed FIT or other stool-based tests over referrals for screening colonoscopy; using mailed FIT kits, some with labels filled in or self-addressed envelopes to facilitate return; and offering contactless FIT drop-off options.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Using an iterative approach to qualitative data collection and analysis, our study yielded three validated themes that describe how clinics modified CRC screening promotion efforts during the COVID-19 pandemic: (1) offering mailed FIT kits for CRC screening with mail or drop-off return, (2) increasing the use of patient education and engagement strategies, and (3) increasing the use of or improving automated patient messaging systems.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
During interviews, respondents discussed benefiting from increasing use of automated patient messaging systems while responding to COVID-19 to disseminate CRC screening reminders and establishing or streamlining FIT kit standing orders to reduce burden on heavily strained clinic staff.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
A majority of focus group respondents agreed that increased reliance on automated patient messaging systems to reach patients was a modification implemented by their clinic partners to promote CRC screening during COVID-19.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
For the reluctance to support use of CRC screening tests other than colonoscopy, recipients described the importance of support from clinic champions and framing of messaging to clinic staff to get them on board with using mailed FIT kits to reach more patients, particularly during a time when clinics were facing high rates of staff turnover and patients were not able or willing to come into the clinic.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
This public health emergency served as a catalyst for primary care clinics to adopt mailed FIT outreach as a means to continue promoting CRC screening while addressing patient hesitancy to attend in-person appointments, reducing patient risk for COVID-19 exposure and addressing the issue of postponed or missed non-urgent procedures (including screening colonoscopies) during periods of high infection rates.[[10, 15, 16, 43]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Most respondents agreed that their clinic partners increased use of mailed FIT kits with mail or drop off return options and focused on patient education and engagement to promote CRC screening in response to COVID-19.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Continued and improved patient tracking will be essential to supporting screening and rescreening adherence.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
Our assessment of a group of clinics across the nation uncovered positive implementation practices among those implementing mailed fecal testing as well as opportunities for improvement. These opportunities include increasing the proportion of CHCs/FQHCs 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 positive tests can obtain colonoscopy; and increasing sustainability planning and support.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Clinics that used colonoscopy as their primary screening test were significantly less likely to implement mailed fecal testing. Providers’ belief in the effectiveness of FIT may influence their willingness to emphasize its use (Thompson et al., 2019).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Offering mailed fecal testing may be particularly beneficial in rural areas where health care accessibility can be a significant barrier to screening (Davis et al., 2018).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
As COVID-19 continues to impede in-person healthcare visits, mailed fecal testing offers an evidence-based alternative to in-person screening tests, and represent an especially promising approach to reduce CRC screening disparities.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
The COVID-19 pandemic has caused decreases for breast, cervical, and CRC screening, and mailed fecal testing may offer a means to help maintain screening during public health emergencies (Fisher-Borne et al., 2021) and support screening among those who prefer at-home testing even outside of such emergencies.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
As COVID-19 and future pandemics may continue to make in-person healthcare visits more difficult for some time, mailed fecal testing remains an important opportunity to reach populations disproportionately impacted by low CRC screening and poor CRC outcomes (Issaka & Somsouk, 2020; O’Connor et al., 2020).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Because funding for public health programs may be limited or finite, the process of integrating vertical equity is a valuable tool for providing information to target funds where they may be needed most.
Joseph KT, Rice K, Li C. Integrating Equity in a Public Health Funding Strategy. J Public Health Manag Pract. 2016 Jan-Feb;22 Suppl 1(Suppl 1):S68-76. doi: 10.1097/PHH.0000000000000346. PMID: 26599032; PMCID: PMC5737674.
Like the CRCSDP sites, the CRCCP sites partner with health systems, private and public insurers, and FQHCs and encourage the increased use of client and provider reminders at the organizational level to maximize population reach.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
CRCSDP programs encountered problems with patient and provider perceptions that FOBT is an inferior test, limiting its acceptance as a viable alternative to colonoscopy.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
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