Bundling Interventions to Promote CRC, SDOH Screenings Found Feasible, Effective

Encouraging patients who require timely screenings to get one for colorectal cancer (CRC) or social determinants of health (SDOH) can ultimately improve the frequency of screening in these populations, according to a study published in the Journal of General Internal Medicine.

Cancer is the leading cause of death in residents of Massachusetts, with inequities between incidence and outcomes existing between demographics—diagnosis of CRC at distant stage more often occurs in Black non-Hispanic residents compared with White residents. Additionally, there has been an increased need for screening services since the pandemic. Having federal qualified health centers (FQHCs) bundle screenings with other health services could be an incentive for people to attend their routine screenings and help better meet the needs of complex populations while minimizing resource use.

The study aimed to bundle offers for CRC screening through fecal immunochemical testing (FIT) and SDOH screening in Massachusetts to test if patients with an average risk of CRC would complete their screening.

Doctor holding figure of intestines | Image credit: mi_viri - stock.adobe.com

The bundled screening intervention was conducted in 8-week steps at 4 FQHCs located in Massachusetts. The 8-week steps were implemented between December 2020 and November 2021. Patients were included if they were aged between 50 and 75 years, had a visit that was Uniform Data System–qualified within the previous 2 years, had an average risk of CRC, and were overdue for their screening of CRC. People who were at average risk of CRC were patients who had no known family history of CRC or any other related colorectal issues.

The intervention was implemented at the FQHCs in 2 phases, which included initial implementation in the first 4 months and the adaptation of the intervention to address reach and effectiveness in the last 4 months. The researchers measured the overall number of screenings that occurred for both FIT and SDOH following the intervention and any other screenings happening for eligible patients.

There were 2 FQHCs that used approaches based on population health, which included reaching out to patients by phone. Of these, groups with screening rates below the average were targeted by 1 FQHC and groups that had previously screened with FIT were prioritized in the other FQHC. The other 2 FQHCs added bundled screenings to community health worker activities, whereas the other included the intervention in the workflows of pre-visit planning in patients overdue for screenings. Outreach was often slowed or paused due to employee turnover and deployment during the pandemic.

There were 34,588 patients who could be contacted for screening offers during the time of the study; the median age was 61 (IQR, 55-67) years and 54% were female. The participants included 47% White individuals, 20% non-Hispanic Black individuals, 11% Hispanic or Latino individuals, and 10% Asian individuals.

Screening was completed by 3194 unique patients, whereas screening for SDOH was completed by 16,613 unique patients. Patients were more than twice as likely to undergo screening for CRC during the implementation steps compared with the control steps (OR, 2.41), which is about a 1.4 percentage point increase (95% CI, 0.3%-2.3%).

Higher odds of screening for CRC were also seen in the groups who were targeted in the first phase of implementation when compared with the control steps (OR, 2.88). The second-phase adaptation steps did not produce a difference compared with the first implementation phase steps. Odds of SDOH screenings were also not significantly different in implementations steps compared with the control steps overall or in specialized groups.

There were some limitations to this study. Major events like the pandemic introduced vulnerability in the design of the study. External partners for endoscopy and laboratory services are relied on for FQHCs, which means the data relied on the electronic health record from these external sources. Outreach to solely FIT or SDOH was not compared with the bundled screening. This study was also not blinded. Some practices may not be able to feasibly make all of the calls done in this study. Sustainability was also not measured.

The researchers concluded that screenings for SDOH did not decrease when bundling it with FIT screening outreach. This could improve efficiency in time spent on outreach programs to improve screening in complex populations.

Reference

Kruse GR, Percac-Lima S, Barber-Dubois M, et al. Bundling colorectal cancer screening outreach with screening for social risk in federally qualified health centers: a stepped-wedge implementation-effectiveness study. J Gen Intern Med. Published online February 8, 2024. doi:10.1007/s11606-024-08654-5