. Author manuscript; available in PMC: 2014 Dec 16.
Published in final edited form as:J Rural Health. 2013 Oct 25;30(3):322–332. doi:
10.1111/jrh.12052 Abstract PurposeDistance from health care facilities can be a barrier to colorectal cancer (CRC) screening, especially for colonoscopy. Alternatively, an improved at-home stool-based screening tool, the Fecal Immunochemical Test (FIT), requires only a single sample and has a better sensitivity-specificity balance compared to traditional guaiac fecal occult blood tests. Our objective was to determine if FITs mailed to asymptomatic, average-risk patients overdue for screening resulted in higher screening rates versus mailing educational materials alone or no intervention (ie, usual care).
MethodsVeterans ages 51–64, asymptomatic, at average risk for CRC, overdue for screening and in a VA catchment area covering a large rural population were randomly assigned to 3 groups: 1) Education only (Ed) group: mailed CRC educational materials and a survey of screening history and preferences (N=499); 2) FIT group: mailed the FIT, plus educational materials and survey (N=500); 3) Usual Care (UC) group: received no mailings (N=500).
FindingsAt 6 months post-intervention, 21% of the FIT group had received CRC screening by any method compared to 6% of the Ed group (and 6% of the UC group) (P < .0001). Of the 105 respondents from the FIT group, 71 (68%) were eligible to take the FIT. Of those, 64 (90%) completed the FIT and 8 (12%) tested positive.
ConclusionsThis low-intensity intervention of mailing FITs to average risk patients overdue for screening resulted in a significantly higher screening rate than educational materials alone or usual care, and may be of particular interest in rural areas.
Keywords: colorectal cancer screening, fecal immunochemical test, access to care, health services research, program evaluation
Colorectal cancer (CRC) is the third-leading cause of cancer-related deaths in the US, with a lifetime risk of approximately 5% in the general population.1 The majority of people who develop CRC have no major risk factors such as family history or inflammatory bowel disease.1,2 Since most CRC arises from pre-cancerous polyps or adenomas, population screening approaches focused on early detection and removal of these polyps can significantly decrease incidence.3 Risk of CRC increases with age; 90% of new cases occur in those over age 50.1 Screening approaches therefore typically target individuals who are 50 years or older.
CRC is particularly relevant to the Veterans Administration (VA), given that veterans over 45 years old make up over 80% of the total veteran population.4 VA guidelines recommend screening beginning at age 50, unless the presence of high-risk conditions warrant earlier screening. VA screening options include annual fecal occult blood test (FOBT), flexible sigmoidoscopy or double-contrast barium enema (DCBE) every 5 years, or colonoscopy every 10 years for average risk veterans and should take into consideration patients’ preferences and clinical factors. While overall CRC screening rates are high among VA users (80%)5 compared to the non-VA population (63%),6 1 in 5 VA users remain unscreened. Previous reports have suggested transportation problems (eg, lack of a driver), difficulty following pre-procedural instructions (eg, colonoscopy preparation), rural residence, and longer drive times to the nearest medical facility as potential barriers to screening, particularly colonoscopy.7–12
Of the 8.3 million veterans enrolled in the VA, approximately 3.4 million (41%) live in rural areas.13 Rural veterans are more likely to live farther from VA facilities and face longer drive times to access VA care; 21% of enrollees live more than 60 minutes from the nearest VA community-based outpatient clinics and 42% live more than 90 minutes from the nearest VA Medical Center (VAMC).14 Colorectal cancer screening services may be challenging for rural veterans because colonoscopy is only performed in VAMCs, leaving FOBT as the only option available in VA outpatient clinics.
FOBTs are often referred to as “at home tests” because they are typically sent home with the patient and returned by mail, which makes them ideal for patients who face distance barriers to receiving more invasive testing such as colonoscopy. Furthermore, previous studies have illustrated that more people prefer to take non-invasive, home-based, CRC screening than colonoscopy.15–18 Guaiac-based FOBT (gFOBT) is a convenient, low-cost, and non-invasive screening option, but it has limitations which can impact compliance (eg, 3 samples are required) and cause false positives (eg, certain foods and medications must be avoided prior to testing). The Fecal Immunochemical Test (FIT), a type of FOBT that detects globin rather than peroxidase activity, has recently been approved for use in the VA, but it has not yet been widely adopted throughout the VA. Advantages of FIT, in comparison to gFOBT, are that only one sample is required, results are not affected by diet or medications, and FIT has a better sensitivity/specificity balance.19–21 Studies have also shown that completion rates for FIT are significantly greater than those for gFOBT.22,23
Studies that have involved mailing FITs to subjects have employed multiple steps to improve response rates, such as introductory automated phone calls offering the FIT,23 or an initial mailing with a post card to return if subjects are interested in participating and a phone call to confirm eligibility.22 These methods used by large health systems are ideal, but not always feasible in smaller, rural health practices that want to implement quality improvement (QI) initiatives to improve CRC screening. Despite the size and national scope of the VA, programs are often implemented and tested on a local or regional basis before being considered for widespread national implementation. Furthermore, not all VA Health Care Systems or private sector facilities/clinics have the staffing or funding to develop mechanisms for patient contact and follow-up, particularly those in rural areas. The objective of this study was to test whether a simple one-step mailing of a FIT to veterans’ homes accompanied by educational materials resulted in improved screening rates in an average risk, asymptomatic population overdue for screening compared to 2 other groups: 1) a group receiving education materials only and 2) a usual care group (no intervention).
METHODS ParticipantsRegular users of VA primary care services, defined as having 2 or more primary care visits in the prior 13 months in the Iowa City VA Health Care System, were identified using the Veterans Integrated Service Network (VISN) 23 Clinical Data Warehouse. Only regular users were included to reduce potential biases that may result by including veterans with only occasional VA use.16 The sample included patients aged 51–64, excluding those over age 65 due to their likelihood of using non-VA services covered by Medicare.
Only those overdue for screening were included in this study. Veterans were excluded if they were up-to-date on screening (ie, colonoscopy in past 10 years, flexible sigmoidoscopy or double contrast barium enema (DCBE) in past 5 years, FOBT in past 13 months) according to VA records. Subjects were also excluded if they were experiencing symptoms potentially related to colorectal cancer (eg, rectal bleeding, anemia, anorexia/abnormal weight loss) warranting colonoscopy, or had a medical or family history that would require more frequent surveillance with colonoscopy (eg, personal or family history of CRC, polyps, inflammatory bowel disease). While recent guidelines suggest some patients with positive family histories may still be considered “average risk,”24,25 we did not have sufficient information on the medical histories of subjects’ family members to adequately stratify by risk, nor did we want to take the chance that a potentially false-negative FIT result could provide false reassurance to higher-risk veterans who should have colonoscopy. Previously developed International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) criteria were applied to exclude those with symptoms and/or positive medical histories.26
In order to include as many women as possible to allow for examination of gender differences in the intervention groups, women were oversampled such that approximately 90% of women veterans overdue for screening were included in the intervention groups. A Random Sequence Generator27 was used to randomize assignment of 500 men and women to each of the intervention groups: the education plus FIT (FIT) group or the education only (Ed) group. In addition, 500 veterans who were not assigned to either FIT or Ed group were randomly selected to serve as a usual care (UC) comparison group. Figure 1 displays a diagram of the number of veterans included/excluded per study criteria.
Figure 1.Sampling Flowchart
The VA catchment area targeted in this study includes a large number of rural veterans, and it was selected because many of these rural veterans face substantial driving distances to their nearest VA Medical Center. To keep the intervention simple and administratively non-burdensome, urban veterans were also included in the study population and were used as a comparison group. Rurality was defined according to the VA Urban/Rural/Highly Rural Classification, in which urban areas include those with census tracts belonging to Urbanized Areas, highly rural areas include counties with average population density < 7 residents per square mile, and rural areas include everything not classified as urban or highly rural. 28
InterventionIn April 2011, all veterans assigned to the FIT or Ed groups were mailed a packet containing: 1) a letter explaining the study, 2) educational materials from the Centers for Disease Control and Prevention’s Screen for Life program, 3) consent and HIPAA forms, 4) eligibility screen, 5) brief survey, and 6) postage-paid, self-addressed envelope to return completed materials. In addition, veterans assigned to the FIT group received a Polymedco OC FIT-CHEK® (Polymedco, Inc., Cortlandt Manor, New York) kit with instructions and a postage-paid, self-addressed envelope to return the test directly to the laboratory in the VA Medical Center. Veterans in the UC group received no mailings from the study team; however, it is important to note that the VA employs a clinical reminder system to prompt primary care providers to assess need for CRC screening during visits. At the time of intervention, the percentage of CRC screening clinical reminders that were resolved was 71.6%; reminders for patients who have refused CRC screening can be considered “resolved” for up to 6 months.29
FIT group participants with positive FIT results were contacted by a study physician, a note was placed in their electronic medical record, and their primary care provider was notified. The study physician discussed appropriate follow-up and facilitated appointments with VA gastroenterology specialists when appropriate. All participants were mailed a thank you letter documenting FIT results, and for positive results, physician follow-up recommendations.
MeasuresSix months after the mailing, information was extracted from the VISN 23 Clinical Data Warehouse about screening tests received by all who were mailed study packets. In addition, screening test information for the UC group was extracted for the same 6-month period. Analysis of historical controls was done entirely retrospectively via administrative records, and no patient contact was initiated; thus the requirement for patient consent was waived for this group by the Institutional Review Board and local VA Research and Development Committee.
One year after the mailing, individual electronic medical records (including clinical notes and pathology and procedure reports) of those with positive FIT results were reviewed by a study physician to determine outcomes and ensure appropriate follow-up. A second chart review was performed by the study coordinator to ensure completeness of information abstracted.
Survey InstrumentThe mailed survey began with an eligibility screening tool developed for use in previous studies of CRC screening among non-veterans.11,30 Screening questions assessed whether subjects had blood in their stools, a change in bowel habits, thin/pencil-like stools, or great difficulty passing stools in the past 2 months, personal history of inflammatory bowel disease, colon polyps, CRC, or family history of CRC, adenomatous polyposis, or hereditary non-polyposis colon cancer. If respondents answered “yes” to any questions, they were instructed to stop, return the survey, and were subsequently contacted by a study team physician; appropriate referrals to care were made. Those who answered “no” to all eligibility questions were instructed to continue.11,30,31 Remaining questions assessed demographics (eg, current health, education, marital status, health care coverage, and if they had a non-VA primary care provider), history of colonoscopies, gFOBTs, and FITs, and reasons why a colonoscopy or at-home test (ie, gFOBT or FIT) were not taken, as applicable.
AnalysisMeans and frequencies were computed for demographic variables for the full sample (n=1,499) by group (Ed, FIT, UC) based on administrative data available for all subjects, and between the Ed and FIT groups based on survey data from eligible subjects. Comparisons among all 3 study groups used Analysis of Variance (ANOVAs) with Tukey’s multiple comparison tests for continuous variables and chi-square tests for categorical variables. Differences between eligible respondents from the Ed and FIT groups were identified with Student’s t-tests for continuous variables and chi-square tests for categorical variables or Fisher’s Exact Test for small cell sizes. The primary outcome of interest was receipt of screening within 6 months following the mailing for all 3 study groups. Screening rates were calculated for each study group for the full sample and for eligible respondents only in the Ed and FIT groups. Additional analyses examined screening rates by gender and rurality. Reasons cited for not having sought colonoscopy or at-home tests in the past were summarized for all eligible survey respondents, and differences between study groups were examined. The study was approved by the local University-based Institutional Review Board and the VA Research and Development Committee. All analyses were conducted using SAS® statistical software version 9.1 (SAS Institute Inc., Cary, North Carolina).
RESULTSAs shown in Figure 1, the final study population included 499 participants in the Ed group, 500 in the FIT group, and 500 in the UC group. Table 1 displays demographic characteristics for all sampled veterans, regardless of participation status. While there was a statistically significant difference in average age of subjects among the 3 study groups, the actual difference was less than 1.4 years. Ed and FIT groups had a smaller proportion of males compared to the UC group due to oversampling of women for the intervention groups, but all groups were predominantly male. There were no significant differences in rural residence or presence of a service-connected disability.
Table 1.Demographic Comparisons by Group for Full Sample and for Eligible Respondents Only.
Variable FIT Education Usual Care P value Full Sample % (n)* n=500 n=499 n=500 Age, mean (SD) 59.1 (4.3) 58.7 (4.3) 60.1 (4.0) < .001** Male 87% (435) 84% (421) 99% (493) < .001** Rural or Highly Rurala 50% (249) 51% (252) 51% (256) .92 Service Connected Disabilityb 37% (185) 39% (196) 43% (214) .17 All Respondents n=105 n=69 Eligible 67% (71) 59% (41) NA .76 Eligible Respondents Completing Survey n=60 n=41 Age, mean (SD) 60.1 (4.4) 58.9 (4.2) -- .19 Male 87% (52) 83% (34) -- .60 Rural or Highly Rurala 42% (25) 56% (23) -- .15 Service Connected Disabilityb 43% (26) 32% (13) -- .24 Good Current Healthc 75% (45) 73% (30) -- .84 White 95% (57) 95% (39) -- 1.00† Some college education or mored 58% (35) 71% (29) -- .20 Lives alone 32% (19) 32% (13) -- 1.00 Married or has a partnere 60% (36) 59% (24) -- .88 Has someone to take him/her to health care appointments 93% (56) 98% (39) -- .65† Other health care coverage in past year -- Private individual plan 7% (4) 15% (6) -- .31† Private employer-sponsored plan 30% (18) 34% (14) -- .66 Military-related plan (eg, 5% (3) 7% (3) -- .68† Tricare/CHAMPUS, CHAMPVA) Medicaid 3% (2) 2% (1) -- 1.00† Medicare 8% (5) 5% (2) -- .70† Sees both VA & non-VA primary care providers 29% (17) 54% (22) -- .01 Full SampleThe primary outcome, overall CRC screening rate during the 6 months following the intervention, was retrospectively calculated for all veterans assigned to 1 of the 3 study groups and examined separately for the full sample and for only those meeting eligibility criteria. Among the overall study population, the FIT group had a significantly higher rate of CRC screening (21%) compared to either the Ed (6%) or UC (6%) groups (P < .0001 for both comparisons). Of note, 7 ineligible subjects returned a FIT despite instructions not to do so. In sensitivity analyses excluding these subjects, and assuming no screening would have been performed for them otherwise, the FIT group still had a significantly greater screening compared to Ed and UC groups (19%, 6%, 6%, respectively; P < .001).
Table 2 displays the initial type of CRC screening received by group following the mailing date. The percentage of veterans receiving colonoscopy and gFOBT was similar across groups. Rate of CRC screening (any method) was stratified by rural vs urban residence and females vs males (Table 3). No statistically significant differences were detected between genders or between rural/urban groups. Within each strata, the FIT group had a significantly greater rate of screening compared to the Ed and UC groups (P < .001).
Table 2.Method of Colorectal Cancer Screening Within 6 Months of Mailing Intervention by Study Group for Full Sample and for Eligible Respondents Only.
Screening Type* FITColorectal Screening Rates (any method) by Study Group, Rurality and Gender for the Full Sample and for Eligible Respondents Only.
FIT Education Usual Care FIT Education Usual Care By Rurality* Rural Urban Full Sample, n 249 252 256 250 245 244 Total Screened, % (n) 23% (57) 5% (13) 5% (14) 18% (45) 6% (15) 6% (14) Eligible Respondents, n 28 23 -- 36 18 -- Total Screened, % (n) 93% (26) 9% (2) 89% (32) 0% (0) By Gender* Female Male Full Sample, n 65 78 7 435 421 493 Total Screened, % (n) 26% (17) 6% (5) 14% (1) 20% (86) 5% (23) 5% (27) Eligible Respondents, n 9 7 -- 56 34 -- Total Screened, % (n) 100% (9) 0% (0) 89% (50) 6% (2)Table 4 illustrates the CRC screening test results for the full sample (includes the 7 ineligible subjects who took the FIT). While the majority of subjects in each group receiving an initial colonoscopy had no polyps or hyperplastic polyps only, approximately one-third to one-half had tubular or tubulovillous adenomas detected, which have potential to grow into cancerous lesions. Among all those with positive FITs (n=10) or FOBTs (n=2), 9 underwent follow-up colonoscopy; just over half had no polyps detected and one-third had tubular or tubulovillous adenomas.
Table 4.Results of Colorectal Cancer Screening Tests Received by the Full Sample During the 6-Month Period Following Mailing Intervention.
FITAmong the FIT group, 105 (21%) returned a consent and eligibility screen/survey. As illustrated in Figure 2, 34 (32%) of responders were ineligible to take the FIT due to personal/family medical history or current symptoms and were referred for appropriate care. Of the remaining 71 subjects eligible to take the FIT, 64 (90%) completed the test of which 56 (88%) were negative and 8 (12%) were positive. Of those with positive results, 6 received a colonoscopy, 3 of which had polyps removed (all 3 had tubular adenomas removed, 2 had hyperplastic polyps removed, and 1 had tubulovillous adenomas removed). The remaining 2 patients’ providers advised against colonoscopy due to terminal conditions (ie, chronic lymphocytic leukemia and metastatic lung cancer).
Figure 2.FIT Group Screening Rates
* Study team physician called all ineligible subjects to discuss their personal/family medical history or current symptoms and arrange for follow-up as appropriate; a note was also entered into the electronic medical record. Seven of these 34 subjects returned a FIT (2 with potential symptoms and 5 with personal/family histories that may warrant surveillance with colonoscopy) despite instructions not to do so.
When comparing screening by any method between the eligible respondents in the FIT and Ed groups within 6 months following the intervention (Table 2), the FIT group had a substantially higher rate of screening compared to the Ed group (92% vs 2%, respectively; P < .0001). Similar to the results of the overall analysis, there were no significant differences between study groups in proportions taking other CRC screening tests or in screening rates by rurality or gender (Table 3).
The Ed group had a significantly lower survey participation rate compared to the FIT group, as 74 subjects (15%) returned a consent and eligibility screen/survey compared to 21% of the FIT group (P = .01). There were no differences in response rates between urban and rural veterans. Of the 74 Ed group respondents, 41 (55%) met eligibility criteria, with the remainder reporting current symptoms or medical history warranting colonoscopy.
Of eligible respondents, 88% of the FIT group and 100% of the Ed group completed and returned the survey. There were no significant differences between the 2 groups in demographics, perceived health status, other health care coverage or prior CRC screening recommendations received from their providers. However, the Ed group was significantly more likely to report having both VA and non-VA primary care providers compared to the FIT group (55% vs 29%, respectively; P = .01).
Those who did not have colonoscopy in the past 10 years were asked about reasons for not having had one, and those who did not take an at-home test in the past year were asked about reasons for not taking one. With one notable exception, there were no significant differences found between the Ed and FIT groups, so group rates of agreement were combined (Table 5). The exception was that those in the Ed group were more likely to report that they preferred a colonoscopy to an at-home test compared to those in the FIT group (30% vs 6%, P = .005). The most frequently reported reasons for not having colonoscopy included concerns about pain (39%), not recommended by health care provider (37%), confusion about screening options (35%), and preference for at-home testing (34%). The overwhelming reason for not having at-home testing was that it was not recommended by their health care provider (62%).
Table 5.Reasons Endorsed by Eligible Respondents* for Not Having Sought Colonoscopy or At-Home Tests (gFOBT/FIT).
Did not seek a Colonoscopya Did not take an At-Home Testb Reasons for not having test N Responses N (%)Endorsing Each Itemc N Responses N (%)Endorsing Each Itemc Asked in relation to both colonoscopy & at-home tests Colorectal cancer screening options are confusing 40 14 (42%) 82 14 (17%) Screening is too embarrassing 41 10 (26%) 83 11 (13%) My health care provider did not recommend it 41 15 (26%) 85 53 (62%) I was afraid 34 9 (24%) 81 4 (5%) I did not know how to prepare for the test 41 8 (21%) 82 5 (6%) I was too busy 41 8 (18%) 81 9 (11%) I am very low risk for colorectal cancer 41 7 (15%) 81 18 (22%) It takes too much time 41 6 (12%) 82 1 (1%) The VA Medical Center is too far 40 5 (12%) 83 9 (11%) I had another type of screening 40 5 (4%) 83 46 (55%) Asked only in relation to colonoscopy I thought it would be painful 41 16 (41%) -- -- I prefer to take an a-home test 41 14 (35%) -- -- I did not have transportation 41 7 (18%) -- -- The screening is too difficult to schedule 41 5 (12%) -- -- Asked only in relation to at-home tests I prefer to take a colonoscopyd -- -- 81 13 (16%) DISCUSSIONThis low-intensity intervention of mailing FITs to patients identified as overdue for screening resulted in a three-fold higher rate of screening compared to the Ed and UC groups; mailing education materials was no better than usual care. When examining only those who were asymptomatic and average risk according to the screening tool, the FIT group had a substantially higher rate of screening than the Ed group. Of note, almost one-third of those in the Ed group who responded to the survey indicated that they preferred a colonoscopy to an at-home test, whereas only 6% of FIT group responders indicated they preferred a colonoscopy. It is possible that receiving the FIT and having the ability to examine it first-hand may convince people that it is an acceptable alternative to colonoscopy.
A higher than anticipated one-third of veterans overdue for screening were not eligible to take the FIT due to recently experienced potential symptoms or a medical/family history warranting diagnostic follow-up or surveillance, thus needing colonoscopy rather than FIT. These patients were referred to gastroenterology for appropriate screening and clinical follow-up, and highlight the need for programs like the one described in this report to remind and engage patients to receive care for previously unrecognized high-risk history or symptoms.
It is difficult to compare the overall FIT return rate with other studies due to varying eligibility and recruitment protocols and because our study included only those under age 65, who have been shown to have lower FIT return rates than those over age 65.23,30 In a previous study of veterans due for screening, 24% of those invited via postcard to complete an at-home test agreed to participate; 27% were ineligible and 66% of eligible subjects returned the FIT. When considering the total number receiving invitation letters, the overall FIT completion rate was approximately 7%, slightly less than our overall completion rate of 13%.22
Among non-veteran populations, a study mailing FITs to primary care patients due for screening achieved a 25% FIT completion rate after a single mailing, which only increased to 26% after a reminder mailing; subjects were not required to sign an informed consent document and the recruitment letter was issued by the subjects’ own provider.32 Levy et al30 mailed recruitment invitations to primary care patients without prior knowledge of their CRC screening status, and offered subjects $20 to complete a questionnaire. Responses were received from 24% of subjects, of whom 37% were eligible; 47% of eligible subjects returned the FIT. They therefore had a higher overall response rate related to the survey, but a lower FIT return rate among those who were eligible.
Other intervention studies have shown the effectiveness of reminder phone calls, although studies specifically related to mailing FITs or gFOBTs to patients’ homes have yielded conflicting results regarding their benefit.30,33–35 Large systems such as Kaiser Permanente have employed automated phone calls to determine up-front willingness to take the FIT.23 While this approach would certainly be an ideal future enhancement, the purpose of this study was to evaluate the impact of a single mailing to determine if the lowest-intensity intervention that could be most feasibly and quickly implemented into routine practice would result in improved screening rates.
Several limitations require consideration when interpreting this study. The study sample was limited to a mostly male veteran population under age 65 who use the VA for health care services, and it therefore may not generalize to other populations. However, the VA does represent a health care system that takes longitudinal responsibility for patients’ health like an Accountable Care Organization, and it could be considered a model for integrated care. Also, the data did not capture instances of screening performed outside the VA. We restricted our population to those who were regular VA users under 65 to reduce the likelihood of outside CRC screening, but it is certainly possible that these veterans received services outside the VA. Given our survey response rate of 18%, responses may not be representative of the total sample; however, increasing response rates in a population overdue for screening (ie, non-compliant) may be challenging regardless of outreach methods.
Another limitation is that a formal cost-effectiveness analysis was not completed. However, we estimate the costs of mailing the 500 FIT kits plus the postage to return them to the laboratory was approximately $5,000. In contrast, the cost of treating one patient in the first year after a diagnosis of Stage III CRC has been estimated at $41,796.36 Given the subsequent rate of screening in the FIT group was triple that of the Ed or UC groups, it is highly likely that a single mailing approach would be cost-effective for practices that do not have the funds or resources to incorporate introductory or reminder phone calls. A priority in future studies will be to determine if the cost of the unused FIT supplies in a one-step mailing process is greater than the costs associated with the resources required to conduct introductory phone calls (live vs automated) or multiple mailings that would limit FIT supplies to those confirmed to be interested and eligible to take the test.
ConclusionsIn conclusion, mailing FITs and educational materials to the homes of patients overdue for screening resulted in significantly higher CRC screening rates than mailing educational materials alone or usual care. This low-intensity intervention that transcends distance barriers could be incorporated into practices of small rural and remote clinics, and into the proactive approaches being adopted by the newly implemented VA patient-centered medical homes. This population overdue for screening reported concerns about colonoscopy being too painful and expressed preferences for at-home tests, which is consistent with interim results from a large randomized trial demonstrating higher likelihood of participation among the FIT group compared to the colonoscopy group.18 Unfortunately, this population also frequently reported that at-home tests were not offered to them. The positive FIT results that occurred in 12% of FIT participants may have been the motivating factor that caused most to follow through with getting a colonoscopy, which they may have otherwise avoided. In addition, this intervention identified a number of people at high risk for CRC due to current symptoms or personal/family history, and made them aware that they needed to seek diagnostic or surveillance services.
The VA system is a prime testing ground for this type of intervention because of the extensive information available via electronic health records, access to colonoscopy for those with positive results, and the hub-and-spoke model that allows VA Medical Centers to process FIT results for outlying clinics. Other health care systems that share these characteristics or can develop alternative models may also find this approach to be a low-intensity means of increasing screening rates, particularly among those who live great distances from colonoscopy services or have transportation issues.
AcknowledgmentsFunding Source: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Central Region (VRHRC-CR), and the VA Health Services Research and Development (HSR&D) Service, Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) (HFP 04–149). The views expressed in this article are those of the authors and do not necessarily represent the views or policy of the Department of Veterans Affairs or the United States Government.
The authors would like to thank Stacy Wittrock and Ashley Cozad for their efforts in coordinating this study. We would also like to acknowledge Lindsey Davenport-Landry in the Iowa City VA laboratory for her work in managing all of the laboratory aspects of this project.
FootnotesConflict of Interest Statement: No financial disclosures were reported by any authors.
This research was presented at the 2012 Annual VA Health Services Research and Development Meeting in Washington, D.C.
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