Introduction

Utilizing mailed outreach to increase colorectal cancer (CRC) screening is effective in diverse, resource-poor settings. Whether effectiveness differs by key demographics or over time has not been well evaluated and has important considerations for health equity.

Methods

We examined effectiveness of a mailed stool test program implemented in a safety net system in Central Texas. Patients aged 45-75 who were identified as potentially eligible through electronic health records, were mailed free fecal immunochemical tests (FIT) with lab requisition, written/pictorial instructions, postage-paid lab mailer, and literacy-sensitive CRC screening information (English/Spanish).

Unscreened patients were asked to complete the FIT. Non-responders received a text, then letter reminder. Patients with negative FIT received another in 12 months. Bilingual navigators helped ensure colonoscopy after positive FIT.

Results

From November 2017 - September 2022, 49,520 patients received at least one mailed FIT. Mean age was 56.8 years and 52% were female. The population was diverse: 50% identified as Latino and 12% as Black; 15% had private insurance, 22% had Medicare or Medicaid, 36% were covered through county medical assistance program, and 13% were uninsured.

Those over age 60 (OR 1.2, 95% CI 1.14, 1.26), females (OR 1.21, 95% CI 1.16, 1.27), Latinos (OR 1.07, 95% CI 1.02, 1.13), and uninsured (OR 1.33, 95% CI 1.22, 1.45) were more likely to complete mailed FIT compared with their counterparts. There were no significant differences across years. Response rate for the initial mailer was 18%. In subsequent rounds, 41%, 62%, and 68% responded to the 2^nd, 3^rd, and 4^th mailed FIT, respectively.

Colonoscopy completion after positive FIT was 74%; median time to completion was 68 days.

Conclusion

Mailed outreach was effective in equitably screening patients who were not up to date with CRC screening, including high rate of colonoscopy after positive FIT.