Effect of Reminding Patients to Complete Fecal Immunochemical Testing: A Comparative Effectiveness Study of Automated and Live Approaches

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States.1 In 2017, an estimated 135,000 individuals will be diagnosed with CRC, and 50,000 will die from the disease.1 While screening for CRC has been shown unequivocally to reduce incidence and mortality,2 adherence to screening remains low. In 2015, only 63% of adults aged 50 and older reported being up to date with CRC screening recommendations.1 Screening rates are particularly low among Hispanics (50%), uninsured individuals (25%), and immigrants who have been in the United States for fewer than 10 years (34%). In community health centers providing care to underserved patients, an average of only 38% of eligible adults were found to be up to date in 2015.3 Direct-mail fecal testing programs have been shown to improve CRC screening rates in multiple health care settings, including community health centers,2 ^, 4 ^– 9 with improvements ranging from a 22% to 45% absolute increase.2 ^, 4 ^– 9 Most of these programs delivered follow-up reminders to adults who were mailed fecal test kits, with the reminders generally delivered through a letter or telephone call (either automated or live) or, more recently, through text messages and occasionally patient navigation (staff trained to provide assistance with overcoming screening barriers).2 ^, 4 ^, 8 ^– 11

Despite the widespread use of follow-up reminders for direct-mail fecal testing programs, few studies have evaluated the impact that reminders have on fecal test return rates. To address this important gap in the literature, we compare the effectiveness of reminders for a direct-mail fecal testing program. We partnered with Sea Mar Community Health Centers, the largest community health center in the state of Washington, to answer the question: How well do individual and multiple reminders work for patients who are mailed a fecal immunochemical test (FIT)? A secondary question was: Can we infer a difference in the effectiveness based on patients’ preferred language (English or Spanish)? We also report on the percentage of eligible patients who received the reminders (reach). The results of this study will inform future efforts to optimize the return rate for direct-mail fecal testing programs.

A total of 2010 patients were randomized to one of the seven reminder arms (Fig. 1). Randomized patients were mostly aged 50–64 years, and men and women were represented in similar proportions (Table 2). Hispanics represented about one-quarter of the sample, and nearly 20% of the sample preferred speaking Spanish. Over three-quarters of the sample were insured, and about one-half had family income less than $20,000.

Overall, 512 randomized adults returned their FIT kits, for a return rate of 25.5%. When we include those who returned their FIT kits within the 3 weeks prior to randomization and those in the patient portal group, the estimated overall return rate was 32.7%. In intention-to-treat analysis, patients allocated to live phone call reminders had 50% greater odds of completing their FIT kits than patients allocated to reminder letters (Table 3). In contrast, patients who received text-message reminders had 34% lower odds of returning their FITs than patients who received mailed letters. We found no significant differences in FIT completion rates for other reminder protocols compared to a simple reminder letter. A total of 21% of individuals in the patient portal group returned their FIT kits.

In per-protocol analysis (Table 4), overall FIT return was highest in the groups that received either the live phone calls (OR, 1.73; [95% CI, 1.16–2.58]) or the combination of automated and live calls (OR, 1.74; [95% CI, 1.17–2.60]). In per-protocol analyses stratified by language preference, English-preferring adults had higher odds of FIT return if they were allocated to a live call (OR, 2.17; [95% CI, 1.31–3.59]), a combination of a reminder letter and live call (OR, 1.78; [95% CI, 1.07–2.97]), an automated and live call (OR, 1.73; [95% CI, 1.04–2.88]), or text message and live call (OR, 1.90; [95% CI, 1.15–3.14]). Among Spanish-preferring adults, higher odds of FIT return were associated with the combination of automated and live phone calls (OR, 3.45; [95% CI, 1.42–8.39]).

In total, 79% of randomized adults were reached; reach was highest for the patient portal (98%) and reminder-letter groups (95%) and lowest for the text-message (70%) and automated-call (65%) groups (Table 1). Among the 202 adults reached via automated phone call, 62% received a voice message and 38% were reached in person. Among the 228 reached via the live call, 50% were reached in person.

Previous research has acknowledged the success of direct-mail fecal testing programs and the limitations of point-of-care methods for delivery of fecal testing.5 We assessed the effectiveness of automated reminders and combined automated and live reminders for a direct-mail FIT program in a large, diverse community health center in western Washington. While many direct-mail fecal testing programs have delivered patient reminders, ours is the first study to rigorously test the effectiveness of these reminders in a community health center population, and among patients with differing language preferences.

Overall, patients who received live reminder phone calls were more likely to complete a FIT than those who were mailed reminder letters; this finding is consistent with some previous evaluations and inconsistent with others. Among Latino and Vietnamese patients in a large public hospital, Walsh and colleagues reported a significant boost in self-reported fecal testing rates among patients who received a mailed fecal test and telephone counseling compared to those who received only a mailed fecal test (absolute percentages in each group: 25% vs. 15%; p < 0.01).16 In contrast, Levy and colleagues tested the effectiveness of a direct-mail FIT program targeting 373 consented participants in rural primary practices in Iowa, with and without a structured live reminder phone call delivered by project staff, and found no additional boost in FIT returns (absolute percentages in each group: 45% vs. 49%; p = 0.50).17 Our findings suggest that a live call is superior to a mailed reminder in improving FIT returns.

Contrary to expectations, we observed lower odds of FIT return among adults assigned to receive text-message reminders, and the effect was unchanged in per-protocol analysis where landline phone numbers were removed from the denominator. Baker and colleagues and Gupta and colleagues used text-message reminders in direct-mail FIT programs; however, both combined this approach with concurrently delivered automated phone calls, making it unclear how to attribute the effect.2 ^, 5 However, in sub-analyses limited to those who did and did not receive a text-message reminder, Baker and colleagues reported no difference in return rates (44% vs. 44%), suggesting minimal influence from this approach.2 Our findings show that text messages, by themselves, performed more poorly than reminder letters.

We observed that randomized patients who preferred Spanish returned their FITs at a higher rate than patients who preferred English (FIT return rates: 34% v. 22%, p < 0.001; data not shown). This finding may reflect the relatively low likelihood that Latino patients will discuss CRC screening with their doctors during in-clinic visits.14 Our research team previously reported a higher FIT return rate for Spanish speakers than English speakers in a direct-mail FIT program delivered to patients in a community health center (FIT return rate: 46% vs. 28%, respectively).11 Similarly, Gupta and colleagues reported higher direct-mail FIT return rates by Hispanics than non-Hispanic whites (FIT return rate: 48% vs. 34%, respectively), although the differences were not directly tested.5 In contrast, Baker and colleagues reported no differences in the magnitude of the effect of direct-mail and reminder interventions based on race/ethnicity or preferred language.2

Program reach for follow-up reminders is an important consideration, especially in community health centers, where patients’ contact information may become quickly outdated. Among the limited number of studies conducted in community health centers, Jean-Jacques and colleagues reported that 40% of patients were reached after three live phone attempts, and that 23% of available phone numbers were either incorrect or disconnected.8 Similarly, Singal and colleagues and Baker and colleagues separately reported that only 48% and 37% of intended recipients, respectively, were reached with up to three attempts to deliver a live-call reminder.2 ^, 9 We observed that 81% of intended recipients were reached using up to two attempts to deliver a live call. Previous studies have reported that automated phone calls were successfully delivered to 76–89% of intended recipients,2 ^, 4 ^, 18 with over half (51–54%) of the calls answered by a voice message system.2 ^, 4 We observed lower reach for automated phone calls in our study (65%). Text messages were successfully delivered to 51% of recipients in a study by Baker and colleagues and to 78% of recipients in a study by Goldman and colleagues.2 ^, 4 We observed a 70% reach for text messages. Our findings underscore the importance of maintaining up-to-date telephone contact information for the delivery of both automated and live telephone reminders.

The effectiveness of reminders must be weighed against the costs of delivering those reminders and patient experience with receiving reminders, among other factors. Automated phone calls and text messages are the least costly options to implement, yet live reminders may allow staff to address or triage other patient health care needs. Future research might assess the views of clinic leadership and patients regarding the value of FIT reminders.

Our FIT kit reminder study involved adults receiving care at a community health center in the Pacific Northwest. Our findings show that there are variations in FIT return rates based on reminder mode used and that both the overall return rate and effectiveness of reminder mode differs according to patient language preference. Our data appear to suggest that reminders that included a live call performed better than reminders that relied on written communication (a text or letter).