Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial.
Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial.
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DOI：
10.1001/jamainternmed.2013.9294
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发表时间：
2013-10-14
影响因子：
39
通讯作者：
Skinner CS
中科院分区：
文献类型：
--
作者：
Gupta S;Halm EA;Rockey DC;Hammons M;Koch M;Carter E;Valdez L;Tong L;Ahn C;Kashner M;Argenbright K;Tiro J;Geng Z;Pruitt S;Skinner CS
结直肠癌（CRC）筛查可以挽救生命，但在服务不足的人群中参与率很低。对筛选得不到充分服务者的有效办法，包括可提供的最佳测试类型的了解有限。确定（1）与常规护理相比，有组织的邮寄外展是否能促进CRC筛查，以及（2）在服务不足的人群中，FIT是否上级于结肠镜外展参与CRC筛查。我们确定了未投保的患者，没有最新的CRC筛查，年龄54至64岁，由约翰彼得史密斯健康网络，沃斯堡和塔兰特县，得克萨斯州，一个安全网卫生系统。患者被随机分配到3组中的1组。一组被分配到粪便免疫化学试验（FIT）外展，包括邮寄邀请使用和返回一个封闭的免费FIT（n = 1593）。第二组被分配到结肠镜外展，包括邮寄邀请安排免费结肠镜检查（n = 479）。第三组被分配到常规护理，包括机会性初级保健访视为基础的筛选（n = 3898）。此外，FIT和结肠镜检查外展小组接受电话随访，以促进测试完成。随机化后1年内参与任何CRC检查的筛选。患者平均年龄为59岁; 64%的患者为女性。样本为41%白色，24%黑人，29%西班牙裔，7%其他种族/民族。FIT（40.7%）和结肠镜外展（24.6%）的筛查参与率显著高于常规护理（12.1%）（与常规护理相比，P <0.001）。FIT的筛查显著高于结肠镜外展（P <0.001）。在分层分析中，在白人、黑人和西班牙裔中，FIT和结肠镜外展的筛查率高于常规护理，FIT的筛查率高于结肠镜外展（所有比较P <0.005）。FIT外展的CRC识别率和晚期腺瘤检出率分别为0.4%和0.8%，结肠镜外展的CRC识别率和晚期腺瘤检出率分别为0.4%和1.3%，常规治疗的CRC识别率和晚期腺瘤检出率分别为0.2%和0.4%（结肠镜与常规治疗晚期腺瘤比较P <0.05;所有其他比较P > 0.05）。60例FIT结果异常的患者中有11例未完成结肠镜检查。在那些CRC筛查不是最新的服务不足的患者中，与常规护理相比，邮寄的外展邀请导致CRC筛查明显更高。FIT的外展比结肠镜检查邀请更有效。clinicaltrials.gov标识符：NCT 01191411
Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited. To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population. We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system. Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visit-based screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion. Screening participation in any CRC test within 1 year after randomization. Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation. clinicaltrials.gov Identifier: NCT01191411