Centralized Outreach And Colorectal Screening In FQHCs

Key Takeaways

• A pragmatic randomized clinical trial in federally qualified health centers found that centralized mailed FIT outreach with navigation significantly increased colorectal cancer screening completion compared with usual care (30.0% vs 9.7% at 6 months).
• The intervention included mailed fecal immunochemical test kits, reminders, and navigation to colonoscopy after abnormal results.
• Secondary findings showed higher colonoscopy completion after abnormal FIT and increased detection of advanced colorectal neoplasia in the intervention group.

Investigators conducted a pragmatic randomized clinical trial to evaluate whether a centralized colorectal cancer (CRC) screening outreach strategy could improve screening rates in safety-net primary care settings.

The study was carried out across federally qualified health centers (FQHCs), which serve diverse and often underserved populations and face persistent challenges in preventive care delivery.

The trial enrolled 4002 adults aged 50 to 75 years who were not up to date with CRC screening and were at average risk. Participants were randomized 1:1 to receive either usual care alone or a centralized outreach intervention in addition to usual care. The intervention was coordinated through an academic cancer center and implemented across 12 clinical sites within 2 independent FQHC systems in North Carolina.

The centralized outreach strategy consisted of mailed screening materials, including an introductory letter followed by a fecal immunochemical test (FIT) kit with instructions and prepaid return packaging. Participants who did not return the test received up to 2 reminder mailings. For those with abnormal FIT results, patient navigation was provided to facilitate timely follow-up colonoscopy.

The primary outcome was completion of a US Preventive Services Task Force–recommended CRC screening test within 6 months of randomization. Screening completion was significantly higher in the intervention group compared with usual care (30.0% vs 9.7%; difference, 20.29 percentage points; 95% CI, 17.85–22.73). This effect was consistent across insurance categories, including commercially insured, Medicaid, Medicare, and uninsured populations.

Secondary outcomes further characterized downstream care. Among participants with abnormal FIT results, 68.8% in the intervention group completed follow-up colonoscopy within 6 months compared with 44.4% in the usual care group, although this difference did not reach statistical significance. In addition, detection of advanced colorectal neoplasia—including advanced adenomas and colorectal cancer—was higher in the intervention group (1.4% vs 0.7%; difference, 0.68 percentage points; 95% CI, 0.05–1.35), indicating increased identification of clinically meaningful disease.

Most screening in the intervention group occurred via stool-based testing, reflecting the mailed FIT approach, whereas usual care included a higher proportion of colonoscopy-based screening initiated during clinic visits. The intervention’s centralized design reduced reliance on clinic-level resources by shifting outreach, tracking, and navigation functions to a coordinated external team.

The authors concluded that centralized mailed FIT outreach combined with navigation substantially improved CRC screening in FQHC populations and increased detection of advanced neoplasia. They emphasized that this model may help address screening gaps in safety-net settings and could be scalable, although further work is needed to evaluate cost and long-term implementation.