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Mark Koch, MD

The effect of deadlines on cancer screening completion: a randomized controlled trial

Wed, 07/07/2021 - 05:00

Sci Rep. 2021 Jul 6;11(1):13876. doi: 10.1038/s41598-021-93334-1.


Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low-particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines-both with and without monetary incentives tied to them-increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines-especially short ones-can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.

PMID:34230556 | PMC:PMC8260724 | DOI:10.1038/s41598-021-93334-1

Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Fri, 08/09/2019 - 04:04
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Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Cancer Epidemiol Biomarkers Prev. 2019 Aug 06;:

Authors: Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Ahn C, Balasubramanian BA, Argenbright KE, Gupta S

BACKGROUND: Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for three years.
METHODS: Patients, aged 50-64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n=6,565), outreach plus $5 (n=1,000), or $10 (n=1,000) incentive for completion. Patients who completed the test were re-invited using the same incentive the following year, for 3 years. In Year 4, patients who returned the kit in all preceding three years were re-invited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 vs. outreach alone, $10 vs. outreach alone, and $5 vs. $10.
RESULTS: Year 1 FIT completion was 36.9% with incentives vs. 36.2% outreach alone (P=0.59) and was not statistically different for $10 (34.6%; P=0.31) or $5 (39.2%; P=0.070) vs. outreach alone. Year 2 completion was 61.6% with incentives vs. 60.8% outreach alone (P=0.75) and not statistically different for $10 or $5 vs. outreach alone. Year 3 completion was 79.4% with incentives vs. 74.8% outreach alone (P=0.080), and was higher for $10 (82.4%) vs. outreach alone (P=.033), but not for $5 vs. outreach alone. Completion was similar across conditions in Year 4 (no incentives).
CONCLUSIONS: Offering small incentives did not increase FIT completion relative to standard outreach.
IMPACT: This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.

PMID: 31387970 [PubMed - as supplied by publisher]

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Thu, 05/16/2019 - 11:20
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Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Clin Gastroenterol Hepatol. 2019 May 11;:

Authors: Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S

BACKGROUND & AIMS: Non-invasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cutoff concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.
METHODS: We performed a prospective study of 17,017 uninsured patients, 50-64 years old, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cutoff value for an abnormal FIT result from ≥ 20 to ≥ 10 μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions with abnormal FIT results and neoplasia yield for standard vs lower cutoff values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cutoff on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared to the standard, higher, hemoglobin concentration cutoff value.
RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the ≥ 10 μg hemoglobin/g feces and 6.6% at the standard ≥ 20 μg hemoglobin/g feces cutoff value (P=.0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P=.12) and 0.9% vs 1.2% for CRC (P=.718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P=.053) and 1.7% vs 2.4% for CRC (P=.659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations ≥ 20 μg/g feces. In the 10-19 μg hemoglobin/g feces range, there were 3 patients with CRC (3/11, 27.3%) and 36 with advanced adenoma (36/110, 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison <.001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cutoff value (44.4%) than the standard cutoff (39.1%) (P=.1103).
CONCLUSION: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cutoff value (to the ≥ 10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cutoff value, to optimize CRC detection and prevention. no: NCT01946282.

PMID: 31085338 [PubMed - as supplied by publisher]

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Wed, 01/30/2019 - 08:28
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Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Am J Gastroenterol. 2016 Nov;111(11):1630-1636

Authors: Gupta S, Miller S, Koch M, Berry E, Anderson P, Pruitt SL, Borton E, Hughes AE, Carter E, Hernandez S, Pozos H, Halm EA, Gneezy A, Lieberman AJ, Sugg Skinner C, Argenbright K, Balasubramanian B

OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population.
METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis.
RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups.
CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

PMID: 27481306 [PubMed - indexed for MEDLINE]