Mailed fecal tests, patient navigators and colorectal cancer for the win

Trial shows promise for boosting colorectal cancer screening in rural Medicaid enrollees

A new study shows that a combination of mailing stool-based tests and providing patient navigation to follow-up procedures significantly increased screenings for colorectal cancer, or CRC, among Medicaid enrollees in rural areas. 

The trial involved 28 rural clinics in Oregon in partnership with three Medicaid health plans and aimed to tackle low participation in CRC screening, a longstanding challenge in these areas. The results are published today in JAMA Network Open. 

The research was a collaborative effort between University of Arizona Health Sciences, Oregon Health & Science University’s Oregon Rural Practice-based Research Network and the Kaiser Permanente Center for Health Research.  

The trial aimed to improve participation by using mailed fecal immunochemical tests, or FIT kits, and offering patient navigation for follow-up colonoscopies if results were abnormal. 

Gloria Coronado, an epidemiologist and associate director of population science for the University of Arizona Cancer Center and professor in the U of A Mel and Enid Zuckerman College of Public Health, co-led the randomized study in 28 rural Oregon clinics affiliated with three Medicaid health plans. 

“Medicaid provides coverage for low-income individuals in the U.S. Individuals who live in rural regions often face additional barriers to receiving cancer screening exams,” Coronado said. “We partnered with Medicaid health plans because they could offer centralized resources to promote colorectal cancer screening.” 

Trial findings

Approximately 60 million adults live in rural U.S. areas, where CRC screening rates have traditionally been low, especially among Medicaid recipients. Screening for colorectal cancer is crucial for early detection and prevention.  

“Effective treatments can be slow to reach rural populations,” said the study’s senior author, Melinda Davis, PhD, director of OHSU’s Oregon Rural Practice-based Research Network. “This research and other studies by our team help bridge this gap to ensure all patients receive high quality care whether they live in rural or urban areas.” 

Participants included 5,614 Medicaid enrollees between 50 and 75 years old who were due for colorectal cancer screening, an age group slightly older than the U.S. Preventive Services Task Force recommended age of first screening at 45.  

Each participant in the intervention was mailed a FIT kit and assigned a patient navigator following an abnormal FIT result. Patient navigators were trained in the FIT test procedures and how to use patient tracking tools. 

In the study, patient navigators contacted patients with abnormal test results via phone and conducted a barrier assessment, reviewed colonoscopy preparation, provided an appointment reminder and followed up on the results of the colonoscopy. 

The results were promising. In the intervention group, 11.8% of participants completed CRC screening within six months, compared to just 4.5% in the usual care group. Additionally, those in the intervention group who had abnormal FIT results were much more likely to complete a follow-up colonoscopy — 43.3% compared to just 15.4% in the usual care group. 

Innovation gains backing during COVID-19 

The study intervention occurred between May 2021 and June 2022, during the COVID-19 pandemic. Rural communities and clinics were hit especially hard by care suspensions, re-deployed staff, and a push to telehealth-delivered care due to the pandemic. 

Coronado said because of COVID-19 national organizations were already promoting mailed stool tests as an alternative to office visits and Medicaid partners mailed stool tests to patients’ homes through third-party vendors, freeing busy clinic staff. 

In fact, Coronado found from her research that home-based screening offers many advantages in the face of pandemics and similar natural disasters.  

“COVID-19 taught many of us how to do home nasal swabs – perhaps an important precursor to cancer screening,” Coronado said. “We were pleasantly surprised that the study was possible and successful during such a difficult time for delivering health care.” 

Coronado is now collaborating with other researchers at the University of Arizona to expand her rural-based cancer screening research.  

“My hope is to support cancer quality improvement initiatives in rural clinics in Arizona and beyond,” Coronado said. 

This study was funded by the National Institutes of Health through award numbers UG3CA244298 and UH3CA244298.