Mailed Reminder to Increase Completion of Fecal Occult Blood Testing (FOBT) for Veterans

Each year in the United States, approximately 50,000 people die from colorectal cancer (CRC), the second-leading cause of cancer-related deaths. Military veterans account for 3% of all cancer cases in the United States, approximately 40,000 per year. CRC is one of the top five cancers diagnosed among cancer patients served by the U.S. Department of Veterans Affairs (VA).

CRC screening can detect colorectal cancer at an early stage to maximize the potential for treatment to be effective. Further, the detection and removal of polyps can prevent colorectal cancer from developing. The U.S. Preventive Services Task Force recommends regular screening beginning at age 50 and continuing until age 75 using high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy. Despite these recommendations, only 65% of adults are up to date with colorectal cancer screening. Interventions designed to promote colorectal cancer screening are needed among military veterans.

Mailed Reminder To Increase Completion of Fecal Occult Blood Testing (FOBT) for Veterans is an intervention designed to increase colorectal cancer screening among men and women aged 50 years and older who are patients at a VA medical center primary care clinic. The intervention is intended to serve as a follow-up to usual care, which includes identifying primary care patients who are eligible for FOBT screening and providing them with FOBT kits (i.e., test card, instructions on how to complete the test, postage paid return envelope). The intervention involves mailing a personalized educational reminder to all patients 10 days after they receive the FOBT kit. Written at an eighth-grade reading level, the mailer consists of four components: a reminder to return the FOBT card, a few facts about CRC and CRC screening (e.g., risks of developing the disease, benefits of screening), a quote from a veteran who survived CRC, and the phone number patients can call with questions about FOBT.

-- 3 minutes per patient for the clinician to review the chart and assemble and send the educational reminder

The intervention is intended for U.S. veterans aged 50 years and older who are not currently receiving inpatient care.

The intervention is designed to be implemented in primary care settings and in the home.

Required resources to implement the program include the following:

-- Mailed Reminder Flyer

For costs associated with this program, please contact the developers, Samuel B. Ho or Gelareh (Rose) Ganji. (See products page on the EBCCP website for developer contact information.)
 

A double-blind, randomized controlled trial was conducted to evaluate the impact of the intervention on CRC screening among U.S. veterans who were patients at the VA medical center primary care clinics in San Diego and Vista, California. Over about a 3-month period, patients who were asymptomatic of CRC, agreed to screening, received an FOBT card kit, and were at least 50 years old were recruited to participate. Patients receiving care on an inpatient unit were excluded.

During visits to the clinics, patients were instructed by the physician to pick up an FOBT kit for screening at the laboratory, complete it, and return it using the postage-paid return envelope. Patients who picked up the cards were subsequently randomized to the intervention group (n=389) or the usual care group (n=386) with the use of a random-number generator. The average age of participants was 63.1 years; 96.3% were male, 72.8% were White, 11.7% were African American, and 56.6% were unmarried. The groups were well matched in terms of demographic and clinical characteristics at baseline.

Ten days after the visit, patients in the intervention group received mailed reminders. The primary outcome was percentage of patients returning the FOBT card within 6 months of receiving it. Screening rates were assessed through the review of administrative databases and an electronic medical record database by a clinical research assistant who was blinded to the patients' study group assignment. To examine factors associated with FOBT completion, other data extracted from patient records included demographic characteristics, prior FOBT completion, number of scheduled and kept VA appointments over the past year, history of several diseases and mental disorders, current or recent use of illicit drugs, and current use of tobacco or alcohol.
 

• At 6-month follow-up, FOBT screening rates were higher in the intervention group than the usual care group (64.6% vs. 48.4%; p<.001).

Additional Findings

• Having a history of completing FOBTs was a significant predictor of FOBT completion, with higher compliance rates found among patients who had completed a greater number of previous FOBTs (compared with no history of FOBT completion, completion of one FOBT, OR=1.87; completion of two FOBTs, OR=3.89; completion of three FOBTs, OR=4.05). Current or recent illicit drug use was a significant predictor of FOBT non-completion (OR=0.26).