Effectiveness of a mailed colorectal cancer screening outreach program in community health clinics: The STOP CRC Cluster Randomized Clinical Trial

JAMA Internal Medicine Aug 10, 2018

Coronado GD, et al. - In this cluster randomized pragmatic clinical trial, researchers tested the efficacy implementing an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program in health centers as part of standard care. Findings revealed that an EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. They found that higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program.


  • This trial was carried out in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n=13) or usual care (n=13).
  • Study participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015).
  • Interventions included:
    • Electronic health record-embedded tools to determine eligible adults and to facilitate implementation of a stepwise mailed intervention including:
      • an introductory letter
      • a mailed FIT
      • a reminder letter
    • Training, collaborative learning, and facilitation through a practice improvement process.
  • Researchers measured efficacy as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015.
  • In addition, they measured implementation as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT.


  • According to the findings, 41,193 adults (mean [SD] age, 58.5 [6.3] years; 22,994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21,134 patients) or usual care (13 clinics; 20,059 patients).
  • It was observed that intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%) vs usual care clinics.
  • Large variation was found across health centers in effectiveness (FIT completion differences range, -7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%).
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