Abstract PR01: Systems-level intervention to increase CRC screening in community health centers
Authors: Muthukrishnan Meera , Yan Yan , Wang Jean , Colditz Graham , James Aimee S. 
Published: May 2016

Abstract
Introduction: Colorectal cancer (CRC) is a leading cause of cancer death in the US. Although routine screening is effective in reducing CRC incidence and mortality, only 59% of adults are reportedly up-to-date. With even lower rates of screening and higher rates of late-stage diagnoses among under- and uninsured patients, there is a critical need for interventions that are effective, practical, and sustainable in this population. Many of these patients are served in the healthcare safety-net, including federally qualified health centers, which serve patients regardless of their insurance. System- or multi-level interventions have been effective at increasing screening in previous studies, but most have been implemented and evaluated in higher-resource settings. Using community based participatory research (CBPR) methods and a randomized trial design, we aim to select, implement, and test evidence-based systems-level strategies aimed at increasing CRC screening in safety-net healthcare settings that serve patients who are under- or uninsured.
Methods: To meet CBPR principles, health centers were engaged in determining study procedures and interventions at their sites. After recruiting eleven safety-net health centers in two networks (one mostly urban, one mostly rural), six health centers were randomly assigned to the intervention arm. Provider reminders, changes to the patient materials, and patient reminders were the most common strategies selected. The primary outcome is CRC screening adherence at 12-months post-baseline as measured by self-report. Data were collected regarding patient socioeconomic factors, healthcare, and screening utilization. Data analysis included examination of bivariate associations as well as logistic regression with GEE robust standard error to assess CRC screening in intervention and control sites.
Results: The study population included 490 participants at baseline from 11 health centers in 2 separate health networks; 273 (55.7%) participants completed the 12-month follow-up survey. Of this final sample, most were black (53.5%), unemployed (53.9%), had a monthly income &lt;$1200/month (63.4%), had public insurance (65.6%), and reported they had a particular doctor or health care provider (84.3%). Participants were also evenly divided between the 2 health networks (50.9% and 49.1%). Most participants were up-to-date with any type of CRC screening at 12 months (65.6%) compared to 46.1% at baseline. The up-to-date screening rate was not significantly different between intervention and control (OR=1.06, p&gt;0.05), in an adjusted model.
Discussion: We reached a very low income sample, who experienced occasional homelessness, unexpected changes in contact information, and had relatively high unemployment rates. Participants had a relatively high baseline screening rate, but our participatory recruitment methods may have over-selected people who were already screened. The health centers were also under-resourced and faced challenges, particularly in helping patients access colonoscopy. Despite safety-net health centers adopting and adapting evidence-based intervention strategies to fit the needs of their patients, screening rates were not significantly higher in intervention clinics compared to control. There are several possible explanations. Control clinics may have been affected by the intervention, as they were in the same health network and there was occasional but unmeasured cross-over in terms of patients and providers. The lack of Medicaid expansion in Missouri meant that many patients remain uninsured. Also, the urban specialty clinic providing colonoscopy to under- and uninsured patients closed during the study, complicating access and creating long wait times for appointments. The study offers valuable insights into the challenges of implementing screening interventions with low-resource patients in low-resource settings.
This abstract is also presented as Poster A43.
Citation Format: Meera Muthukrishnan, Yan Yan, Jean Wang, Graham Colditz, Aimee S. James. Systems-level intervention to increase CRC screening in community health centers. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr PR01.