Financial incentives associated with increased FIT uptake but not increased CRC screening overall

A three-arm trial of incentives for fecal immunochemical testing (FIT) and colorectal cancer screening (CRC) tested mail-only, mail and monetary, and mail and lottery interventions.

Financial incentives appeared to increase completion of fecal immunochemical testing (FIT) but not overall completion of screening for colorectal cancer (CRC), according to a new study.

Researchers in Washington state performed a parallel, three-arm randomized clinical trial to determine whether different types of financial incentives would increase completion of CRC screening. Participants who were 50 to 75 years of age and were overdue for screening were included in the trial after completion of a questionnaire that included sociodemographic and psychosocial questions. The interventions tested were mail notification only, defined as up to three mailings including information on the importance of CRC screening and choice of screening tests, plus a reminder mailing if needed; mail notification and monetary reward, defined as the mailings plus $10 guaranteed at completion of screening; and mail notification and reward lottery, defined as the mailings plus a 1 in 10 chance of receiving $50 at completion of screening.

Completion of any CRC screening within six months of randomization was the primary outcome; secondary outcomes were completion of FIT or colonoscopy within six months of randomization. Effects of the interventions were compared by sociodemographic and self-reported psychosocial measures. The study results were published July 5 by JAMA Network Open.

A total of 838 patients were included in the trial, 284 in the mail-only group, 270 in the mail and monetary group, and 284 in the mail and lottery group. The mean age of participants was 59 years, 62.5% were women, 52.2% were white, and 12.1% were Hispanic. Rates of completion of any CRC screening did not differ significantly between the incentive groups (76.7% for the mail and monetary group and 76.7% for the mail and lottery group) and the mail-only group (71.5%) (P=0.11). However, for FIT completion, net increases of 7.7% (95% CI, 0.3% to 15.1%) and 7.1% (95% CI, −0.2% to 14.3%) were seen in the mail and monetary and mail and lottery groups, respectively, versus the mail-only group (P=0.04). Among patients with Medicaid, incentives yielded a net increase of 37.7% (95% CI, 11.0% to 64.3%) in FIT completion versus 5.6% (95% CI, −0.9% to 12.2%) among patients who were not insured through Medicaid (P=0.03 for interaction).

The authors noted that only patients who returned the baseline questionnaire were included in the study and that return rates were lower than expected. In addition to other limitations, the invitation letter for the study included $2, so patients who did return the questionnaire may have been more likely to respond in general to financial incentives. The authors said that the results of their secondary analyses regarding disparities are hypothesis-generating but concluded that financial incentives increased FIT completion rates, but not CRC screening overall, in their study population. They called for larger studies that could confirm their findings in other settings.