Behavioral economics does not appear to affect participation in colorectal cancer (CRC) screening by fecal immunochemical testing (FIT), researchers reported.
The study by Shivan J. Mehta, MD, MBA, of the Perelman School of Medicine of the University of Pennsylvania found that while mailing out FIT kits directly to patients increased screening uptake, offering a small – perhaps too small – financial incentive had no incremental effect.
At month 2, the overall FIT completion rate in the mail-out program was 23.5%, rising to 28.9% at month 6. “This was a substantial rate of CRC screening uptake in a population that was not up to date and typically received recommendation for colonoscopy in the clinic setting,” the team wrote online in JAMA Network Open.
But among the 897 participants, no statistically significant difference in screening uptake at 2 and 6 months emerged between three different incentive arms and a mailed outreach-only arm. The patients were assigned to one of four groups:
- No incentive (n=223)
- An unconditional $10 gift card incentive included with the mailed FIT kit (n=224)
- A $10 gift card incentive conditional on FIT completion (n=224)
- A conditional lottery with a one-in-10 chance of winning $100 after FIT completion (n=226)
“Our study showed high uptake of mailed FIT, but financial incentives of $10 equivalent value did not affect screening response rates in this population,” Mehta’s group wrote. “Further efforts are needed to enhance uptake of CRC screening to make it more scalable and effective.”
By study group, the 2-month completion rates were as follows:
- 26.0% (95% CI 20.4%-32.3%) in the no-incentive arm
- 27.2% (95% CI 21.5%-33.6%, P=0.77) in the unconditional-incentive arm
- 23.2% (95% CI 17.9%-29.3%, P=0.49) in the conditional-incentive arm
- 17.7% (95% CI 13.0%-23.3%, P=0.03) in the lottery-incentive arm
Patients were drawn from an academic family practice at the University of Pennsylvania, and eligible candidates, ages 50 to 70, were identified via electronic health records from December 2015 to July 2017. All received a letter from their primary care clinician with a FIT kit and instructions for use.
With a median age of 57 (interquartile range of 52-62), 56% of patients were women and 69% were black. All groups had similar median household incomes of about $31,000 a year.
The majority had commercial insurance (54%), while 25% had Medicare, 21% had Medicaid, and fewer than 1% were self-payers.
Although completion rates increased somewhat at 6 months, again, there was no significant difference between the study arms:
- 32.7% (95% CI 26.6%-39.3%) in the no-incentive arm
- 31.7% (95% CI 25.7%-38.2%, P=0.82 ) in the unconditional-incentive arm
- 26.8% (95% CI 21.1%-33.1%, P=0.17) in the conditional-incentive arm
- 24.3% (95% CI 18.9%-30.5%, P=0.05) in the lottery-incentive arm
In 2017, Mehta’s group reported a modest increase in CRC screening rates with financial incentives. But although the current study applied behavioral economic principles known to increase response in health and non-health contexts, the authors conceded that the incentive may have been too small to overcome the perceived time burden of testing: “The results of our follow-up surveys suggested that a median of $15 may be necessary to account for the time and effort to participate,” the team wrote.
Last year, a randomized trial conducted by Kaiser Permanente found a modest 3.4% higher FIT completion when kits were directly mailed (with no incentive) to screening candidates.
In a commentary that accompanied the new study, Liam Rose, PhD, of Stanford University’s Surgery Policy Improvement Research and Education Center in California, agreed that while sending kits by mail positively affected uptake, pecuniary incentives seem to have little to no effect on increasing completion rates beyond kit mail-out reminders: “It is possible that there is no cost-effective way to provide financial incentives to bring patients into compliance with CRC screening, and targeted outreach will be the optimal approach for most care and insurance provider groups,” he wrote.
Rose noted that in addition to Kaiser Permanente’s successful mailed-out kit program, the Department of Veterans Affairs has achieved high screening rates using a patient reminder system.
Mehta and co-authors cited several study limitations, including its focus only on FIT with no option for colonoscopy. In addition, the primary study outcome involved following patients for only 2 months, and the study had limited power to detect small differences between arms. Furthermore, the analysis evaluated financial incentives only in the context of mailed outreach, with no interaction by telephone or in person.
The study received funding from the Abramson Cancer Center of the University of Pennsylvania and the National Cancer Institute. Several co-authors reported grants from the Commonwealth of Pennsylvania and the National Cancer Institute.
Mehta reported having no conflicts of interest; two co-authors reported being principals in the behavioral economics consulting firm VAL Health, and one of them reported financial relationships with CVS Caremark, Humana, Discovery (South Africa), Hawaii Medical Services Association, Oscar, and Weight Watchers.
Rose reported having no competing interests.