Patient-Refined Messaging for a Mailed Colorectal Cancer Screening Program: Pilot Findings from the PROMPT Study Jamie Thompson, MPH Kaiser Permanente Center for Health Research - Northwest Kaiser Permanente Center for Health Research

Topics Background Design + Methods Pilot Outcomes Conclusions Next Steps – Main Trial

Background Colon cancer is the second-leading cause of cancer death in the U.S. Colon cancer screening rates are disproportionately low among Latinos Community Preventive Services Task Force recommends multi- component interventions, including patient reminders, to improve uptake of colon cancer screening

Design + Methods What is the PROMPT study? PROMPT = Participatory Research to Advance Colon Cancer Prevention Five-year study Collaboration between Kaiser, AltaMed Health Services, and OHSU Improve rates of colon cancer screening in a Latino-serving community health center in California OBJECTIVE: Using patient-refined materials, we examined FIT (fecal immunochemical test) completion rates following automated and live approaches in a 3-arm pilot pragmatic trial. 4

Study Setting: AltaMed Health Services One of the largest FQHCs in the US Serves almost 300,000 patients in Los Angeles and Orange Counties in Southern California Operates 25 medical clinics 80% of patients are Latino Los Angeles County Orange County 5

Overall Study Design Overall Study Design 6

Pilot Study Design Eligible participants were Intervention Latino Ages 50 to 75 years Not up-to-date with colon cancer screening recommendations Had a clinic visit in each of the previous two years at either two participating health center clinics Intervention Automated (Group 1): A text message alert, a mailed FIT kit, and a series of two automated phone call reminders Live (Group 2): A mailed FIT and up to three live call reminders Auto + Live (Group 3): The combination of a text message alert, a mailed FIT, two automated call reminders, and up to three live call reminders The interventions were delivered between 9/5/2017 – 10/20/2017.

Overview of Boot Camp Translation Process Format and content of alerts and reminders were selected using a validated patient- engagement approach called boot camp translation conducted between May and July 2017. 8

English Language Session Spanish Language Session Who Participated in Boot Camp Translation? English Language Session Spanish Language Session Number of participants (in-person meeting) 12 13 Number of patients 10 11 Number of clinic staff 2 PATIENTS ONLY   Age (years), mean 57.1 56.6 Female, % 60 91 Latino, % 80 100 Medicaid, % 36 Uninsured, % Annual household income less than $20,000, % 50 82 Less than high school education, % 20 73 Born outside of the United States, % 9

Products Drafted based on in-person meeting and refined using iterative phone conversations Final Materials: What/Mode Timing Text Message Alert Before Auto Call Reminder Message After Live Call Reminder Script Intro Letter With Kit 1-Page Educational Fact Sheet Final materials are available at www.mailedfit.org 10

Automated Phone Call Reminder Text Message Alert AltaMed is mailing you a free colon health test to do at home. Complete the test - it could save your life! Questions? Call 1-888-499-9303 Automated Phone Call Reminder Hello [INSERT Patient First Name], I am calling from AltaMed to remind you to complete the free colon health test we sent you. Take control of your health and complete the test today. You and your family will be happy you did! If patient answers: To speak with an AltaMed staff member, please press 0. If voicemail is reached: If you have questions about the test, please call us at 1-888-499-9303. 11

Letter with FIT Kit Mailing 12

1-Page Educational Fact Sheet 13

Pilot Outcomes Among randomized participants (n=1,767), 553 (31.3%) completed a FIT within 6 months. 14

Pilot Outcomes (continued) Female Latino Spanish-Speaking Uninsured Missed Appointment 57% 83% 59% 25% 66% 15

Pilot Outcomes (continued) In bivariate comparisons, FIT completion rates differed significantly by: Preferred language (p < .01) English: 25.5% Spanish: 35.1% Other: 39.7% Number of clinic visits in the past year (p < .01) At least one: 33.9% None: 1.2% Prior FIT testing (p < .01) Yes: 45.1% No: 17.1% 16

Pilot Outcomes (continued) Adjusted difference and associated 95% confidence intervals between intervention groups: Controlling for clinic, adults allocated to the live condition had a significantly higher FIT completion rate than those in the automated condition. 17

Conclusions Live phone call reminders, either alone or in combination with automated alerts and reminders, outperformed automated approaches alone. Using multiple touchpoints and communication modes might have the greatest impact on FIT completion rates. 18

Next Steps Main Trial Patients who have never completed a FIT, have not had a recent clinic visit, or speak English may benefit from in- person or phone-based discussions about the importance of colon cancer screening. To boost screening in the group that has never completed a FIT, future work will test the effectiveness of live phone calls delivered before a FIT is mailed. Conduct budget impact analysis 19

Acknowledgements Kaiser Center for Health Research Gloria Coronado, PhD Michael Leo, PhD David Smith, PhD Jennifer Schneider, MS Amanda Petrik, MS Sacha Reich, MS Jennifer Rivelli, MA Jamie Thompson, MPH Analyst: Denis Nyongesa Graphics: Lisa Fox, Alex Wijnen-Hannon Oregon Health & Science University Melinda Davis, PhD LeAnn Michaels, BS AltaMed Health Services Alex Chen, MD Anne Escaron, PhD Melissa Castillo, MSW Brittany Younger, MSW Marta Castro, BA Funding is provided by the National Institutes of Minority Health and Health Disparities 20

Thank you! Questions? Jamie Thompson, MPH Project Director, PROMPT Kaiser Permanente Center for Health Research Portland, OR Phone: (503) 335-6335 Email: Jamie.H.Thompson@kpchr.org 21