br The study wide ICER for STOP CRC of
The study-wide ICER for STOP CRC of $483 per SEP-adjusted completed FIT ($441 in lagged data) is somewhat higher than those of other CRC screening outreach studies (Lewis et al., 2008; Tangka et al., 2013; Liss et al., 2016; Sequist et al., 2010; Meenan et al., 2015). However, each of these studies diﬀer from ours in significant ways, ranging from multi-modality (Lewis) to clinical cost assessment (Tangka) to simulation-based budget impact analysis (Liss) to a multi-specialty group practice (Sequist) to an integrated health care system in which all patients had insurance, with colonoscopy costs all or mostly covered and with easy access to endoscopy services (Meenan). This diﬀers from Rottlerin clinics, in which screening colonoscopies are less common because of less insurance coverage and limited access (Bass et al., 2011; Davis et al., 2017; Ferreira et al., 2005; Robinson et al., 2011).
To our knowledge, this is the first cost-eﬀectiveness analysis of a pragmatic CRC screening study conducted across a variety of FQHCs. The overall ICERs mask considerable heterogeneity in performance
across the eight participating organizations. In both primary and lagged data, in three organizations the intervention did not increase the number of SEP-adjusted completed FITs over usual care. In the other organizations, the ICERs varied widely. This was in part due to the pragmatic aspects of the STOP CRC trial in which organizations im-plemented the intervention in a manner appropriate for their system and resources. The study's pragmatic nature likely resulted in higher costs for clinic staﬀ to conduct data cleaning and training, especially in smaller clinics without extensive organizational infrastructure.
The pragmatic design may also have contributed to our observation, within the primary dataset, that the proportion of abnormal FITs re-ceiving follow-up colonoscopy was higher in usual care clinics than in intervention clinics, which decreased the overall incremental cost per returned FIT. This could reflect small-sample randomness or could re-flect the fact that usual care clinics primarily distributed FIT kits during clinical encounters; such kits typically received better follow-up than mailed kits. An abnormal result in usual care would prompt a provider referral following a visit in which the kit was distributed. A mailed FIT may have had an abnormal result, but a more recent colonoscopy could have been found in the patient's record, co-morbidities (e.g., cancer) that made colonoscopy follow-up inappropriate, or the patient may simply have been lost to follow-up.
Despite the heterogeneous results across organizations, a few les-sons from our experience may be useful to future adopters. First, since mailing activities represent the largest portion of cost across organi-zations, dissemination methods that can be integrated well into regular staﬀ activities would enhance the eﬃciency of programs such as STOP CRC. This is especially salient, given the varied ability of clinics to reach screening-eligible patients. As noted earlier, screening uptake among contacted patients was comparable to many previous studies, so
HC: Health Center
staﬀ training in eﬃcient dissemination methods could yield significant benefits in terms of more screened patients. Second, macroevolution is important to exploit extant programs whenever possible, e.g., use existing quality improvement staﬀ, if available, to enhance consistent and eﬃcient program delivery. Third, “scrubbing” data records (i.e., removing or amending incorrect, incomplete, or duplicate data) is expensive. Processes that generate correct and current data the first time will fa-cilitate eﬃcient identification of relevant screening events. Fourth, clinics will benefit from the continued rollout of EHR systems within FQHCs and related tools, such as Reporting Workbench. As these sys-tems become more prevalent, and clinic staﬀ become more experienced users, challenges, for example, of data capture (e.g., colonoscopy un-derreporting, verification of FIT mailing) should gradually lessen, re-ducing costs. This is not to ignore the importance of external factors such as staﬀ turnover and conflicting management priorities, but simply to acknowledge the potential for improved information flows that will enhance the success of programs such as STOP CRC. Fifth, always be in a “learning” mode; clinics should use documented evidence and the experience of other systems to inform their ongoing program activities. To that end, regular meetings with other implementing clinics can help participants learn from each other's successes and failures.