Introduction: Evidence suggests that wordless instructions might increase fecal immunochemical test (FIT) completion for colorectal cancer (CRC) screening. Through a population health CRC screening program, we distributed FITs and letters that included either a quick response (QR) code (Figure 1) linked to a video with FIT instructions or wordless instructions. The aim of this study was to determine the association between FIT completion and the type of letter received (QR code vs wordless instructions).

Methods: Our study setting was the CRC screening program at the Fred Hutchinson Cancer Center & University of Washington Medicine - a comprehensive cancer center and a large integrated health system that includes Harborview Medical Center (HMC), a safety-net health system. English- and Spanish- speaking patients eligible for outreach were randomized 1:1 to receive a letter with a QR code or wordless instructions between March and July 2023. QR videos were developed in partnership with HMC’s ethnic medicine group, a source for socially and culturally appropriate healthcare materials. The wordless instructions were developed by Coronado GD et al. and adapted by the San Francisco Health Network’s Cancer Outreach Initiative. Demographic factors and clinical outcomes, including FIT completion, were abstracted from electronic health records and the CRC screening program database.

Results: Of the 13,471 English-speaking patients who received mailed outreach, 6733 received a QR code and 6738 received wordless instructions. Among 508 Spanish-speaking patients, 251 received a QR code letter and 257 received wordless instructions. Patient demographic factors are summarized in Table 1. English-speaking patients were more likely to complete a FIT after receiving the QR code letter vs. wordless instructions (33.4% vs 30.3%, p<0.01) but this pattern was not observed in Spanish-speaking patients (36.2% vs. 33.5%, p=0.52). The median (interquartile range (IQR)) time to FIT completion among English-speaking patients who received a QR code vs. wordless instructions was 24 days (14-52) vs. 22 days (12-46); p<0.01). Among Spanish-speaking patients the median time to FIT completion for QR code vs. wordless instructions was 21 days (13-40) vs. 21 (14-48); p=0.16).

Conclusions: Mailed FIT outreach improves CRC screening, but participation may be further enhanced by simple step-by-step instructions. By embedding different types of FIT instructions in a centralized CRC screening program, we found that FIT return rates were higher for both English- and Spanish- speaking patients after receiving a QR code letter, however these results were only statistically significant for the English-speaking population. Offering multiple formats for FIT instructions might be a practical strategy for health systems that seek to improve CRC screening rates through mailed outreach.

Jerry Wood

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