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Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial

Gupta, Samir MD, MSCS1,2; Miller, Stacie RN, MSN, MPH3; Koch, Mark MD3; Berry, Emily MSPH4; Anderson, Paula RN, MN5; Pruitt, Sandi L MPH, PhD5,6; Borton, Eric MS6; Hughes, Amy E PhD6; Carter, Elizabeth MD3; Hernandez, Sylvia NRCMA3; Pozos, Helen NRCMA3; Halm, Ethan A MD5,6,7; Gneezy, Ayelet MBA, PhD8; Lieberman, Alicea J MPH, PhD-C8; Skinner, Celette Sugg MA, PhD5,6; Argenbright, Keith MD, MMM4,5,6; Balasubramanian, Bijal MBBS, PhD5,9

American Journal of Gastroenterology: November 2016 - Volume 111 - Issue 11 - p 1630–1636
doi: 10.1038/ajg.2016.286

OBJECTIVES: Offering financial incentives to promote or “nudge” participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population.

METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50–64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis.

RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%,P=0.32 vs. no incentive) or $5 incentive (39.2%,P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups.

CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

1San Diego Veterans Affairs Healthcare System, San Diego, California, USA

2Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, San Diego, California, USA

3Department of Family Medicine, John Peter Smith Health Network, Fort Worth, Texas, USA

4UT Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas, USA

5University of Texas Southwestern Medical Center Harold C. Simmons Cancer Center, Dallas, Texas, USA

6Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, USA

7Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA

8Rady School of Management, University of California San Diego, La Jolla, California, USA

9Department of Epidemiology, Genetics, & Environmental Science, University of Texas School of Public Health Dallas Regional Campus, Dallas, Texas, USA

Correspondence: Samir Gupta, MD, MSCS, Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, 3350 La Jolla Village Dr, MC 111D, San Diego, California 92160, USA. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at,,

Received 21 January 2016; accepted 06 June 2016

Guarantor of the article: Samir Gupta, MD, MSCS.

Specific author contributions: Planning and/or conducting the study, collecting and/or interpreting data, and drafting the manuscript: all authors.

Financial support: The study is funded by the Cancer Prevention and Research Institute of Texas #PP120229 (Argenbright, PI).

Potential competing interests: None.

© The American College of Gastroenterology 2016. All Rights Reserved.
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