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Invited Commentary
Gastroenterology and Hepatology
August 25, 2021

Financial Incentives to Improve Colorectal Cancer Screening—Time to Cut Our Losses

Author Affiliations
  • 1Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 2Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle
  • 3National Gastroenterology and Hepatology Program, Veterans Health Administration, VA Puget Sound Health Care System, Seattle, Washington
JAMA Netw Open. 2021;4(8):e2122661. doi:10.1001/jamanetworkopen.2021.22661

Colorectal cancer (CRC) screening reduces mortality from this second leading cause of cancer deaths in the United States.1 However, only 69% of eligible adults in the United States are up to date with CRC screening, with lower rates of screening among racial/ethnic minority groups and individuals with lower socioeconomic status.1 Therefore, evidence-based interventions to improve CRC screening adherence are needed, especially interventions that address screening disparities.

In their systematic review and meta-analysis of randomized clinical trials (RCTs), Facciorusso et al,2 evaluated the benefit of financial incentives for CRC screening uptake. This study included RCTs of adults who were eligible for CRC screening and received various financial incentives (fixed-amount or lottery-based incentives that were unconditional or conditional on screening completion) or no financial incentives (screening reminders or mailed outreach alone). The primary outcome of interest was CRC screening completion using recommended tests within 12 months of receiving the intervention. The authors analyzed 8 RCTs, which represented 110 644 patients (53 444 were offered financial incentives, and 57 200 were not offered financial incentives). These US-based studies, which were published between 2014 and 2020, included screening with fecal occult blood test or fecal immunochemical test (FIT; 4 RCTs), colonoscopy (3 RCTs), or other approved screening tests (1 RCT). The economic interventions included fixed amounts of $5 to $20, lotteries with a 1:10 chance of winning $50 to $100, and even a raffle with a $500 prize.2

Facciorusso et al2 found that adding financial incentives was estimated to improve the CRC screening rate only modestly, such that for those who were undergoing stool-based testing, screening adherence would be expected to increase by 3.5% from a baseline of 30% to 33.5%. The study also revealed that the magnitude of benefit from adding financial incentives decreased as the proportion of individuals who had lower socioeconomic status, were from racial/ethnic minority groups, and were overdue for CRC screening increased.2 These populations are disproportionately affected by CRC and among whom the need to improve CRC screening is the greatest. Furthermore, these findings were not significantly affected by the type or amount of incentive or the screening modality. Among higher-quality studies and those that included only individuals who were not up-to-date with screening, financial incentives had no significant benefit.

Behavioral economics principles suggest that financial incentives are useful when behavioral change can reduce future health expenditures.3 For this reason, financial incentives have been explored to promote smoking cessation, physical activity, cancer screenings, and vaccinations, including against COVID-19. Evidence shows that financial incentives may motivate behavioral change when the change is simple (eg, one-time change), is tied to controllable outcomes, and reinforces what individuals already want to do.4 As Facciorusso et al2 reported, the benefit of adding financial incentives was significantly higher when CRC screening completion was assessed within 3 months of receiving the incentive than at longer intervals. This finding is consistent with the theory that individuals who are already primed to complete CRC screening may be motivated to do so with a financial incentive.

When it comes to financial incentives, size matters. Small incentives, which were most frequently examined in the included RCTs, can sometimes backfire by decreasing intrinsic motivation and performance compared with no incentive at all.5 Rather than focusing on the intrinsic health benefits of screening, some individuals may interpret the offer of an incentive as compensation for exposure to adverse aspects of the test. Thus, those who receive a financial incentive may defer future screenings without a monetary reward. Conversely, large incentives could potentially be coercive, especially in CRC screening, which is needed the most by historically marginalized and underserved populations.4 Although money may be a powerful motivator, the benefits of financial incentives might not be realized in CRC screening because it requires repeated testing over many years and the outcome of each screening episode is uncertain.

Facciorusso et al2 found little evidence to support financial incentives, but other interventions have been demonstrated to consistently increase CRC screening uptake.6 Such interventions include mailed FIT outreach7 and patient navigation, which assists individuals through the screening process beginning with the decision to complete screening and ending with a plan for follow-up of abnormal results or repeated screening. Implementation of proven strategies are especially important given the recent Grade B recommendation from the US Preventive Services Task Force to begin CRC screening in adults aged 45 to 49 years.1 As a result, an additional 20 to 22 million US residents are now eligible for CRC screening. Although colonoscopy remains the primary modality for CRC screening in the United States, greater demand for this limited resource may lead to increased adoption of population health strategies, including mailed FIT outreach. Because the screening behavior of individuals aged 45 to 49 years is unknown, financial incentives may be explored to incentivize screening in this population. However, based on the mounting evidence on this topic as summarized by Facciorusso et al,2 we would advise investigators to proceed with caution. Considering the limited health care dollars available, future resources might be best spent doubling down on interventions that have demonstrated efficacy and cost-effectiveness, such as mailed FIT7 outreach and patient navigation. Doing so could be critical for individuals in racial/ethnic minority groups, those with lower socioeconomic status, and other populations that have yet to realize the full benefit of CRC screening.

Multiple other aspects of CRC screening could benefit from financial investments. First, we need to ensure that CRC screening, whether through FIT, colonoscopy, or another recommended modality, is high quality. For example, timely completion of colonoscopy to evaluate an abnormal noncolonoscopic screening test would reduce CRC-associated mortality. Unfortunately, adherence to follow-up procedures is highly variable, ranging from 30% to 82%.6 Second, we need to address persistent race/ethnicity– and socioeconomically based disparities in CRC mortality as a result of inadequate screening. Third, we need to couple our efforts to minimize the underutilization of CRC screening with strategies to address the potential harms from overutilization (eg, screening those who are too frail to benefit).

The study by Facciorusso et al2 suggests that it is time we stop giving small financial incentives to individuals for questionable short-term benefits and to begin investing in practices that remove known patient, clinician, health system, and policy barriers to screening. As the saying goes, “money isn’t everything,” but in CRC screening, investing in evidence-based strategies could be everything for those who are affected by this all too common but highly preventable disease.

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Article Information

Published: August 25, 2021. doi:10.1001/jamanetworkopen.2021.22661

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Issaka RB et al. JAMA Network Open.

Corresponding Author: Jason A. Dominitz, MD, MHS, National Gastroenterology and Hepatology Program, Veterans Health Administration, 111-S-Gastro, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108 (jason.dominitz@va.gov).

Conflict of Interest Disclosures: Dr Issaka reported receiving grants from the National Cancer Institute of the National Institutes of Health outside of the submitted work. No other disclosures were reported.

Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of the National Institutes of Health, the US Department of Veterans Affairs, or the US government.

References
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Facciorusso  A, Demb  J, Mohan  BP, Gupta  S, Singh  S.  Addition of financial incentives to mailed outreach for promoting colorectal cancer screening: a systematic review and meta-analysis.   JAMA Netw Open. 2021;4(8):e2122581. doi:10.1001/jamanetworkopen.2021.22581Google Scholar
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Pauly  MV, Held  PJ.  Benign moral hazard and the cost-effectiveness analysis of insurance coverage.   J Health Econ. 1990;9(4):447-461. doi:10.1016/0167-6296(90)90005-N PubMedGoogle ScholarCrossref
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Gneezy  U, Meier  S, Rey-Biel  P.  When and why incentives (don't) work to modify behavior.   J Econ Perspect. 2011;25:191-210. doi:10.1257/jep.25.4.191 Google ScholarCrossref
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Issaka  RB, Avila  P, Whitaker  E, Bent  S, Somsouk  M.  Population health interventions to improve colorectal cancer screening by fecal immunochemical tests: a systematic review.   Prev Med. 2019;118:113-121. doi:10.1016/j.ypmed.2018.10.021 PubMedGoogle ScholarCrossref
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Gupta  S, Coronado  GD, Argenbright  K,  et al.  Mailed fecal immunochemical test outreach for colorectal cancer screening: summary of a Centers for Disease Control and Prevention-sponsored Summit.   CA Cancer J Clin. 2020;70(4):283-298. doi:10.3322/caac.21615PubMedGoogle ScholarCrossref
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