Financial Incentives Result in Small Increase in CRC Screening

Adding financial incentives to outreach provides a small uptick in the number of people who complete colorectal cancer screening, according to a meta-analysis of eight randomized clinical trials published August 25, 2021, in JAMA Network Open.

Investigators estimated that mailed outreach results in 30% screening completion, and adding financial incentives may increase the completion rate to 33.5%. Investigators found the same uptick regardless of how the incentive was structured, the amount of the incentive, screening test, or mode of outreach.

But they also found an even smaller increase in screening in the studies conducted in low-income neighborhoods and communities of racial/ethnic minorities. Investigators speculate this may have more to do with social determinants of health.

“Financial incentives represent a nudge that makes desired activities easier to do,” investigators wrote. “Underserved individuals may have such low awareness as well as face limited access and systemic barriers to health promotion that small incentive amounts may not be sufficient to overcome the systemic challenges. Other factors, such as health literacy regarding how the incentive was presented, could create higher barriers to perceiving the benefit, in particular when conditional or lottery-based incentives.”

The National Cancer Institute estimates that in 2021, there will be an estimated 149,000 new cases of colorectal cancer, representing 7.9% of all new cancers. In 2018, there were an estimated 1,365,135 people living with colorectal cancer in the United States. Early screening is associated with a decrease in incidence and deaths from colon cancer.

The CDC recommends that adults begin screening for colorectal cancer beginning at age 45. The U.S. Preventive Services Task Force in May 2021 lowered the guidelines for screening from age 50 to 45.

In 2018, about 68% of eligible adults were up to date on screening, according to the CDC. People who do not get screened cite several reasons, including fear, embarrassment, financial difficulties, logistical challenges, and it being a low priority.

Investigators in this analysis searched for randomized clinical trials that involved adults older than 50 years who were eligible for colorectal screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone. The search strategy identified 835 studies, of which eight trials met the inclusion criteria and were included in the meta-analysis. The incentives offered were generally less than $20.

Investigators caution, however, that the studies selected could have a risk of bias because participants could not be blinded. Three studies were deemed to be moderate quality, and the others were rated as low quality because of inadequate follow-up, lack of physician blinding, or mixed population.