Abstract
INTRODUCTION: Low-literacy, pictorial instructions improve fecal immunochemical test (FIT) completion and might enhance colorectal cancer (CRC) screening. The aim of this study was to compare FIT completion among English-speaking and Spanish-speaking patients in an organized CRC screening program based on the type of instructions received (quick response [QR] code linked to video vs pictorial instructions). METHODS: In this randomized controlled quality improvement study, English-speaking and Spanish-speaking patients eligible for mailed outreach through an organized CRC screening program were randomized 1:1 to receive a FIT kit with either a QR code-linked video or pictorial instructions in their preferred language. Patient demographics (sex, age, race, ethnicity, and insurance type) and clinical outcomes (FIT completion and time to completion) were abstracted from electronic health records. RESULTS: Thirteen thousand four hundred seventy-one English-speaking patients and 508 Spanish-speaking patients were included. Overall, 31.9% of patients who received mailed outreach completed CRC screening by FIT. However, FIT completion was higher among patients who received QR code instructions vs pictorial instructions (33.5% vs 30.4%, absolute difference 3.1%, 95% confidence interval 1.5%-4.6%). These findings were similar among English-speaking and Spanish-speaking patients. The median time to FIT completion was 2 days longer (24 days, 95% confidence interval 23-25) for patients who received QR code instructions versus pictorial instructions; however there was no difference in time to FIT completion by the language group. DISCUSSION: Providing QR code-based education offers a promising format for delivering low literacy instructions, which might be a practical strategy to improve FIT completion for CRC screening.