PROJECT SUMMARY/ ABSTRACT Despite effective strategies for prevention, early detection, and treatment, colorectal cancer (CRC) remains the second leading cause of cancer death in the United States. While there have been considerable policy and system-level efforts to increase CRC screening rates, uptake remains well below national goals of 80% participation, and racial/ethnic disparities remain. Colonoscopy and FIT are considered evidence-based and top-tier tests for CRC screening, but most screening programs rely heavily on one of these tests. The overall goal of this proposal is to evaluate a multi-level intervention that could durably increase CRC screening rates by incorporating principles of behavioral economics, such as opt-out framing, simplifying choice, and effort reduction. Through partnership with the University of Pennsylvania Health System (UPHS), we will develop a centralized program that includes clinician-directed nudges facilitated by the electronic health record (EHR) and direct outreach to patients. We will also evaluate the effectiveness of sequential choice (colonoscopy, then FIT to those who defer or decline) compared to offering colonoscopy only. This is a 3-year pragmatic clinical trial with 2 x 3 factorial design at 30 diverse primary care practices with 20,000 average-risk patients who are overdue for screening. Clinicians will be cluster randomized in a 1:1 ratio (at the practice level) to A) colonoscopy only, or B) sequential choice (colonoscopy, then FIT if no colonoscopy is completed) nudges in the EHR during clinic visits (Aim 1). Concurrently, patients will be individually randomized in a 1:2:2 ratio to 1) no outreach, 2) colonoscopy only, or 3) sequential choice outreach of colonoscopy, then FIT (Aim 2). The primary outcome is completion of guideline-recommended colorectal cancer screening. Through surveys and qualitative interviews, we will explore patient and clinician factors impacting the effectiveness of the intervention.

PROJECT NARRATIVE Colorectal cancer is the 2nd leading cause of cancer death, and despite effective methods for prevention and early detection, screening rates remain low. Recent insights from behavioral economics have shown that reducing effort and providing timely nudges can encourage clinicians and patients to engage with preventive health activities. We will conduct a pragmatic trial evaluating if offering a sequential choice of screening options during clinic visits and through direct patient outreach can increase colorectal cancer screening completion.