Multi-modal quality improvement's impact on colorectal cancer screening among people experiencing homelessness at a safety-net clinic.

Abstract

e23290 Background: Preventive cancer screening rates are low among people experiencing homelessness (PEH), contributing to high cancer-related mortality. Fecal immunohistochemical tests (FITs) paired with quality improvement (QI) offer a scalable approach to promote colorectal cancer (CRC) screening in PEH, but evidence is limited. This Lean QI project aimed to improve CRC screening rates among PEH at Venice Family Clinic (VFC), a federally qualified health center in Los Angeles. Methods: Building on prior root cause analysis at The People Concern Annenberg Access Center (OPCC), a PEH-serving site within VFC, five interventions were sequentially employed over each of five months (Apr-Aug 2025): 1) shifting staff roles for FIT handling; 2) permanent $10 grocery card incentive for FIT return; 3) clinic posters promoting screening; 4) provider training to discuss bathroom access; 5) visual-based CRC and FIT education. Measures were obtained monthly including CRC screening rate (outcome), FIT order rate, and FIT completion rate within 2 months (process), with balance measures pending. Pre- (Dec 2024-Mar 2025) and post-intervention (Apr-Nov 2025) comparisons were made against a concurrent control clinic within VFC using a difference-in-differences (DiD) design. Logistic regression estimated pre–post changes and DiD odds ratios. Parallel trends were assessed with pre-intervention slope comparisons. Event study analyses were conducted when appropriate. Results: Baseline characteristics and CRC screening disparities at VFC were previously reported. OPCC saw 36.5 ± 9.6 screening-eligible PEH per month across the study period compared to 236.3 ± 29.8 PEH at the control clinic. CRC screening rates for PEH at OPCC increased from 26.3% pre- to 42.5% post-intervention (OR 2.07, 95% CI 1.35-3.17; p<0.001) but declined at the control clinic (32.6% to 29.2%; OR 0.85, 95% CI 0.72-1.01; p=0.062). DiD analysis showed significant intervention effect (OR 2.43, 95% CI 1.54-3.84; p<0.001) with a null placebo test (OR 1.08; p=0.688). Event study analysis indicated the largest post-intervention gain began in month three. FIT order rates for eligible PEH rose at OPCC from 27.1% to 70.3% (OR 6.35, 95% CI 3.71-10.87; p<0.001) and modestly at the control clinic (23.4% to 36.5%; OR 1.88, 95% CI 1.52-2.33; p<0.001). FIT completion rates increased at OPCC from 15.6% to 35.8% (OR 3.02, 95% CI 1.08-8.40; p<0.05) but declined at the control clinic (40.7% to 12.9%; OR 0.22, 95% CI 0.14-0.33; p<0.001). Pre-intervention trends for FIT process measures were non-parallel, limiting causality. Conclusions: A multi-modal QI intervention was associated with significant improvement across all CRC screening measures for PEH at a safety-net setting, with shifted staff roles and FIT incentives seeming to most benefit total screening rates. Future work aims to target linkage to colonoscopy and oncology care.