Real-World Completion of Multitarget Stool DNA Testing Among Texas Medicare Beneficiaries: Associations With Payer Type, Digital Outreach, and Social Vulnerability

Background Colorectal cancer is a leading cause of cancer-related morbidity and mortality in the United States; however, a substantial proportion of eligible adults do not complete screening. Objectives To evaluate real-world completion of multitarget stool DNA (mt-sDNA) testing for colorectal cancer screening among Medicare beneficiaries in Texas and to identify beneficiary-, provider-, and outreach-related factors associated with test completion. Methods This retrospective cohort study included Texas beneficiaries aged 65 to 85 years with traditional Medicare or Medicare Advantage coverage who received an mt-sDNA kit between October 2014 and December 2024. Completion was defined as return of a valid test kit within 1 year of shipment. Multivariable logistic regression was used to identify factors associated with completion. Kaplan–Meier and Cox proportional hazards models were used to evaluate time to kit return. Results Among 710 515 beneficiaries, 538 377 (75.8%) completed mt-sDNA testing within 1 year. Completion was higher among beneficiaries with traditional Medicare vs Medicare Advantage (81.7% vs 71.7%). In adjusted analyses, gastroenterologist ordering (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.53-2.79), full digital outreach (OR, 1.73; 95% CI, 1.69-1.77), and prior mt-sDNA use (OR, 1.61; 95% CI, 1.59-1.64) were associated with higher odds of completion. Higher neighborhood income and lower social vulnerability were also associated with higher completion rates. Time-to-event analyses were consistent, with faster completion observed among patients receiving digital outreach, with prior mt-sDNA use, and those with gastroenterologist-ordered tests. Discussion These findings suggest that both patient context and modifiable care delivery factors influence screening completion and may inform the design of more effective and equitable CRC screening programs. Conclusions In this large real-world Medicare cohort, mt-sDNA completion was high overall but varied by payer type, provider specialty, outreach modality, and socioeconomic vulnerability.