Background <p>The multi-target stool DNA (mt-sDNA) test is a growing and convenient option for colorectal cancer (CRC) screening. Adherence to screening is critical to optimize patient outcomes. This study aimed to evaluate real-world adherence to mt-sDNA testing and the rate of follow-up colonoscopy after positive results among average-risk patients within a large regional health system.</p> Methods <p>This retrospective cohort study included patients aged 45–75 years in the Hartford HealthCare system whose provider ordered an mt-sDNA test between August 2014 and May 2023. Those at high risk of CRC were excluded. Adherence was defined as the return of a successfully completed test with valid results within 365&#xa0;days of shipment. Rates of and time to follow-up colonoscopy were assessed in mt-sDNA–positive patients. Logistic regression assessed characteristics associated with adherence.</p> Results <p>Of 24,945 included patients, 96.8% had never previously taken an mt-sDNA test and 60.5% were female. Overall, 17,240 patients (69.1%) adhered to the mt-sDNA test. Younger adults aged 45–49 years had high adherence (74.0%). Logistic regression found age 45–49 years, income &gt; $75K, history of mt-sDNA adherence, and seeing a gastrointestinal specialist were predictors of greater adherence. Of 2,468 patients (14.3%) with positive test results, 1,686 (68.3%) had follow-up colonoscopies within a year, and 1,322 (53.6%) within 4 months, of the test result.</p> Conclusions <p>In this regional health system, nearly 70% of patients adhered to mt-sDNA testing. Among those with positive results, 68.3% completed follow-up colonoscopies. These findings highlight the potential utility of mt-sDNA testing in supporting CRC screening and follow-up in certain clinical settings.</p> Impact <p>mt-sDNA testing may support improved CRC screening adherence and timely follow-up in certain health care settings.</p>