An Automated Intervention With Stepped Increases in Support to Increase Uptake of Colorectal Cancer Screening

Abstract

Background Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals. Objective To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years. Design 4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047) Setting 21 primary care medical centers. Patients 4675 adults aged 50 to 73 years not current for CRC screening. Intervention Usual care, EHR-linked mailings (“automated”), automated plus telephone assistance (“assisted”), or automated and assisted plus nurse navigation to testing completion or refusal (“navigated”). Interventions were repeated in year 2. Measurements The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2). Results Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]). Limitation Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability. Conclusion Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly. Primary Funding Source National Cancer Institute, National Institutes of Health.

Get Screened: A Randomized Trial of the Incremental Benefits of Reminders, Recall, and Outreach on Cancer Screening

“…Our results support those of previous studies. 11,[22][23][24] Green et al recently found that an automated mailing led to twice as many persons being screened for colorectal cancers. 23 Adding navigated interventions, such as guided support from a registered nurse, led to further improvements in CRC screening rates.…”

Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial

“…13 Several randomized trials have reported that outreach with FOBT can improve CRC screening rates. [14][15][16][17][18][19][20] However, most were conducted in integrated health plans. 15 , 16 , 18 , 19 Few targeted vulnerable populations cared for in community health centers (CHCs) and other safety net settings.…”

“…[14][15][16][17][18][19][20] However, most were conducted in integrated health plans. 15 , 16 , 18 , 19 Few targeted vulnerable populations cared for in community health centers (CHCs) and other safety net settings. [21][22][23][24] We previously reported that a multifaceted outreach and reminder intervention using mailed FITs increased adherence to annual screening, compared to point-of-care strategies that maximize FIT distribution at clinic visits, for patients due for repeat screening.…”

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

“…[4][5][6][7][8] However, CRC screening rates remain suboptimal, even after decades of public health campaigns, public reporting of health plan CRC screening rates, and implementation of visitbased preventive service reminders in electronic health records (EHRs). 4,7,[9][10][11] Therefore, a growing number of private and public health systems are taking a population health perspective and using outreach approaches to promote CRC screening that do not require a face-to-face primary care visit. 12 Active outreach strategies, such as mailed invitations for colonoscopy and/or stool blood testing, can substantially increase screening rates.…”

“…12 Active outreach strategies, such as mailed invitations for colonoscopy and/or stool blood testing, can substantially increase screening rates. [9][10][11] The extent to which primary care continues to play an important role in CRC screening in health systems with active population screening outreach programs is unknown.…”