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Intervention helps colorectal cancer screening rates

Tuesday March 5, 2013
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Using electronic health records to identify patients who were not screened regularly for colorectal cancer, researchers doubled these patients’ rates of on-time screening and saved health costs over a two-year period, according to a study.

"Screening for colorectal cancer can save lives, by finding cancer early — and even by detecting polyps before cancer starts," study leader Beverly B. Green, MD, MPH, a family physician at Seattle-based Group Health and an affiliate investigator at Group Health Research Institute, said in a news release. "But screening can't help if you don't do it, and do it regularly.”

More than one in 20 Americans will develop colorectal cancer, which is second only to lung cancer in causing deaths from cancer, Green said. Screening for colorectal cancer is strongly recommended for everyone ages 50 to 75, but almost half of Americans do not get screened regularly. The screening rate is far below that for cervical and breast cancer.

As reported in the March 5 issue of the Annals of Internal Medicine, the SOS (Systems of Support to Increase Colorectal Cancer Screening) trial started by identifying 4,675 Group Health patients, ages 50 to 73, who were not up to date for colorectal cancer screening. The patients were randomly assigned to one of four groups.

The first group received "usual” care, which includes both patient and clinic reminders for those overdue.

The second group received usual care plus "automated" care, which included a letter informing them they were due for colorectal cancer screening and a pamphlet about screening choices and the pros and cons of three screening options recommended by Group Health and the U.S. Preventive Services Task Force: fecal occult blood testing yearly; flexible sigmoidoscopy every five years (with one FOBT in between); or colonoscopy every decade. Those patients who did not call to schedule a colonoscopy or sigmoidoscopy received a FOBT kit in the mail with illustrated instructions and a postage-paid return envelope, and a reminder letter three weeks later if the kit was not completed.

The third group received usual care, automated interventions and an additional step called "assisted" care if they still had not completed screening. Assisted care included a call from a medical assistant to ask which screening option they preferred and provide simple assistance to get screened, such as sending a request for a colonoscopy to the patient’s physician or reviewing the FOBT instructions.

The fourth group received usual care, automated care, the assisted intervention and an additional step called "navigated" care if they still were overdue for screening or requested a colonoscopy or sigmoidoscopy during the automated or assisted steps. Navigated care included a call from a nurse to advise patients and facilitate screening for those who wanted help in making their choice or did not get screened after the medical assistant's call. Patients who chose colonoscopy or sigmoidoscopy were helped with making an appointment and preparing for the procedure, and were followed until the test was completed.

Each step of the SOS intervention raised the percentage of patients who were current for colorectal screening for both years: 26% for usual, 51% for automated, 57% for assisted and 65% for navigated care.

The two-year costs of the automated intervention plus the screening were actually $89 lower than if the patients had received only usual care. The reason was that compared with patients who received usual care, more of those in the automated care group happened to choose FOBT instead of sigmoidoscopy or colonoscopy.

"Traditionally, the onus has been on each primary-care doctor to encourage their patients to get health screening tests on schedule," Green said. Group Health pioneered the use of a centralized registry to remind women to be screened regularly for breast cancer. "We borrowed that approach and applied it to colorectal cancer. We empowered patients to do testing on time, by giving them options or sending them a FOBT kit by default if no choice was made."

The researchers next plan "to test whether improved adherence persists for more than two years," Green said. This aspect particularly is important for patients who choose FOBT, which should be repeated every year. "We are also testing this intervention in 'safety-net' clinics, which serve low-income people," Green added. More of those clinics have electronic health records and can leverage the technology to provide population-based care, similar to Group Health and Kaiser Permanente.

The study abstract is available at http://annals.org/article.aspx?articleid=1656409.


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