Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial

Abstract

Objective To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965. Design Pragmatic randomized controlled trial. Setting 43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020. Participants Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period. Interventions This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content). Main outcome measures Proportion of patients who completed HCV testing within four months. Results 21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001). Conclusions Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages. Trial registration ClinicalTrials.gov NCT03712553 .

Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake

“… 4 , 5 , 6 However, these same biases can often be overcome or even harnessed with different message frames that increase uptake of screening and vaccination. 7 , 8 , 9 The concept of endowment suggests that people place higher value on items in their possession. If the vaccine is described as already reserved for the patient, that approach could take advantage of this sense of ownership, as patients may feel remorse giving up the allocated vaccine.…”

“…The second approach was to deploy insights from the field of behavioral science, as humans have systematic biases or heuristics that impede participation in health prevention activities . However, these same biases can often be overcome or even harnessed with different message frames that increase uptake of screening and vaccination . The concept of endowment suggests that people place higher value on items in their possession.…”

Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients

“…Yartel et al conducted a cluster randomized trial at an academic medical center and found that a conventional interruptive best-practice alert to the medical assistant and clinician in a primary care setting resulted in an increase in screening completion from 3.6% in the control group to 30.9% in the intervention group. Another trial in the primary care setting at our own health system showed that bulk ordering with opt-out framing increased HCV screening from 19.2% to 43.1%. Interestingly, in the outpatient setting, only 0.4% of screening tests completed were positive for viral load, whereas 1.6% were positive in the previous study, suggesting that inpatients may have a higher risk of HCV.…”

Keynote Session: Strategies for Prevention and Control of HPV-Associated Cancers

“…He reported that rates doubled, from 19% to 43%. 6 But perhaps the most actionable step, Dr. Mehta said, is to require families and adolescents to "opt out" rather than "opt in" for the vaccine. In other words, make vaccination the default option, which ensures it is easier to get the vaccine than to refuse it.…”