Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

Abstract

BackgroundA national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.ObjectiveTo evaluate the effectiveness of an enhanced invitation method using the question–behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.DesignThree-arm randomised trial and cohort study.ParticipantsAll participants invited for a health check from 18 general practices. Individual participants were randomised.Interventions(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.Main outcome measuresThe primary outcome was completion of the health check within 6 months of invitation. Ap-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving ‘opportunistic’ health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.ResultsIn total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) –0.12% to 2.97%;p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI –0.03% to 3.07%;p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was –0.01% (95% CI –1.59% to 1.58%;p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an ‘opportunistic’ health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99;p < 0.001).ConclusionsUptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.Trial registrationCurrent Controlled Trials ISRCTN42856343.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care

“…Overall uptake of health checks in response to an invitation was low and our results do not exclude the possibility of an effect of the intervention in the context of higher overall uptake. In the present context, low health check uptake might be explained by service organization and delivery factors that impede the ease with which people can obtain a health check [28].…”

“…Trial practices tended to have larger patient list sizes than non-trial practices but showed similar levels of achievement of clinical performance metrics. Trial practice populations were similar with respect to social and material deprivation and proportion of non-White participants to the entire populations of the two boroughs [28]. Each practice participated in the trial for a minimum of 12 months to allow for seasonal variation in uptake of health checks.…”

“…The first 2 months were therefore considered to act as a pilot study and data from these months were excluded from the main trial analysis. The two randomization methods are compared in detail elsewhere [28].…”

“…The development of the intervention has been described in more detail elsewhere [28,30]. Following Conner et al [17], the QBE questionnaire drew on the Theory of Planned Behavior (TPB) with additional items for anticipated regret [31].…”

Patient experiences of telephone outreach to enhance uptake of NHS Health Checks in more deprived communities and minority ethnic groups: A qualitative interview study

“…Various methods aimed at increasing uptake of invitations to NHS Health Checks have been investigated. A review of evidence found modified invitation letters and use of text messages to be promising methods for the general eligible population . However, it is of particular interest to understand how to increase uptake amongst groups who may be at higher risk of cardiovascular disease.…”