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

Abstract

BACKGROUND:Rates of breast cancer (BC) and colorectal cancer (CRC) screening are particularly low among poor and minority patients. Multifaceted interventions have been shown to improve cancer-screening rates, yet the relative impact of the specific components of these interventions has not been assessed. Identifying the specific components necessary to improve cancer-screening rates is critical to tailor interventions in resource limited environments. OBJECTIVE: To assess the relative impact of various components of the reminder, recall, and outreach (RRO) model on BC and CRC screening rates within a safety net practice. DESIGN: Pragmatic randomized trial. PARTICIPANTS: Men and women aged 50-74 years past due for CRC screen and women aged 40-74 years past due for BC screening. INTERVENTIONS: We randomized 1,008 patients to one of four groups: (1) reminder letter; (2) letter and automated telephone message (Letter + Autodial); (3) letter, automated telephone message, and point of service prompt (Letter + Autodial + Prompt); or (4) letter and personal telephone call (Letter + Personal Call). MAIN MEASURES: Documentation of mammography or colorectal cancer screening at 52 weeks following randomization. KEY RESULTS: Compared to a reminder letter alone, Letter + Personal Call was more effective at improving screening rates for BC (17.8 % vs. 27.5 %; AOR 2.2, 95 % CI 1.2-4.0) and CRC screening (12.2 % vs. 21.5 %; AOR 2.0, 95 % CI 1.1-3.9). Compared to letter alone, a Letter + Autodial + Prompt was also more effective at improving rates of BC screening (17.8 % vs. 28.2 %; AOR 2.1, 95 % CI 1.1-3.7) and CRC screening (12.2 % vs. 19.6 %; AOR 1.9, 95 % CI 1.0-3.7). Letter + Autodial was not more effective than a letter alone at improving screening rates. CONCLUSIONS:The addition of a personal telephone call or a patient-specific provider prompt were both more effective at improving mammogram and CRC screening rates compared to a reminder letter alone. The use of automated telephone calls, however, did not provide any incremental benefit to a reminder letter alone.KEY WORDS: cancer screening; colorectal cancer; breast cancer; outreach; inreach.

Improving Breast and Colon Cancer Screening Rates: A Comparison of Letters, Automated Phone Calls, or Both

“…25,[27][28][29] The addition of automated phone calls to letters nearly doubled rates of mammography screening and increased rates of CRC screening by 8%. Yet in a previous study we found that the use of automated phone calls was of no additional benefit beyond that of a personalized letter alone in improving cancer screening rates (12.2% vs 15.3%; P Ͼ 0.05) 21 The difference in findings may have resulted from higher poverty rates in the previous study and correspondingly lower automated phone reminder completion rates (82% vs 91%). These differences also could reflect possible differences in patients' responses to automated calls within the 2 practices.…”

“…We previously found relatively greater improvements in cancer screening from combined outreach and point-of-care prompts, suggesting that both outreach and in-reach may be needed to optimize responses. 20,21 Organized team approaches may also help. 37 With implementation of the Affordable Care Act, physician revenues are becoming more dependent on achieving certain quality metrics such as cancer screening rates.…”

“…Our previous research showed that interventions caused smaller absolute increases in screening among uninsured pa-tients. 20,21 The conditions indicating a higher risk of cancer based on chart data abstraction included prior cancer, premalignant conditions (eg, ulcerative colitis, familial polyposis), inadequately evaluated breast masses, positive FOBT/FIT result at last testing, or a first-degree relative with a previous diagnosis of BC or CRC. Higher-risk patients and those without insurance who were past due were not randomized but were given the most intensive intervention, that is, both a letter and an automated phone call, and were not analyzed.…”

“…18 A systematic review confirmed the benefit of mailed reminders for BC and CRC screening. 19 Our own research suggests that multimodal interventions are effective, 20,21 but which component(s) of the interventions really prompted increases in screening rates is unclear from prior studies.…”

Capsule Commentary on Fortuna et al., Get Screened: A Randomized Trial of the Incremental Benefits of Reminders, Recall, and Outreach on Cancer Screening

“…F ortuna et al 1 assess and compare the effectiveness of phone, mail, and personal reminders as methods to improve rates of breast and colorectal cancer screening in an underserved population. Compared to reminder letters alone, cancer screening rates were increased with the addition of reminders at the point of care or a personalized phone call.…”