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An Automated Intervention With Stepped Increases in Support to Increase Uptake of Colorectal Cancer Screening: A Randomized Trial

Beverly B. Green, MD, MPH; Ching-Yun Wang, PhD; Melissa L. Anderson, MS; Jessica Chubak, PhD, MBHL; Richard T. Meenan, PhD; Sally W. Vernon, PhD; and Sharon Fuller, BA
[+] Article, Author, and Disclosure Information

From the Group Health Research Institute, Group Health Physicians, University of Washington School of Medicine, Fred Hutchinson Cancer Center, and University of Washington School of Public Health, Seattle, Washington; Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and University of Texas School of Public Health, Houston, Texas.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Acknowledgment: The authors thank Robert S. Thompson, MD, Group Health Physicians, Group Health Permanente, study design; Kim Riddell, MD, Group Health Permanente, laboratory support; Peggy Rogers, Group Health Cooperative, laboratory support; David Carrell, PhD, Group Health Research Institute, programmer; Kathryn Horner, MS, San Francisco General Hospital; Ed Wagner, MD, MPH, Group Health Research Institute, McColl Center, conceptual model, advisor; Stephen Taplin, MD, MPH, National Cancer Institute, study design; Jackie St. John, BS, Group Health Research Institute, project manager; Andy Bogart, MS, Group Health Research Institute, biostatistician; Mary Lyons, BFA, Group Health Research Institute, research specialist; Kris Hansen, BA, Group Health Research Institute, research specialist; Chris Tachibana, PhD, Group Health Research Institute, scientific editor; Camille Campbell, BA, Group Health Research Institute, administrative support; and Annie Shaffer, BA, Group Health Research Institute, administrative support.

Grant Support: By grant R01CA121125 from the National Cancer Institute of the National Institutes of Health.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2071.

Reproducible Research Statement: Study protocol: Available from reference (10) or from Dr. Green (e-mail, green.b@ghc.org). Statistical code: Available from Ms. Anderson (e-mail, anderson.melissa@ghc.org). Data set: Available from Dr. Green (e-mail, green.b@ghc.org)

Requests for Single Reprints: Beverly B. Green, MD, MPH, Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466; e-mail, green.b@ghc.org.

Current Author Addresses: Dr. Green, Ms. Anderson, Dr. Chubak, and Ms. Fuller: Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466.

Dr. Wang: Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, PO Box 19024, Seattle, WA 98109-1024.

Dr. Meenan: Kaiser Permanente Center for Health, 3800 North Interstate Avenue, Portland, OR 97227-1098.

Dr. Vernon: The University of Texas Health Science Center at Houston, 7000 Fannin, UCT 2560, Houston, TX 77030-5400.

Author Contributions: Conception and design: B.B. Green, C.Y. Wang, R.T. Meenan, S.W. Vernon.

Analysis and interpretation of the data: B.B. Green, C.Y. Wang, M.L. Anderson, J. Chubak, R.T. Meenan, S.W. Vernon, S. Fuller.

Drafting of the article: B.B. Green, C.Y. Wang, M.L. Anderson, J. Chubak, R.T. Meenan, S.W. Vernon.

Critical revision of the article for important intellectual content: B.B. Green, C.Y. Wang, M.L. Anderson, J. Chubak, R.T. Meenan, S.W. Vernon, S. Fuller.

Final approval of the article: B.B. Green, C.Y. Wang, M.L. Anderson, J. Chubak, R.T. Meenan, S.W. Vernon, S. Fuller.

Provision of study materials or patients: B.B. Green.

Statistical expertise: B.B. Green, C.Y. Wang, M.L. Anderson.

Obtaining of funding: B.B. Green, C.Y. Wang.

Administrative, technical, or logistic support: B.B. Green.

Collection and assembly of data: B.B. Green, M.L. Anderson, S. Fuller.

Ann Intern Med. 2013;158(5_Part_1):301-311. doi:10.7326/0003-4819-158-5-201303050-00002
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Chinese translation

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.


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Figure 1.

Study flow diagram.

CRC = colorectal cancer.

* Provided written request to be withdrawn from the study and to have data removed from study databases.

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Figure 2.

Type of colorectal testing completed for those current for testing, both years 1 and 2.

Current is defined as receiving a FS or CS in year 1 or FOBT in year 1 plus FOBT, colonoscopy, or flexible sigmoidoscopy in year 2. Patients with FOBT in year 1 and who were ineligible in year 2 (death, colorectal cancer, or disenrollment in year 1) were defined as current for the primary analysis (n = 68). CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy.

Grahic Jump Location




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