In a large cohort of patients who were overdue for screening, we demonstrated that personalized mailings to individual patients produced a modest increase in colorectal cancer screening, particularly by FOBT and among patients in the oldest age group, suggesting patients represent an untapped resource for improving quality of care. Patients frequently report they have not received effective counseling regarding the importance of colorectal cancer screening.11, 34
However, once eligible patients are appropriately informed, most opt to be screened for colorectal cancer.35, 36
Our findings underscore that informed patients can play an active role in completing effective preventive services.37
Electronic reminders to physicians did not significantly increase overall screening rates, in part because over one-third of patients had no visits with their primary physicians during the 15-month study period. However, physician reminders exhibited a trend toward increased overall screening rates among patients with at least 3 primary-care visits over this period. Orders for colonoscopy were modestly increased by reminders to physicians but without a corresponding increase in completed procedures, as nearly half of patients for whom a colonoscopy was ordered did not complete this procedure. This finding underscores the need for more effective communication with patients to encourage them to complete colonoscopy procedures that are scheduled.38, 39
The limited effectiveness of our electronic physician reminders may reflect the challenges primary care physicians face in providing adequate preventive counseling amid competing demands during brief office visits.12
We provided “active” alerts that required physician to respond,40
but some physicians may have disregarded the alerts if they disrupted their workflow or were deemed inaccurate.41
Although we validated the accuracy of our algorithm for detecting whether patients were up-to-date with screening, many physicians viewed the electronic reminders as substantially less accurate, and nearly half of physicians viewed the reminders as ineffective. This suggests that reminders to physicians via electronic health records may require further collaboration with practicing physicians who receive the reminders to achieve a greater impact on screening rates.
Our study highlights an important contrast between the screening strategy pursued by patients and the preferences of their physicians. The patient mailings produced a modest increase in the use of FOBT, but all physicians viewed colonoscopy as the preferred screening test for their patients. This finding is consistent with recent studies indicating a preference for fecal occult blood testing over colonoscopy among patients provided information to make an informed choice,42
whereas physicians report a strong preference to recommend colonoscopy.43
This contrast highlights one potential challenge to engaging patients in quality improvement programs. For services such as colorectal cancer screening for which multiple reasonable options exist, quality improvement programs will need to address the possibly differing preferences of patients and their physicians and develop methods to reconcile such differences.44, 45
Increased screening is essential to reduce the incidence, morbidity, and mortality of colorectal cancer. One recent study estimated that U.S. mortality from this disease could be reduced 23% by 2020 if screening rates rose to 70%.46
The importance of colorectal cancer screening has been recognized through expanded Medicare coverage for this service in 200147
and the endorsement of colorectal cancer screening as a health plan performance measure by the National Committee for Quality Assurance in 2005.48
Published studies of interventions to improve rates of colorectal cancer screening have targeted patients, physicians, or both groups.14, 15, 17-28
Physician-directed interventions such as reminders16, 23, 24, 28
and performance feedback25
have increased screening rates in some settings. Patient-directed interventions including videotaped decision aids,19
educational mailings,20, 21
and nurse counseling18
may also increase screening rates.
Our randomized trial builds on these studies in several important ways. First, these prior studies occurred in a setting where baseline screening rates were much lower than the screening rate of 63% in our population, often produced larger absolute increases in screening rates, and focused on increasing use of FOBT or flexible sigmoidoscopy. These studies may not apply to the current era in which screening rates are higher and colonoscopy has become a preferred screening strategy among physicians43
and is therefore increasingly used.47
In fact, more recent interventions that have included use of colonoscopy in their recommendations have not successfully increased overall screening rates.22, 26, 27
Our study provides important insights into the effect of interventions focused on patients who remain unscreened as screening rates rise through usual care. The modest effect of patient reminders in our study suggests the need to develop more effective strategies to actively engage these remaining patients and encourage them to be screened for colorectal cancer. However, the clear advantage of patient involvement over physician reminders in our study suggests that future strategies should increasingly involve patient-based activity. Promising alternatives include the use of the internet to facilitate patient-provider communication and promote increased patient involvement in their preventive health issues.49
Patient navigators have also been used with success in promoting cancer screening, particularly among low-income and minority groups.50
Second, our intervention simultaneously evaluated the use of personalized mailings to patients and electronic reminders to physicians. We found patient mailings were more effective than physician reminders in raising overall screening rates, and trends of borderline significance in detection of colorectal adenomas were evident with each approach. Involving patients in decisions about colorectal cancer screening fits well with models that promote informed, patients,37
moving them through the “stages of decision” from awareness of screening options through the decision to be screened.19, 51-53
Third, our large sample and rigorous study design allowed reasonably precise estimates of the intervention effects.
Fourth, the use of data from electronic medical records provided relatively complete clinical information on this large patient population, including data on clinical processes and outcomes. Approximately three-quarters of the positive fecal occult blood tests in our study population were followed by a colonoscopy. Although closing this loop is essential to realizing the benefits of a screening program,54
many studies demonstrate a similar gap in care.55-63
Physicians may not recommend appropriate follow-up testing to patients,56, 57, 62
patients may refuse further testing,57
or appropriate systems may not be in place to help clinicians identify abnormal test results and ensure appropriate follow-up.63
The generalizability of our study must also be considered. We implemented our intervention within a single group practice using an advanced electronic health record, so our findings may not apply to less structured settings. In particular, integrated medical groups generally provide higher quality care for screening services.27, 64
However, our patient mailing intervention could be implemented across a wide range of health care settings, and the adoption of electronic health records is being actively promoted to improve ambulatory care.65
Our study demonstrated how electronic data can be used to create clinical registries for outreach to patients, and it assessed the utility of decision support directly integrated with computerized order entry for physicians providing ambulatory care. After our study found that the patient mailings were effective, the integrated group practice instituted a routine protocol to identify patients overdue for colorectal cancer screening (including patients in our control group) and send them mailings regarding their need for screening.
In conclusion, this randomized trial of personalized patient mailings and electronic reminders to physicians in a large integrated group practice found that patient mailings produced modest increases in rates of colorectal cancer screening, whereas electronic physician reminders tended to promote screening only among patients who more frequently use primary care. These complementary approaches have the potential to promote the overarching goal of widespread screening to reduce the incidence, morbidity and mortality of colorectal cancer.