Among health plan enrollees eligible for cancer screening, receipt of a PHE was significantly associated with completion of CRC testing, screening mammography, and PSA testing. Receipt of a PHE was particularly strongly associated with CRC and PSA testing. The association between PHE receipt and cancer testing was substantial regardless of patient age, sex, or outpatient visit frequency.
Although patients and physicians believe that PHEs are of proven value,3,4
there has been relatively little empirical support for the efficacy of the PHE in health promotion or disease prevention. Whereas other investigators10– 16,25
have observed an association between preventive visits and cancer testing, the present study provides timely confirmation and quantification of the association between PHEs and completion of CRC, breast cancer, and prostate cancer testing in population-based cohorts with confirmed eligibility for screening. Moreover, this analysis adjusts for a range of important confounding factors, including comorbidity and previous preventive services use. Finally, these large samples allow us to stratify by outpatient visit frequency and to estimate the impact of PHE on patients with varying opportunities for cancer screening promotion outside of the PHE.
An association between the PHE and cancer screening could arise if patients schedule PHEs to request the desired screening. The PHE, on the other hand, may afford physicians the opportunity to counsel patients regarding the methods, benefits, and risks of cancer screening, whereas physicians may find it difficult to thoroughly discuss cancer screening during time-restricted illness visits.6
In a recent survey, nearly all primary care physicians (97%) reported recommending CRC screening during PHEs, whereas few reported recommending CRC screening during other visits.26
In population-based surveys, “receiving a physician’s recommendation” has been strongly associated with receipt of CRC,7
and prostate cancer9
screening. Thus, the strong associations between PHE receipt and CRC and PSA testing in the present study may have arisen because health plan physicians frequently recommend those tests during PHEs.
have urged physicians and policymakers to emphasize the opportunistic delivery of preventive services outside of dedicated well visits. In patients in the present study who did not receive PHEs, adjusted testing incidences gradually increased with an increasing number of outpatient visits (), suggesting that physicians sometimes order cancer testing outside of preventive visits. In no case, however, did the testing incidences in patients who did not receive a PHE reach the levels of patients who did. Indeed, the adjusted incidences of CRC and PSA testing were 30% greater in PHE recipients compared with nonrecipients even in patients who received 24 or more outpatient visits during the 2-year study period. Meanwhile, adjusted testing incidences in patients who received a PHE were similar regardless of the number of outpatient visits. Thus, in a population that has received a PHE, screening rates may reach a ceiling beyond which subsequent opportunistic recommendations may have little impact.
The present findings suggest that the PHE may promote evidence-based screening, such as CRC and breast cancer screening, and screening with less empirical support, such as PSA testing. Although neither the health plan nor the US Preventive Service Task Force recommends PSA screening, we observed comparable population incidences of PSA and CRC testing and similarly large incidence differences associated with PHE receipt. In a national sample, eligible men reported more frequent receipt of PSA screening than CRC screening, which may be attributable to the relative ease of completing a blood test.18
During PHEs, physicians probably order other blood and urine tests that lack strong evidential support.3,4
Mammography screening incidences were relatively high in this population, and incidence differences associated with PHE were relatively lower, which may be attributable to the plan’s population-based breast cancer screening program. Although the PHE was associated with incrementally higher mammography screening rates, population-based screening programs may hold promise for the promotion of other evidence-based cancer screening, such as CRC testing.
We did not ascertain the presence of cancer symptoms, and some CRC and PSA tests may have been performed for diagnostic purposes rather than for screening. If such symptoms led some enrollees to seek a “preventive” examination, and if physicians responded by ordering tests to diagnose cancer, then the results would overstate to some extent the impact of the PHE on cancer screening. In addition, misclassification of some covariates (eg, benign prostatic hyperplasia diagnoses) may have allowed residual confounding.
Unmeasured differences between patients who do and do not receive PHEs may partly explain the observed differences in cancer screening. However, we adjusted for baseline preventive services use to account for attitudes and beliefs that may predispose patients to seek cancer screening or adhere to provider recommendations independently from the PHE. Still, randomized studies could allow more accurate quantification of the association between PHE receipt and cancer screening and potentially explore the association between PHEs and other preventive services, such as health behavior counseling. In addition, these study findings may not be generalizable to uninsured populations or fee-for-service settings. Finally, these findings for CRC and breast cancer screening may not be comparable with publicly reported quality measures (such as the Health Plan Employer Data and Information Set) because of differences in patient sampling, observation periods, and screening test definitions.28
In a managed care population, receipt of a PHE was significantly associated with screening for CRC, breast cancer, and prostate cancer. The associations were particularly strong for CRC and prostate cancer, for which the health plan provides no centralized screening program. In similar populations, the PHE may serve as a clinically important forum for the promotion of evidence-based CRC and breast cancer screening and of prostate cancer screening, which is not universally recommended. Experimental studies could confirm the efficacy of the PHE in health promotion, elucidate the ideal content of PHEs, and guide the development of interventions to help physicians make the most of PHEs.