Mailing reminders boosts colon cancer screening

Katie Couric's on-air colonoscopy in 2000 was just one element of a larger awareness-raising effort that helped increase the colorectal cancer screening rate among eligible adults from about 25% a decade ago to 60%, according to 2008 data from the Centers for Disease Control and Prevention.

Yet experts have looked for ways to help primary care physicians push the rate even higher. Screening all eligible patients for colon cancer could prevent an estimated 75,000 cases annually through the timely removal of precancerous polyps, according to the American Cancer Society.

Now there is more evidence that time-squeezed doctors weighed down with recommending ever more preventive health measures need help getting patients screened.

A randomized controlled trial at Harvard Vanguard Medical Associates, a 14-site multispecialty group practice in eastern Massachusetts, found that mailing individualized screening reminders to patients worked better than using electronic medical records to alert physicians. The results from the study of 110 doctors and 21,860 patients were published in the Feb. 23 Archives of Internal Medicine.

"Physicians already have a pretty full plate," said Thomas D. Sequist, MD, MPH, first author of the study and an internist at Harvard Vanguard. "There are so many things competing for their time that even sending an active alert that popped up on the screen when they looked at a patient's record -- they couldn't get in that discussion during a busy 15-minute appointment. Sending the information to the patient at home in a less time-constrained environment really seemed to be more effective."

Previous studies have documented the effectiveness of mailing patient reminders about colon cancer screening, but this was the first to compare how that approach fared with alerting physicians directly.

Patients who were mailed reminders were 15% more likely to complete some form of colon cancer screening than those who did not get a reminder. But patients whose doctors received electronic reminders were no more likely to get screened than patients whose physicians were not prompted.

Neither approach is possible without an EMR system to identify eligible patients and send reminders to them and their doctors, said Robert Fletcher, MD, a study co-author and professor emeritus in the Dept. of Ambulatory Care and Prevention at Harvard Medical School in Massachusetts.

"When I give a talk about getting a prevention agenda done, I show a picture of our dog, who gets from the veterinary hospital a reminder about the need for her next immunizations," Dr. Fletcher said. "Reminders work. So we're kind of behind on that."

Screening requires team effort

The new research reinforces the idea that physicians need help getting the screening message to patients, said Dorado Brooks, MD, director of colorectal cancer for the American Cancer Society.

"The effort needs to start with the patient-doctor relationship in the clinical encounter," Dr. Brooks said. "But primary care doctors are often very busy and have a lot of different priorities in dealing with patients." Other parts of the health system could help lighten doctors' loads, he added.

There is no silver-bullet solution, said Richard C. Wender, MD. He is chair of the professional education and practice task group at the National Colorectal Cancer Roundtable, a coalition of the American Cancer Society, the CDC and other groups working to increase colon cancer screening rates.

"Sending reminders to patients does make a difference, but it's not automatic," said Dr. Wender, who is also chair of the Dept. of Family and Community Medicine at Jefferson Medical College in Pennsylvania. "Colon cancer screening is relatively complex, and we won't see massive change with a single intervention. The effort has to be persistent and repeated and accelerated."

Dr. Wender said the biggest improvement would come with rewarding physician practices for delivering quality care along several dimensions, such as chronic disease management and preventive health. The Centers for Medicare & Medicaid Services should integrate cancer screening rates into its pilot tests of the medical-home model, he said.

"If ever there was a time in history when we had the chance to bridge public health and clinical practice, that time is now," he said.