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Service Delivery Innovation Profile

Letter From Personal Physician With Video Decision Aid and Direct-Access Testing Improves Colon Cancer Screening Rates


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Snapshot

Summary

Patients received a mailed package that included a personalized letter from the patient's physician, a colon cancer screening decision aid video, and instructions for scheduling a screening test without an office visit. The initial nonrandomized, comparative study of 237 previously unscreened patients found that the program significantly increased screening rates (which were 15 percent in the intervention group, compared with 4 percent in the control group), although relatively few patients watched the video. A subsequent trial conducted in two waves comprising a total of almost 1,500 patients yielded similar findings for attending physicians' patients (13 percent vs. 4 percent for the control group) but not for resident physicians' patients (6.9 percent vs. 2.4 percent for the control group) whose letter was signed by the practice director. (Updated May 2014.)

See the Description and Results for more detailed information about the most recent nonrandomized trial. See Tools and Other Resources for information about published results of the most recent trial. See Resources Used for costs of the 2006 waves. (Updated May 2014.)

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized, comparative study of an intervention and control group.
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Developing Organizations

University of North Carolina Ambulatory Care Center
Chapel Hill, NCend do

Date First Implemented

2005
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Patient Population

Age > Middle-aged adult (45-64 years); Senior adult (65-79 years)end pp

Problem Addressed

Many people contract and die from colorectal cancer, even though screening and treatment options exist that could significantly reduce the clinical burden of this disease.
  • High incidence and mortality: Colorectal cancer is the third most common cancer diagnosed in American men and women, with more than 101,600 new cases of colon cancer and more than 40,000 new cases of rectal cancer estimated in 2011. Colorectal cancer is the third leading cause of cancer deaths among U.S. adults, with almost 50,000 deaths estimated in 2011.1
  • Underutilization of screening that can prevent the disease: The majority of colorectal cancer deaths can be prevented with appropriate screening, which enables the detection and removal of colorectal polyps before they progress to cancer. In fact, incidence has been declining in recent years due to an increase in screening.1 However, despite a growing awareness of its necessity, screening is underutilized, with only 57 percent of eligible U.S. adults up to date with recommended screenings.2
  • Many reasons for not pursuing screening: Patients may not pursue screening for several reasons, including lack of awareness of different screening options, lack of adequate time during office visits to discuss options, fear of the test, and lack of patient awareness that the test is due.3 Providing patients with reminders, decision aids, and other information outside of the practice setting may encourage them to be screened.

What They Did

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Description of the Innovative Activity

A multimodal colon cancer screening package was mailed to eligible patients at the University of North Carolina Ambulatory Care Center's general internal medicine practice. The package included a personalized letter from the patient's physician, a decision aid video with descriptions of different screening options, and instructions for scheduling a screening test without an office visit. The intervention was pilot tested in 137 patients in 2005, with a larger trial of two waves conducted in 2006; the program has not been adopted beyond the testing timeframes. Key elements of the program included the following:
  • Target population: Eligible individuals were active patients (defined as those who had been seen at the practice at least once in the previous 2 years) between the ages of 50 and 75 years old who had not been recently screened for colon cancer, as documented in the practice's billing database. Any patient who did not have documentation of a colonoscopy in the last 10 years, flexible sigmoidoscopy in the last 5 years, or fecal occult blood testing in the last 11 months was considered eligible (although it is possible that these patients had received screening outside of the university system).
  • Personalized letter: Patients received a letter, signed by their physician (in the case of attending physicians) or by the practice director (in the case of resident physicians), reminding patients that they were due for screening and encouraging them to get screened. The package also included a questionnaire for research purposes.(Updated May 2014.)
  • Decision aid: The letter accompanied a previously developed video, titled "Colon Cancer Screening: Deciding What's Right for You,” provided in VHS and DVD format. This 35-minute decision aid provides an introduction to colon cancer, describes the risk of developing and dying from the disease, emphasizes the importance of screening, and reviews the different screening modalities (including colonoscopy, fecal occult blood testing, barium enema, sigmoidoscopy, and a combination of fecal occult blood testing and sigmoidoscopy). Descriptions include how the test is done, how often it needs to be repeated, time needed to complete the test, effectiveness, convenience, discomfort, and test-related risks. Patient testimonials describing personal experiences with each test are interspersed throughout the descriptions.
  • Direct access to testing: The package provides instructions on how to obtain the test of choice. Patients could request fecal occult blood testing cards by calling a nurse facilitator at the practice or could telephone the gastroenterology outpatient suite affiliated with the university to schedule either sigmoidoscopy or colonoscopy. (Barium enema was not offered as an option even though it was in the video because it is not considered a standard of care in this medical practice.) Patients interested in any of these testing options could access them directly, without a preliminary physician office visit.
  • Reminder contacts: One month after the initial mailing, patients who had not returned the survey received a letter from the patient's physician reminding them that they were due for screening and encouraging them to get screened. In addition, 2 to 3 months after the initial mailing was sent, recipients who had not responded received a reminder phone call; the call script contained the same information as the reminder letter.
  • Two waves of patients in 2006 study: Wave A of the 2006 study comprised 340 patients of attending physician; wave b included 944 patients of resident physicians plus 214 patients of attending physicians.(Updated May 2014.)

Context of the Innovation

The University of North Carolina Ambulatory Care Center, part of the internal medicine practice at the university, serves more than 5,000 adults age 50 years and older (the target population for colorectal cancer screening). The practice includes 15 attending physicians and 46 residents. The center developed this pilot program as part of a larger effort to identify strategies to increase colon cancer screening rates, which were roughly 50 percent (similar to the national average) before initiation of the program.

Did It Work?

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Results

A nonrandomized, comparative study of 237 previously unscreened patients found that the program significantly increased screening rates, even though relatively few patients watched the video. Two subsequent waves—one of 340 patients (wave A) and another of more than 1,100 patients (wave B)—showed mixed results (updated May 2014).
  • Increased screening for some patients: Chart reviews conducted 5 months after the initial mailing found that those patients receiving the package were much more likely to get screened than those who did not, with 15 percent (20/137) of the intervention group being screened, compared with just 4 percent (4/100) of the control group.Wave A results showed that screening rates increased among attending physicians' patients who received a letter signed by their physician (13 percent compared with 4 percent for the control group). Wave B results showed that screening rates did not improve over the control group for resident physicians' patients, whose letter was signed by the practice director and not the physician (1.3 percent compared with 1.9 percent for the control group). A small increase in screening with the intervention was seen in attending physicians' patients in wave B (6.9 percent compared with 2.4 percent for the control group). (Updated May 2014.)
  • Low use of decision aid: Study participants reported generally low usage of the decision aid. Only 4 out of 12 individuals responding to a survey included in the initial mailing watched the video, whereas 6 out of 30 individuals responding to a telephone survey conducted 2 months after the mailing watched it. Most patients indicated that they did not have time to watch the video.

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized, comparative study of an intervention and control group.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Creating the mailing list: Patients were identified based on the eligibility criteria described previously. Attending physicians reviewed these lists and eliminated patients whom they deemed too ill to benefit from screening.
  • Creating the letter and testing instructions: The patient letter was drafted and edited to ensure that it served to encourage patients to obtain screening and provided clear instructions on how to obtain testing.
  • Arranging for direct access to screening: A nurse facilitator was instructed to mail fecal occult blood testing cards to patients who requested them. Schedulers at the gastroenterology suite were instructed to schedule pilot study patients for sigmoidoscopy or colonoscopy without a prior physician visit.

Resources Used and Skills Needed

  • Staffing: Approximately 9 hours of administrative staff time was required to organize the mailing.
  • Costs: The program cost $1,512 for the 137 pilot study participants, or $94.50 per additional patient screened. Costs included $252 for mailing, $285 for return envelope postage, $685 for video/DVD duplication, $137 for packaging materials, and $153 for staff time (9 hours at $17 per hour).Wave A costs totaled $449.63 ($267.03 for postage, $114.60 for materials, and $68 for staff). Wave B costs were not calculated because there was not a significant increase in screening in the patients of either the residents or the attending physicians. (Updated May 2014.)
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Funding Sources

National Cancer Institute; Foundation for Informed Medical Decision Making; University of North Carolina
The Foundation for Informed Medical Decision Making provided grant funding to cover development of the video decision aid. Researchers were funded in part by the K07 Cancer Prevention, Control, and Population Sciences Mentored Career Development Award from the National Cancer Institute and by the University of North Carolina Center for Health Promotion and Economics.end fs

Tools and Other Resources

"Colon Cancer Screening: Deciding What's Right for You" (DVD #: DVDCRC001 v.02; Booklet #: CRC001B v.03; Worksheet:CRC001Wv.02) is available from HealthDialog by calling (800) 276-0993. The video is appropriate for men and women age 50 to 80 years old who are at average risk for colon cancer and are considering screening for colon cancer.

Lewis CL, Brenner AT, Griffith JM, et al. Two controlled trials to determine the effectiveness of a mailed intervention to increase colon cancer screening. N C Med J. 2012;73(2)93-8. (Added May 2014.)

Adoption Considerations

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Getting Started with This Innovation

  • Consider patient literacy levels: Ensure that all written materials are clear, straightforward, and understandable to the target audience.
  • Adjust technology to the target population: For example, it may not be necessary to mail both a DVD and a VHS tape if the vast majority of the target population is likely to have a DVD player.

Sustaining This Innovation

  • Consider omitting the video if costs become a concern: As noted, screening rates increased considerably even though few participants viewed the video. Letters alone may be enough to encourage screening.

More Information

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Contact the Innovator

Carmen L. Lewis, MD, MPH
Associate Professor of Internal Medicine
University of Colorado Anschutz Medical Campus
(720) 848-9500
E-mail: carmen.l.lewis@ucdenver.edu

Alison T. Brenner, PhD

Postdoctoral Researcher
Cecil G Sheps Center for Health Services Research
University of North Carolina
725 Martin Luther King Jr Blvd
Chapel Hill, NC, 27599-7590
(919) 843-3392
E-mail: alison.brenner@unc.edu

Innovator Disclosures

Dr. Lewis and Ms. Brenner have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Lewis CL, Brenner AT, Griffith JM, et al. The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial. Implement Sci. 2008;3:32. [PubMed]

Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening: a randomized, controlled trial. Ann Intern Med. 2000;133(10):761-9. [PubMed]

Footnotes

1 Colorectal Cancer Facts & Figures 2011-2013. Available at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-028323.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 U.S. Centers for Disease Control and Prevention. Increased use of colorectal cancer tests—United States, 2004 and 2004. MMWR Morb Mortal Wkly Rep. 2006;55(11):308-11. [PubMed]
3 Lewis CL, Brenner AT, Griffith JM, et al. The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial. Implement Sci. 2008;3:32. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 27, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 19, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.