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Cancer Screening: Provider Reminder and Recall Systems – Colorectal Cancer

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 25 studies (search period 1986 - November 2004). The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.

The effectiveness of provider-directed interventions was determined by considering evidence across all three cancer screening sites combined, as long as there were not differences in effectiveness by screening test. This was done because provider behavior was thought to be less influenced than client behavior by the nature of screening tests.

Context

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Summary of Results

Detailed results from the systematic review are available in the CPSTF finding pdf icon [PDF - 126 kB].

Twenty-six studies qualified for the review of provider reminders to increase breast, cervical, or colorectal cancer screening.

  • Completed screenings increased by a median of 7.2% (interquartile interval [IQI]: 2.4% to 19.7%; 34 study arms).
  • Recommended or ordered screenings increased by a median of 7.9% (IQI: 6% to 12%; 14 study arms)
  • Effect estimates did not vary substantially by method of generating the reminder (electronic versus manual), delivery, content, format (client-specific vs generic), or by training status of provider.
  • For all screening modalities, the absolute effect of provider reminders on completed screenings appeared to diminish over time.

Intervention effects on colorectal cancer screening by FOBT or flexible sigmoidoscopy:

  • Completed FOBTs and flexible sigmoidoscopy increased by a median of 15.3% (IQI: 1.0% to 24.2%; 7 study arms).
    • For FOBT alone, the median increase was 10.5% (IQI: 0% to 23.1%; 6 study arms).
    • For flexible sigmoidoscopy alone, the median increase was 24.3% (1 study arm).
  • Recommended or ordered screening by FOBT ranged from 4% to 33% (3 studies).

Summary of Economic Evidence

An economic review of this intervention did not find any studies specific to colorectal cancer screening. Evidence was found, however, for the use of provider reminder systems to increase breast and cervical cancer screening.

Applicability

  • These findings apply across a broad range of clinical settings and provider and client populations, including clients rarely or never screened.
  • Evidence was insufficient to determine the effectiveness of provider reminders in increasing colorectal cancer screening by colonoscopy because no studies evaluated this screening modality.

Evidence Gaps

Each Community Preventive Services Task Force (CPSTF) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the CPSTF finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the CPSTF recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the CPSTF recommendation is based.

Identified Evidence Gaps

The following outlines evidence gaps for reviews of provider reminder and recall systems to increase breast, cervical, and colorectal cancer screening.

Effectiveness

Effectiveness of provider reminders for increasing cancer screening by mammography, Pap tests, FOBT, and flexible sigmoidoscopy is established. Additional studies will be necessary to determine whether provider reminders are also effective in promoting screening colonoscopy. It is also not known whether benefits and cost savings can be achieved by provider reminder systems when used to promote multiple preventive services simultaneously.

Applicability

  • What contextual or population prevalence factors help to explain the reduced impact of reminders on mammography in more recent studies compared to older studies?

Other positive and negative effects

  • How can provider reminder systems that encourage use of cancer screening services be adapted for other preventive healthcare services?

Economic evaluations

  • How are the costs and cost-effectiveness of these interventions related to the structural characteristics of the settings of interventions?
  • In particular, can HMOs address logistical problems (e.g., contacting providers and reducing administrative time) more efficiently than fee-for-service practices, thereby lowering costs and improving cost-effectiveness?

Study Characteristics

  • Studies evaluated provider reminders delivered as printed or electronic chart notations or flags based on client screening history.
  • Provider reminder systems were automated (computer generated or assisted) or required manual record reviews.
  • While most study populations consisted entirely of fully trained physicians, some consisted entirely or mostly of resident trainees.
  • Provider reminder systems were implemented in a variety of healthcare settings, including university and non-university clinics and offices and in urban, rural, and mixed urban and rural areas.
  • Race and ethnicity of client populations were generally not reported, although some studies specified that these populations included white or African-American clients or both.
  • Studies were conducted in the U.S., the United Kingdom, Italy, Canada, Australia, Israel.

Publications