Cancer Screening: Provider Reminder and Recall Systems Colorectal Cancer

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends provider reminder systems based on strong evidence of their effectiveness in increasing colorectal cancer screening by fecal occult blood test (FOBT) and sufficient evidence of their effectiveness in increasing colorectal cancer screening by flexible sigmoidoscopy.

The CPSTF concluded there was insufficient evidence to determine the effectiveness of using provider reminders to increase colorectal cancer screening by colonoscopy or double contrast barium enema because none of the included studies evaluated these modalities.

The CPSTF has related findings for provider reminder and recall systems specific to the following:

Intervention

Reminders inform health care providers it is time for a client’s cancer screening test (called a “reminder”) or that the client is overdue for screening (called a “recall”). The reminders can be provided in different ways, such as in client charts or by e-mail.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

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 CPSTF 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.

Summary of Results

Detailed results from the systematic review are available in the CPSTF finding.

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

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are 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.

Analytic Framework

Effectiveness Review

Analytic Framework see Figure 1 on page 112

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of interventions to increase breast, cervical, and colorectal cancer screening

Included Studies

The following list of included studies is for reviews of provider reminder and recall systems to increase breast, cervical, and colorectal cancer screening. * Notes studies that included colorectal cancer screening.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Bankhead C, Richards SH, Peters TJ, et al. Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care. J Med Screen 2001;8(2):99-105.

*Becker D, Gomez E, Kaiser D, Yoshihasi A. Improving preventive care at a medical clinic: how can the patient help? Am J Prev Med 1989;5:353-9.

Binstock M, Geiger A, Hackett J, Yao J. Pap smear outreach: a randomized controlled trial in an HMO. Am J Prev Med 1997;13:425-6.

Burack R, Gimotty P, George J, et al. How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial. Cancer 1998;82:2391-400.

Burack R, Gimotty P, George J, Simon M, Dews P, Moncrease A. The effect of patient and physician reminders on use of screening mammography in a health maintenance organization: results of a randomized controlled trial. Cancer 1996;78:1708-21.

Cecchini S, Grazzini G, Bartoli D, Falvo I, Ciatto S. An attempt to increase compliance to cervical cancer screening through general practitioners. Tumori 1989;5:615-8.

Chambers C, Balaban D, Carlson B, Ungemack J, Grasberger D. Microcomputer-generated reminders: improving the compliance of primary care physicians with mammography screening guidelines. J Fam Pract 1989;29(3):273-80.

Cheney C, Ramsdell J. Effect of medical records’ checklists on implementation of periodic health measures. American Journal of Medicine 1987;83:129-36.

Cohen D, Littenberg B, Wetzel C, Neuhauser D. Improving physician compliance with preventive medicine guidelines. Med Care 1982;20:1040-5.

*Cowan J, Heckerling P, Parker J. Effect of a fact sheet reminder on performance of the periodic health examination: a randomized controlled trial. Am J Prev Med 1992;8:104-9.

Gonzalez J, Ranney J, West J. Nurse-initiated health promotion prompting system in an internal medicine residents’ clinic. Southern Medical Journal 1989;82(3):342-4.

Grady K, Lemkau J, Lee N, Caddell C. Enhancing mammography referral in primary care. Preventive Medicine 1997;26:791-800.

Landis S, Hulkower S, Pierson S. Enhancing adherence with mammography through patient letters and physician prompts. N C Med J 1992;53:575-8.

*Litzelman D, Dittus R, Miller M. Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med 1993;8:311-7.

*McDonald C, Hui S, Smith D. Reminders to physicians from an introspective computer medical record: a two-year randomized trial. Ann Intern Med 1984;100:130-8.

McDowell I, Newell C, Rosser W. Computerized reminders to encourage cervical screening in family practice. J Fam Pract 1989;28(4):420-4.

*McPhee S, Bird J, Jenkins C, Fordham D. Promoting cancer screening: A randomized, controlled trial of three interventions. Arch Intern Med 1989;149:1866-72.

*Ornstein S, Garr D, Jenkins R, Rust P, Arnon A. Computer-generated physician and patient reminders: tools to improve population adherence to selected preventive services. J Fam Pract 1991;32(1):82-90.

Pierce M, Lundy S, Palanisamy A, Winning S, King J. Prospective randomised controlled trial of methods of call and recall for cervical cytology screening. Br Med J 1989;299:160-2.

Pritchard D, Straton J, Hyndman J. Cervical screening in general practice. Aust J Public Health1995;19(2):167-72.

Richards SH, Bankhead C, Peters TJ, et al. Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening. J Med Screen 2001;8(2):91-8.

Schreiner D, Petrusa E, Rettie C, Kluge R. Improving compliance with preventive medicine procedures in a house staff training program. Southern Medical Journal 1988;81:1553-7.

*Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care 1986;24(8):659-66.

*Vinker S, Nakar S, Rosenberg E, Kitai E. The role of family physicians in increasing annual fecal occult blood test screening coverage: a prospective intervention study. Isr Med Assoc J 2002;4(6):424-5.

Williams B. Efficacy of a checklist to promote a preventive medicine approach. J Tenn Med Assoc 1981;74:489-91.

*Williams R, Boles M, Johnson R. A Patient-initiated system for preventive health care: a randomized trial in community-based primary care practices. Arch Fam Med 1998;7:338-45.

Economic Review

Chirikos TN, Christman LK, Hunter S, Roetzheim RG. Cost-effectiveness of an intervention to increase cancer screening in primary care settings. Preventive Medicine 2004;39:230 8.

Additional Materials

Planning Guide

Evidence-Based Intervention Planning Guide
Developed by CDC’s Division of Cancer Prevention and Control
This planning guide provides tips to help clinic staff implement provider reminders to increase screening for breast, cervical, and colorectal cancer. The guide includes a process flow diagram of the intervention theory; process evaluation metrics, outputs, and example measures; a list of resources needed to support implementation, such as partnerships, staff, and tools; lessons learned from studies included the Community Guide systematic reviews; and intervention components.

Action Guide

Increasing Colorectal Cancer Screening: An Action Guide for Working with Health Systems
Developed by CDC’s Division of Cancer Prevention and Control

Search Strategies

The following outlines the search strategy used for reviews of interventions to increase breast, cervical, and colorectal cancer screening.

Effectiveness Review

The review team searched five computerized databases from the earliest entries in each through November 2004:

  • MEDLINE, database of the National Library of Medicine (from 1966)
  • Cumulative Index to Nursing and Allied Health database (CINAHL, from 1982)
  • Chronic Disease Prevention database (CDP, Cancer Prevention and Control subfield, from 1988)
  • PsycINFO (from 1967)
  • Cochrane Library databases

Medical subject headings (MeSH) searched (including all subheadings) are shown below. The team also scanned bibliographies from key articles and solicited other citations from other team members and subject-matter experts. Conference abstracts were not included because, according to Community Guide criteria, they generally do not provide enough information to assess study validity and to address the research questions.

Search Terms
General
  • Neoplasms combined with any of the following headings: Early detection Mass screening Multiphasic screening Preventive health services Screening
Breast cancer
  • Breast neoplasms Mammography
Cervical cancer
  • Cervical intraepithelial neoplasia (Uterine) cervical neoplasms Cervix dysplasia Vaginal smears
Colorectal cancer
  • Colonic neoplasms Colorectal neoplasms Occult blood Sigmoid neoplasms Sigmoidoscopy

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Provider reminders may increase use of other preventive services linked to the system.
  • Administrative burden and lack of information technology infrastructure are potential barriers to provider reminder use.
  • Provider reminders are intended to reach people who receive health care, at least occasionally. They may not be the best approach to use in communities with limited access to health care or among groups who underuse healthcare services.
  • In selecting an intervention to increase cancer screening, consideration should be given to overall population screening rates, location and identity of populations in greatest need, opportunities to deliver specific interventions, availability of tracking systems, and local context, culture, needs, and screening history.

Crosswalks

Healthy People 2030

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.