Cancer Screening: Provider Reminder and Recall Systems — Colorectal Cancer
Findings and Recommendations
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 full CPSTF Finding and Rationale Statement and supporting documents for Cancer Screening: Provider Reminder and Recall Systems — Colorectal Cancer are available in The Community Guide Collection on CDC Stacks.
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.
About The Systematic Review
The CPSTF finding is based on evidence from 25 studies (search period 1986 – November 2004).
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.
Study Characteristics
- Studies evaluated provider reminders delivered as printed or electronic chart notations or flags based on client screening history; preventive care checklists (not specific to client screening history); or memoranda listing clients who were overdue for screening or had never been screened.
- 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.
- Some studies specified that client populations included people who had never been screened or who were several years overdue for screening.
- Studies were conducted in the U.S., the United Kingdom, Italy, Canada, Australia, Israel.
Summary of Results
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
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?
Implementation Considerations and Resources
- 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 includes the following objectives related to this CPSTF recommendation.