Studies examine effects of EHR nudges, physician uptake on CRC screening

Active choice interventions in an EHR prompted an increase in ordering of cancer screenings but not patient follow-through, while physicians who themselves underwent colorectal cancer (CRC) screening had more patients do so as well.


Two unrelated studies looked at ways to potentially improve colorectal cancer screening rates.

In the first study, an active choice intervention in the EHR was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests but not with a significant change in patient completion of either cancer screening test during one year of follow-up.

From 2016 to 2017, three primary care practices at the University of Pennsylvania Health System in Philadelphia implemented an active choice intervention in the EHR that prompted medical assistants to inform patients about cancer screening during check-in and provided template orders for clinicians to review during the visit. The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within one year of the primary care visit. Results of the study were published Nov. 15 by JAMA Network Open.

Overall, 43,647 patients were eligible for colorectal cancer screening. The intervention was associated with a significant increase in clinician ordering of colorectal cancer screening tests (13.7 percentage points; 95% CI, 8.0 to 18.9 percentage points; P<0.001) but no change in patient completion (1.0 percentage point; 95% CI, −3.2 to 4.6 percentage points; P=0.36). Results were similar in the 26,269 women eligible for breast cancer screening (22.2 percentage points [95% CI, 17.2 to 27.6 percentage points; P<0.001] and 0.1 percentage point [95% CI, −4.0 to 4.3 percentage points; P=0.45], respectively).

“Our findings indicate that nudges facilitated by the EHR can increase clinician ordering of cancer screening tests but may need to be combined with other interventions to improve patient completion,” the authors wrote. Limitations of the study include its observational design and potential lack of generalizability.

The second study found that patients are more likely to undergo colorectal cancer testing if their family physician has been tested.

Researchers in Ontario, Canada, collected demographic and health care information from administrative databases for patients at average risk of colorectal cancer who were between 52 and 74 years of age. Information on physicians was obtained from a list of all physicians in Ontario, and 11,434 physicians were matched with 45,736 patients by age, sex, and residential location. Uptake of colorectal cancer screening tests was defined as a record of a fecal occult blood test in the past two years, flexible sigmoidoscopy in the past five years, or colonoscopy in the past 10 years. The researchers determined which patients used a particular physician by reviewing billing claims; the family physician with the most submitted claims for a patient was defined as that patient's family physician. Results of the study were published online Nov. 1 by Gastroenterology.

Uptake of colorectal screening tests was 67.9% (95% CI, 67.0% to 68.7%) by physicians and 66.6% (95% CI, 66.2% to 67.1%) by nonphysicians. Physicians were less likely than nonphysicians to undergo fecal occult blood testing (prevalence ratio, 0.44; 95% CI, 0.42 to 0.47) and were more likely to undergo colonoscopy (prevalence ratio, 1.24; 95% CI, 1.22 to 1.26). Uptake of colorectal screening tests by family physicians was associated with greater uptake by their patients (adjusted prevalence ratio, 1.10; 95% CI, 1.08 to 1.12).

The authors noted that they were not able to exclude those at high risk for colorectal cancer and could not tell why a particular test was done, among other limitations. However, they concluded that physicians are uniquely positioned to influence health behaviors in their patients and that those who practice healthy behaviors themselves might more effectively counsel their patients to do likewise.

“If a physician feels comfortable to share they were screened, they may be more credible and motivating to their patients. Conversely, many physicians report difficulty counseling patients about behaviors they do not practice themselves,” the authors wrote. “Given the clear benefits of colorectal cancer screening, programs that promote greater screening in physicians warrant consideration.”