Spotlight on screening in primary care

Patient-specific reminders for clinicians performed best for increasing colorectal cancer screening in a French study, while an EHR alert appeared to successfully increase hepatitis C virus screening rates for baby boomers in a U.S. health care system.

Two recent studies tested interventions to increase screening for colorectal cancer and hepatitis C virus (HCV) in primary care.

The colorectal cancer screening study involved 1,446 general practitioners at 801 practices in France with more than 30,000 patients ages 50 to 74 years who were at average risk of colorectal cancer and not up to date with colorectal cancer screening.

Researchers randomized practitioners to one of three groups: a patient-specific reminders group (n=496), a generic reminders group (n=495), and a usual care group that received no reminders (n=455). Practitioners in the patient-specific reminder group received a list of patients who had not undergone screening, whereas the generic reminders group received a letter describing the region's screening adherence rates.

The primary endpoint was patients' participation in colorectal cancer screening with fecal immunochemical testing (FIT) one year after the intervention. Results were published online on Sept. 5 by JAMA.

At one year, follow-up was available for 31,229 patients. Compared with usual care, the specific reminders resulted in a small but significant increase in FIT participation, but the generic reminders did not significantly increase participation. The proportion of patients who participated in FIT at one year was 24.8% (95% CI, 23.4% to 26.2%) in the patient-specific reminders group, 21.7% (95% CI, 20.5% to 22.8%) in the generic reminders group, and 20.6% (95% CI, 19.3% to 21.8%) in the usual care group.

The authors noted limitations of the study, such as the small 4% increase in absolute FIT participation and the potential lack of generalizability to settings that do not have the data and resources necessary to create a patient list.

Practices with sufficient resources should implement outreach effects with a choice of FIT- or colonoscopy-based screening, followed by sufficient support to ensure high levels of adherence (e.g., text message reminders, patient navigation), an accompanying editorial noted. “Timing such outreach in advance of an upcoming primary care visit enables the primary care clinician to support these outreach efforts and help overcome ambivalence in patients who are not quite ready to take action or who may have additional questions,” they wrote.

Another study found that an EHR alert increased HCV screening rates in a population of baby boomers in primary care at one U.S. health system.

The “best practice advisory” prompted primary care clinicians to perform HCV screening for patients who were born between 1945 and 1965, lacked a prior diagnosis of HCV infection, and lacked prior documented anti-HCV testing.

Researchers compared pre- and post-advisory screening rates, and results were published online on Sept. 14 by Hepatology.

In the three years leading up to the intervention, 52,660 baby boomers were seen in primary care clinics, and 28% were screened. Significantly more patients were screened after the EHR advisory was in place: 72% of 27,789 eligible patients in the year following the intervention, compared to 7.6% of 22,488 eligible patients in the six months prior to implementation (P<0.001).

The authors noted limitations to the study, such as a fairly homogeneous patient population with a potentially lower risk of HCV infection and the limited generalizability to practices without EHRs. “This type of EHR-based intervention represents a low-cost, efficient, and effective means to improve HCV screening, diagnosis, and access to care,” they wrote.