title: Effects of standardized outreach for patients refusing preventive services: a quasiexperimental quality improvement study.
abstract: OBJECTIVE
  To determine the effect of standardized outreach on the receipt of preventive services for patients whose physicians record that the patient refused the service.
  
  
  METHODS
  Prospective observational study of a quality improvement intervention using a nonrandomly assigned comparator group.
  
  
  METHODS
  Patients from a large internal medicine practice with recorded refusals to preventive services were included. A nonclinician care manager mailed plain-language educational brochures, attempted telephone contact, and provided logistical assistance. The primary patient outcome was the time from refusal to first receipt of a refused service (colorectal cancer screening, breast cancer screening [mammography], cervical cancer screening, osteoporosis screening [bone density testing], or pneumococcal vaccination). We compared the time to completion of refused sevices during the period when outreach was performed (February 8, 2008, to November 25, 2008 [outreach cohort]), and during a subsequent period when refusals were recorded but no outreach was performed (November 26, 2008, to December 1, 2009 [nonintervention cohort]), using Cox proportional hazards regression models adjusted for patient characteristics. We recorded the time spent performing outreach.
  
  
  RESULTS
  In total, 407 patients refused 520 preventive services in the outreach cohort, and 378 patients refused 510 services in the nonintervention cohort. After 6 months of follow-up, 6.1% of the outreach cohort and 4.8% of the nonintervention cohort had received a refused service (adjusted hazard ratio, 1.3; 95% confidence interval, 0.7-2.5). The care manager spent 214 hours performing the outreach.
  
  
  CONCLUSIONS
  Standardized educational outreach was not a promising strategy for improving preventive services use among patients who have refused services recommended by their physician. The amount of time required to perform the outreach was substantial.
authors.affiliation: Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA. spersell@nmff.org
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Persell
authors.forename: Elisha M
authors.initials: EM
authors.lastname: Friesema
authors.forename: Nancy C
authors.initials: NC
authors.lastname: Dolan
authors.forename: Jason A
authors.initials: JA
authors.lastname: Thompson
authors.forename: Darren
authors.initials: D
authors.lastname: Kaiser
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
mesh_terms: D015331:Cohort Studies; D003695:Delivery of Health Care / Q000379:methods / Q000592:standards; D006801:Humans; D010353:Patient Education as Topic / Q000379:methods*; D011314:Preventive Health Services / Q000379:methods* / Q000592:standards; D011446:Prospective Studies; D016312:Treatment Refusal / Q000523:psychology*