title: An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial.
abstract: BACKGROUND
  Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.
  
  
  OBJECTIVE
  To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.
  
  
  METHODS
  4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)
  
  
  METHODS
  21 primary care medical centers.
  
  
  METHODS
  4675 adults aged 50 to 73 years not current for CRC screening.
  
  
  METHODS
  Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.
  
  
  METHODS
  The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).
  
  
  RESULTS
  Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).
  
  
  CONCLUSIONS
  Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.
  
  
  CONCLUSIONS
  Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.
authors: Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466, USA. green.b@ghc.org
authors: Beverly B
authors: BB
authors: Green
authors: Ching-Yun
authors: CY
authors: Wang
authors: Melissa L
authors: ML
authors: Anderson
authors: Jessica
authors: J
authors: Chubak
authors: Richard T
authors: RT
authors: Meenan
authors: Sally W
authors: SW
authors: Vernon
authors: Sharon
authors: S
authors: Fuller
mesh_terms: D000368:Aged; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000517:prevention & control; D057186:Comparative Effectiveness Research; D003365:Costs and Cost Analysis; D055088:Early Detection of Cancer / Q000379:methods; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D009780:Occult Blood; D010349:Patient Compliance; D011177:Postal Service; D017010:Reminder Systems / Q000191:economics; D012812:Sigmoidoscopy; D013689:Telephone