title: Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.
abstract: BACKGROUND
  High value screening tests such as colonoscopy and mammography can improve early cancer detection but are often underutilized.
  
  
  METHODS
  We evaluated an active choice intervention using the electronic health record (EHR) to confirm patient eligibility for colonoscopy or mammography during the patient's clinic visit and prompt the physician and his/her medical assistant to actively choose to "accept" or "cancel" an order for it. We fit multivariate logistic regression models using a difference-in-differences approach to evaluate changes in physician ordering and patient completion of colonoscopy and mammography at the intervention practice compared to two control practices, adjusting for time trends, patient and clinic visit characteristics.
  
  
  RESULTS
  The sample comprised 7560 patients due for colonoscopy and 8337 patients due for mammography. Pre-intervention trends between practices did not differ. In the adjusted models, compared to the control group over time, the intervention practice had a significant increase in ordering of colonoscopy (11.8% points, 95% CI: 8.0-15.6, P<0.001) and mammography (12.4% points, 95% CI: 8.7-16.2, P<0.001). There was a significant increase in patient completion of colonoscopy (3.5% points, 95% CI: 1.1-5.9, P<0.01), but no change in mammography (2.2% points, 95% CI: -1.0 to 5.5, P=0.18).
  
  
  CONCLUSIONS
  Active choice through the EHR was associated with an increase in physician ordering of colonoscopy and mammography. The intervention was also associated with an increase in patient completion of colonoscopy but no change in patient completion of mammography.
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Wharton School, University of Pennsylvania, Philadelphia, PA, United States; Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, United States. Electronic address: mpatel@upenn.edu.
authors.forename: Mitesh S
authors.initials: MS
authors.lastname: Patel
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Wharton School, University of Pennsylvania, Philadelphia, PA, United States; Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, United States.
authors.forename: Kevin G
authors.initials: KG
authors.lastname: Volpp
authors.affiliation: The Wharton School, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Dylan S
authors.initials: DS
authors.lastname: Small
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Craig
authors.initials: C
authors.lastname: Wynn
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Jingsan
authors.initials: J
authors.lastname: Zhu
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Lin
authors.initials: L
authors.lastname: Yang
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Steven
authors.initials: S
authors.lastname: Honeywell
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Susan C
authors.initials: SC
authors.lastname: Day
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data; D016022:Case-Control Studies; D002755:Choice Behavior; D003113:Colonoscopy / Q000706:statistics & numerical data*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008327:Mammography / Q000706:statistics & numerical data*; D008875:Middle Aged; D010349:Patient Compliance; D010818:Practice Patterns, Physicians'
keywords: Active choice; Behavioral economics; Cancer screening; Choice architecture; Colonoscopy; Electronic health record; Mammography; Physician behavior