Mailed Letter Versus Phone Call to Increase Uptake of Cancer Screening: A Pragmatic, Randomized Trial

Tara Kiran; Sam Davie; Rahim Moineddin; Aisha Lofters

doi:10.3122/jabfm.2018.06.170369

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Figure 1.
Summary of patients randomized and included in intention-to-treat and per protocol analysis.
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Table 1.

Baseline Characteristics of Patients Randomized to Receive a Reminder Letter or Phone Call as of March 31, 2015

Patient Characteristics	Female			Male
Patient Characteristics	Randomized to Receive Letter (n = 1896)	Randomized to Receive Phone Call (n = 1837)	P value^{^†}	Randomized to Receive Letter (n = 739)	Randomized to Receive Phone Call (n = 798)	P Value^{^†}
Age, years [n (column %)]
21 to 29	214 (11.3)	190 (10.3)	.3225	—	—	.5404
30 to 39	353 (18.6)	380 (20.7)		—	—
40 to 49	317 (16.7)	271 (14.8)		—	—
50 to 59	558 (29.4)	565 (30.8)		487 (65.9)	516 (64.7)
60 to 69	357 (18.8)	335 (18.2)		195 (26.4)	228 (28.6)
70 to 74	97 (5.2)	96 (5.2)		57 (7.7)	54 (6.8)
Income quintile [n (column %)]
Q1 (lowest)	504 (28.6)	480 (27.9)	.3449	198 (29.3)	236 (32.2)	.6854
Q2	304 (17.2)	321 (18.6)		110 (16.3)	116 (15.9)
Q3	288 (16.3)	305 (17.7)		124 (18.3)	119 (16.3)
Q4	278 (15.8)	277 (16.1)		116 (17.1)	117 (16.0)
Q5 (highest)	390 (22.1)	340 (19.7)		129 (19.1)	144 (19.7)
Missing	132	114		62	66
Overdue for cancer screening [n (column %)]
Pap test only	1036 (54.6)	967 (52.6)	.7235	—	—	n/a
Mammogram only	190 (10.0)	175 (9.5)		—	—
CRC screen only	214 (11.3)	214 (11.7)		739 (100)	798 (100)
Pap test and mammogram	62 (3.3)	75 (4.1)		—	—
Mammogram and CRC screen	171 (9.0)	181 (9.9)		—	—
Pap test and CRC screen	62 (3.3)	65 (3.5)		—	—
Pap test, mammogram, CRC screen	161 (8.5)	160 (8.7)		—	—

↵† χ² test.
CRC, colorectal cancer.

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Table 2.

Outcomes 6-Months Postintervention (Intention-to-Treat Analysis), Female Patients

Outcomes^*	No./Total No. (%)		Absolute Difference, % (95% CI)	P Value^{^†}
Outcomes^*	Reminder Letter (n = 1896)	Reminder Phone Call (n = 1837)	Absolute Difference, % (95% CI)	P Value^{^†}
Patients who received at least one screening test for which they were due	626/1896 (33.0)	756/1837 (41.2)	8.1 (5.1–11.2)	<.001
Patients overdue for a Pap test who received a Pap test	386/1321 (29.2)	479/1267 (37.8)	8.6 (5.0–12.2)	<.01
Patients overdue for a mammogram who received a mammogram	138/584 (23.6)	164/591 (27.8)	4.1 (−0.9 to 9.1)	.106
Patients overdue for CRC screening who received a CRC screen	156/608 (25.7)	186/620 (30.0)	4.3 (−0.7 to 9.4)	.090
Patients overdue for CRC screening who receive an FOBT	123/608 (20.2)	163/620 (26.3)	6.1 (1.4–10.8)	.012
Patients overdue for CRC screening who receive a colonoscopy	41/608 (6.7)	30/620 (4.8)	−1.9 (−4.5 to 0.7)	.153

↵* Patients in the phone call arm who did not receive the intervention but were up to date with screening at the time of outcome ascertainment were only considered screened if they received the screening test within 6 months of the date that letters were sent.
↵† χ² test.
CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test.

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Table 3.

Outcomes 6-Months Postintervention (Intention-to-Treat Analysis), Male Patients

Outcomes^*	No./Total No. (%)		Absolute Difference, % (95% CI)	P Value^{^†}
Outcomes^*	Reminder Letter (n = 739)	Reminder Phone Call (n = 798)	Absolute Difference, % (95% CI)	P Value^{^†}
Patients overdue for CRC screening who received a CRC screen	183/739 (24.8)	230/798 (28.8)	4.1 (−0.4 to 8.5)	.073
Patients overdue for CRC screening who receive an FOBT	156/739 (21.1)	198/798 (24.8)	3.7 (−0.5 to 7.9)	.085
Patients overdue for CRC screening who receive a colonoscopy	34/739 (4.6)	41/798 (5.1)	0.5 (−1.6 to 2.7)	.625

↵* Patients in the phone call arm who did not receive the intervention but were up to date with screening at the time of outcome ascertainment were only considered screened if they received the screening test within 6 months of the date that letters were sent.
↵† χ² test.
CRC, colorectal cancer; CI, confidence interval; FOBT, fecal occult blood test.

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Table 4.

Outcomes 6-Months Postintervention (Per Protocol Analysis), Female Patients

Outcomes	No./Total No. (%)		Absolute Difference, % (95% CI)	P Value^*
Outcomes	Reminder Letter (n = 1459)	Reminder Phone Call (n = 977)	Absolute Difference, % (95% CI)	P Value^*
Patients who received at least one screening test for which they were due	370/1459 (25.4)	395/977 (40.4)	15.1 (11.3–18.9)	<.001
Patients overdue for a Pap test who received a Pap test	241/1029 (23.4)	269/653 (41.2)	17.8 (13.2–22.4)	<.001
Patients overdue for a mammogram who received a mammogram	72/441 (16.3)	72/315 (22.9)	6.5 (3.0–12.3)	.024
Patients overdue for CRC screening who received a CRC screen	84/464 (18.1)	81/339 (23.9)	5.8 (0.1–11.5)	.045
Patients overdue for CRC screening who receive an FOBT	69/464 (14.9)	72/339 (21.2)	6.4 (0.9–11.8)	.019
Patients overdue for CRC screening who receive a colonoscopy	18/464 (3.9)	14/339 (4.1)	0.3 (−2.5 to 3.0)	.858

↵* χ² test.
CRC, colorectal cancer; CI, confidence interval; FOBT, fecal occult blood test.

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Table 5.

Outcomes 6-Months Postintervention (Per Protocol Analysis), Male Patients

Outcomes	No./Total No. (%)		Absolute Difference, % (95% CI)	P Value^*
Outcomes	Reminder Letter (n = 600)	Reminder Phone Call (n = 430)	Absolute Difference, % (95% CI)	P Value^*
Patients overdue for CRC screening who received a CRC screen	109/600 (18.2)	105/430 (24.4)	6.3 (1.2–11.4)	.015
Patients overdue for CRC screening who receive an FOBT	98/600 (16.3)	92/430 (21.4)	5.1 (0.2–9.9)	.039
Patients overdue for CRC screening who receive a colonoscopy	16/600 (2.7)	16/430 (3.7)	1.1 (−1.2 to 3.3)	.336

↵* χ² test.
CRC, colorectal cancer; CI, confidence interval; FOBT, fecal occult blood test.

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Table 6

Logistic Regression Results Examining the Effect of Income Quintile on the Likelihood of Patients Receiving at Least 1 Screening Test for Which They Were Due Within 6-Months Postintervention (Intention-to-Treat Analysis), Adjusted for Age, Female Patients

Income Quintile Subgroup	No. of patients	No./Total No. (%)		Odds Ratio (95% CI)	P value for Interaction
Income Quintile Subgroup	No. of patients	Reminder Letter and Received at Least 1 Screening Test for Which They Were Due	Reminder Phone Call and Received at Least 1 Screening Test for Which They Were Due	Odds Ratio (95% CI)	P value for Interaction
Q1 (lowest)	984	152/504 (30.2)	191/480 (39.8)	1.53 (1.17–2.00)	.9871
Q2	625	100/304 (32.9)	128/321 (39.9)	1.36 (0.97–1.89)
Q3	593	99/288 (34.4)	127/305 (41.6)	1.33 (0.95–1.86)
Q4	555	114/278 (41.0)	115/277 (41.5)	1.02 (0.73–1.43)
Q5 (highest)	730	121/390 (31.0)	150/340 (44.1)	1.73 (1.28–2.36)

CI, confidence interval.

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Table 7.

Logistic Regression Results Examining the Effect of Income Quintile on the Likelihood of Patients Receiving at Least 1 Screening Test for Which They Were Due within 6-Months Postintervention (Intention-to-Treat Analysis), Adjusted for Age, Male Patients

Income Quintile Subgroup	No. of patients	No./Total No. (%)		Odds Ratio (95% CI)	P Value for Interaction
Income Quintile Subgroup	No. of patients	Reminder Letter and Received at Least 1 Screening Test for Which They Were Due	Reminder Phone Call and Received at Least 1 Screening Test for Which They Were Due	Odds Ratio (95% CI)	P Value for Interaction
Q1 (lowest)	434	52/198 (26.3)	65/236 (27.5)	1.08 (0.71–1.66)	.7118
Q2	226	29/110 (26.4)	32/116 (27.6)	1.06 (0.59–1.91)
Q3	243	23/124 (18.5)	32/119 (26.9)	1.62 (0.88–2.97)
Q4	233	30/116 (25.9)	36/117 (30.8)	1.26 (0.71–2.24)
Q5 (highest)	273	37/129 (28.7)	45/144 (31.3)	1.14 (0.68–1.91)

CI, confidence interval.

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Table 8.
Cost Analysis for Female Patients
Letter Phone Call (actual cost^{^†})
Total cost CaD $3,490.42 CaD $7,325.94
Total cost/patient CaD $1.84 CaD $3.86
Total cost/each screening test completed^* CaD $5.07 CaD $8.71
↵* Based on intention to treat analysis.
↵† Based on a student wage of CaD $17/hour, and a clerical assistant wage of CaD $24.78 (mid-range of the salary).
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Table 9.
Cost Analysis for Male Patients
Letter Phone Call (actual cost^{^†})
Total cost CaD $1,360.46 CaD $2,855.42
Total cost/patient CaD $1.84 CaD $3.86
Total cost/each screening test completed^* CaD $7.16 CaD $12.00
↵* Based on intention to treat analysis.
↵† Based on a student wage of CaD $17/hour, and a clerical assistant wage of CaD $24.78 (mid-range of the salary).