Research article
Mailings timed to patients' appointments: A controlled trial of fecal occult blood test cards

https://doi.org/10.1016/j.amepre.2004.02.009Get rights and content

Abstract

Background

Fecal occult blood testing (FOBT) programs cost-effectively reduce colon cancer mortality. To improve the rate of colon cancer screening with FOBT, we tested the effect of mailing FOBT cards timed to appointments on the rates of completion of FOBT.

Design

Controlled trial.

Setting/participants

A total of 119 patients with primary care appointments scheduled in May or June 2000 for an urban, public hospital clinic that serves predominantly low-income, African Americans with chronic diseases. The patients in the study were selected by linking a quality improvement registry, the appointment system database, and an FOBT database to generate a list of clinic patients who had not completed an FOBT in the preceding year.

Intervention

Subjects were assigned to either a system of mailing FOBT cards and reminders 2 weeks prior to a scheduled appointment or usual care.

Main outcome measures

The primary outcomes were the rate of screening at the index appointment and during the year beginning with the date of the index appointment.

Results

The rate of return of the FOBT cards during the year beginning with the index appointment was 40.7% for the intervention group compared to 5% for the usual care group (odds ratio [OR]=13.0, p <0.001). The difference was accounted for largely by increases in screening at the index appointment (35.6% compared to 3.3%, OR=16.0, p <0.001).

Conclusions

Using computer databases to generate a list of patients due for FOBT and then mailing FOBT cards timed to a scheduled appointment significantly increased the rate of colon cancer screening. This may be an efficient approach to increasing colon cancer screening with FOBT.

Introduction

I n 1996, the U.S. Preventive Services Task Force (USPSTF) issued recommendations in support of fecal occult blood testing (FOBT) and/or sigmoidoscopy for colon cancer screening.1 In 2002, the USPSTF issued updated recommendations, in which it concluded that there was evidence to support FOBT, sigmoidoscopy (alone or in combination with FOBT), or colonoscopy for colon cancer screening.2 The findings were based on three randomized controlled trials (RCTs) for FOBT,3, 4, 5 two case–control studies6, 7 and a small RCT for sigmoidoscopy,8 a non-RCT trial of FOBT combined with sigmoidoscopy,9 and extrapolation from multiple data sources supporting the role of colonoscopy.10 The Task Force found that there was insufficient data to determine a superior screening strategy. In a review of cost-effective analyses for the USPSTF, Pignone et al.10, 11 concluded that each of these interventions likely costs <$30,000 per year of life saved.

Nationally, rates of colon cancer screening remain below the Healthy People 2010 goal of 50% for FOBT in the preceding 2 years and 50% ever having had a sigmoidoscopy. The 1998 baseline population-based survey, which serves as the monitoring system for Healthy People 2010, showed that 35% of the population reported completing FOBT in the past 2 years and 37% ever had a sigmoidoscopy.12 In the Behavioral Risk Factor Surveillance System (BRFSS), 21.8% of subjects reported having an FOBT in the preceding year, and 43.2% reported having a sigmoidoscopy or colonoscopy within the preceding 5 years.13 Rates of colon cancer screening were lower for African Americans, low-income people, and individuals with less formal education.12, 13 Rates of colon cancer screening are below those for breast and cervical cancer screening. In the 1998 baseline data for Healthy People 2010, 67% of women reported having a mammogram in the preceding 2 years and 79% had a Pap smear in the preceding 3 years.12 Various strategies have been reported to increase rates of FOBT testing, including distribution of FOBT cards by office nurses,14 reminders for screening,15 mailing in of completed FOBT cards,16 and mailing out of cards.17

In the General Medicine Clinic of Cook County Hospital, constraints in access to screening colonoscopy based on limited resources make FOBT an important screening option. Low rates of FOBT screening prompted us to test the effect of mailing stool cards timed to appointments on the rates of completion of FOBT.

Section snippets

Methods

We conducted a controlled trial that tested a system of mailing FOBT cards and reminders 2 weeks prior to a scheduled appointment versus usual care. The primary outcome was the rate of screening at the index appointment and over the study year based on intention to treat.

Results

We identified 119 General Medicine Clinic patients aged 50 to 80, with scheduled appointments on Tuesday afternoon in May or June 2000, who were not screened with an FOBT during the preceding year. Fifty-nine subjects were assigned to the intervention group and 60 were assigned to the usual care. Table 1 shows the baseline data for the two groups. There were no statistical differences between the groups for any of the baseline variables. There was no difference in the index appointment

Discussion

Mailing FOBT cards timed to a scheduled general medical appointment improved the screening rate compared to usual care. There were significant increases in the rates of return of the FOBT cards both at the index appointment and during the year beginning with the index appointment. Rates of return of the FOBT cards were even higher when it was considered that at least 12% of the participants had incorrect addresses in the hospital database. In a very small subset of patients with a self-reported

Acknowledgements

We are grateful for the contributions of Jennifer Smith, MD, and the General Medicine Clinic Improvement Project, and for support by Kyrungran Shim, MD, Cathy Rowell, RN, and Rhonda Burrows, RN, all members of the Colon Cancer Screening Program.

References (19)

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    Four studies108,112–114 had least-suitable study designs and fair quality of execution. One study115 had greatest suitability of study design, with good quality of execution. Outcomes in update studies included completion of FOBT alone112,115; colonoscopy or FOBT (including fecal immunochemical tests)113; any of the three testing modalities (FOBT, sigmoidoscopy, or colonoscopy)108; and the mean number of colonoscopies per month.114

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    Effective interventions, or positive findings, were reported in 6 of 10 trials. Interventions resulting in higher FOBT completion rates included: (1) A culturally targeted, nurse-delivered educational program with free FOBT cards, instruction/demonstration, and a reminder call at one month17; (2) in-person, home delivery of stool sample collection containers19; (3) mailed FOBT cards with a letter from the provider practice sent to patients 2 weeks in advance of a visit13; (4) a tailored comprehensive print intervention with telephone counseling12; (5) screening education provided by a trilingual, bicultural health educator with language-appropriate video, pamphlets, FOBT cards, and instructions18; and 6) a cancer screening office-based system intervention that included screening checklists, chart stickers, audits, and shared responsibilities for screening among office staff.21 Some trials reported intervention effects that were different for certain subgroups.

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