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A Randomized Controlled Trial of Enhanced Office and Patient Management on Compliance With Colorectal Cancer Screening

Bruce S. Ling, MD, MPH; Robert E. Schoen, MD, MPH; Jeanette M. Trauth, PhD; Abdus S. Wahed, PhD; Theresa Eury, BS, CHES; Deborah M. Simak, BN, MNEd; Francis X. Solano, MD; Joel L. Weissfeld, MD, MPH

Arch Intern Med. 2009;169(1):47-55.

Background  Colorectal cancer screening is underused. Our objective was to evaluate methods for promoting colorectal cancer screening in primary care practice.

Methods  A 2 x 2 factorial randomized clinical trial measured the effects of a tailored vs nontailored physician recommendation letter and an enhanced vs nonenhanced physician office and patient management intervention on colorectal cancer screening adherence. The enhanced and nonenhanced physician office and patient management interventions varied the amount of external support to help physician offices develop and implement colorectal cancer screening programs. The study included 10 primary care physician office practices and 599 screen-eligible patients aged 50 to 79 years. The primary end point was medical-record-verified flexible sigmoidoscopy or colonoscopy. Statistical end-point analysis (according to randomization intent) used generalized estimating equations to account for correlated outcomes according to physician group.

Results  During a 1-year period, endoscopy in the lower gastrointestinal tract (lower endoscopy) occurred in 289 of 599 patients (48.2%). This finding included the following rates of lower endoscopy: 81 of 152 patients (53.3%) in the group that received the tailored letter and enhanced management; 103 of 190 (54.2%) in the group that received the nontailored letter and enhanced management; 58 of 133 (43.6%) in the group that received the tailored letter and nonenhanced management; and 47 of 124 (37.9%) in the group that received the nontailored letter and nonenhanced management. Enhanced office and patient management increased the odds of completing a colonoscopy or flexible sigmoidoscopy by 1.63-fold (95% confidence interval, 1.11-2.41; P = .01). However, the tailored letter increased the odds of completion by only 1.08-fold (95% confidence interval, 0.72-1.62; P = .71).

Conclusions  Approximately one-half of the screen-eligible primary medical care patients aged 50 to 79 years obtained lower endoscopic colorectal cancer screening within 1 year of recommendation. An enhanced office and patient management system significantly improved colorectal cancer screening adherence.

Trial Registration  clinicaltrials.gov Identifier: NCT00327457

Author Affiliations: Departments of Medicine (Drs Ling, Schoen, and Solano and Ms Simak), Epidemiology (Drs Schoen and Weissfeld and Ms Eury), Behavioral and Community Health Sciences (Dr Trauth), and Biostatistics (Dr Wahed), and University of Pittsburgh Cancer Institute (Drs Ling, Schoen, Trauth, and Weissfeld), University of Pittsburgh, and University of Pittsburgh Medical Center Community Medicine, Inc (Dr Solano), Pittsburgh, Pennsylvania.

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