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A Randomized Controlled Trial

Thomas D. Sequist, MD, MPH; Alan M. Zaslavsky, PhD; Richard Marshall, MD; Robert H. Fletcher, MD; John Z. Ayanian, MD, MPP

Arch Intern Med. 2009;169(4):364-371.

Background  Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates

Methods  We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.

Results  Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09).

Conclusions  Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.

Trial Registration  clinicaltrials.gov Identifier: NCT00355004

Author Affiliations: Division of General Medicine and Primary Care, Brigham and Women's Hospital (Drs Sequist and Ayanian), Department of Health Care Policy, Harvard Medical School (Drs Sequist, Zaslavsky, and Ayanian), Harvard Vanguard Medical Associates (Drs Sequist and Marshall), and Department of Ambulatory Care and Prevention, Harvard Medical School (Dr Fletcher), Boston, Massachusetts.

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