Primary Care Intervention Improved Follow-Up of Abnormal Cancer Screening Results

A multilevel primary care intervention that included automated electronic health record (EHR) reminders and patient outreach/navigation improved timely follow-up of overdue abnormal cancer screening test results, a cluster randomized trial showed.

Among nearly 12,000 patients with an abnormal screening test result for colorectal, cervical, breast, or lung cancer, completion of follow-up testing within 120 days of study enrollment was significantly higher with EHR reminders, patient outreach, and patient navigation (31.4%) and EHR reminders and patient outreach (31.0%) compared with only EHR reminders (22.7%), and usual care (22.9%), reported Steven J. Atlas, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues.

The adjusted absolute difference for comparison of the EHR reminders, outreach, and navigation group versus usual care was 8.5% (P<0.001), they noted in JAMA.

Results were similar for completion of recommended follow-up at 240 days and across cancer types and levels of risk.

“Gaps in follow-up care need to be addressed if the full benefits of preventive cancer screening are to be realized,” Atlas and team wrote, suggesting that beyond the need for reminders, educating patients about the meaning of test results, what follow-up procedures involve, and assessing patient preferences should also be addressed.

In subgroup analyses, patients with abnormal cancer screening test results for cervical cancer who received EHR reminders, outreach, and navigation (OR 1.28, 95% CI 0.93-1.77) and those who received EHR reminders and outreach (OR 1.51, 95% CI 1.09-2.09) had greater odds of completing follow-up testing compared with patients who received usual care.

The same was true for patients with abnormal cancer screening test results for colorectal cancer in the EHR reminders, outreach, and navigation group (OR 1.68, 95% CI 1.32-2.16) and those in the EHR reminders and outreach group (OR 1.71, 95% CI 1.33-2.19).

Compared with patients in the usual care group, patients with low- or medium-risk abnormal cancer screening test results had greater odds of completing follow-up with EHR reminders, outreach, and navigation (OR for low risk: 1.66, 95% CI 1.36-2.02; OR for medium risk: 1.57, 95% CI 1.25-1.96) and with EHR reminders and outreach (OR for low risk: 1.58, 95% CI 1.28-1.95; OR for medium risk: 1.55, 95% CI 1.23-1.96).

For this trial, 11,980 patients across 44 primary care practices within three health networks in the U.S. were included. Median age was 60 years, 64.8% were women, and 83.3% were white. All had at least one overdue abnormal cancer screening test result: 69% for colorectal cancer, 22% for cervical cancer, 8% for breast cancer, and 1% for lung cancer. Abnormal test results were categorized as low risk (51%), medium risk (31%), or high risk (18%).

Participants were randomized 1:1:1:1 to four groups: usual care (outreach and the ability to view test results in an online patient portal); EHR reminders; EHR reminders and outreach (patients received a letter and a phone call); or EHR reminders, outreach, and navigation (patients received a letter and a navigator outreach phone call). Patients were followed from August 2020 to December 2021.

The authors noted that one of the limitations of the study was the fact that it was conducted during the COVID-19 pandemic, which likely contributed to more patients having overdue abnormal test results, and not completing follow-up testing.