Effect of Patient Portal Messaging Before Mailing Fecal Immunochemical Test Kit on Colorectal Cancer Screening Rates: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%.

OBJECTIVE

To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis.

INTERVENTIONS

Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group).

MAIN OUTCOMES AND MEASURES

The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate.

RESULTS

The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004).

CONCLUSIONS AND RELEVANCE

Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05115916.

Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up

BACKGROUND

The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy.

AIMS

We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system.

METHODS

The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation.

RESULTS

There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99).

CONCLUSIONS

After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.

Behavioural nudges increase COVID-19 vaccinations

Enhancing vaccine uptake is a critical public health challenge1. Overcoming vaccine hesitancy2,3 and failure to follow through on vaccination intentions3 requires effective communication strategies3,4. Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) (n = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) (n = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies (n = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions5, and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines.

Establishing a Denominator for Palliative Care Quality Metrics for Patients with Advanced Cancer

Background: Measurement and monitoring of palliative care quality metrics for patients with advanced cancer promote early integration of palliative care within the oncology clinic. Accurately identifying the subset of advanced cancer patients within a population of cancer patients who would most benefit from palliative care is critical to the development of palliative care-relevant quality improvement activities. Methods: We evaluated two automated approaches to identifying patients with solid tumors sufficiently advanced to warrant discussions of palliative care and advanced care planning. These approaches included (1) pattern matching of words indicating an advanced cancer in oncology notes, radiology imaging, and active problem lists and (2) International Classification of Diseases (ICD-10) codes. We randomly selected 586 charts of patients with active cancer who are patients in our health system to establish a gold standard for advanced cancer through expert chart review. We evaluated the sensitivity and specificity of these automated approaches to identify advanced cancer patients compared with the gold standard. Results: We found that the highest performing pattern matching method had a specificity of 76% and a sensitivity of 81%. Using our final ICD-10 algorithm, we achieved a specificity of 92% and a sensitivity of 68%. We improved our sensitivity to 76% while maintaining our specificity at 91% when we excluded patients assigned to oncologists who predominantly see hematological malignancies. Conclusions: We achieved high specificity and reasonable sensitivity for an advanced cancer quality metric denominator using an ICD-10 algorithm within an academic oncology practice. This concrete definition will help inform quality improvement efforts locally and beyond.

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions

PROBLEM

With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems.

APPROACH

In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive, value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending, (2) create design teams to understand the patient story, (3) create custom analytics and spending-based risk stratification, and (4) develop care pathways based on spending risk tiers. Primary care patients with three chronic conditions-dementia, chronic kidney disease (CKD), and cancer-were identified as high-cost subpopulations.

OUTCOMES

For each patient subpopulation, a multispecialty, multidisciplinary design team identified reasons for spending and created care pathways to meet patient needs according to spending risk. Larger, lower-risk cohorts received necessary but less intensive interventions, while smaller, higher-risk cohorts received more intensive interventions. Preliminary analyses showed a 1% monthly decrease in inpatient bed day utilization among dementia patients (incident rate ratio [IRR] 0.99, P < .03) and a 2% monthly decrease in hospitalizations (IRR 0.98, P < .001) among CKD patients.

NEXT STEPS

Use of the Patient Health Value framework is expanding across other high-cost subpopulations with chronic conditions. UCLA Health is using the framework to organize care across specialties, build capacity, and grow a culture for value.

Establishing a denominator for palliative care quality metrics for patients with advanced cancer

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Background: Measurement and feedback of palliative care quality metrics for patients with advanced cancer is an important aspect of supporting a shared mental model for the early integration of palliative care within the oncology clinic. Accurately identifying the subset of advanced cancer patients within a population of cancer patients is critical to the development of quality improvement activities; however, there is not a methodology of identifying these patients in real time. Methods: We evaluated two main approaches to identifying patients with advanced cancer among active cancer patients defined as patients who were seen by an oncologist at least twice in the last 6 months and who had received chemotherapy or radiation at least once in the last two years. These approaches included: 1) Pattern matching of words indicating advanced cancer (e.g. metastatic, advanced) in oncology notes, radiology imaging and problem lists and 2) ICD-10 codes. To determine the final set of ICD-10 codes for the second approach, we used a conceptual model of the meaning of advanced cancer (evidence of distant metastasis and/or poor prognostic cancer with > 50% mortality rate at 5 years) and iterative chart review. In order to test our final definitions, we randomly selected 588 charts of patients with active cancer who see one of 64 oncologists in our health system. These charts were abstracted by an oncologist to establish a gold standard for advanced cancer. We evaluated the sensitivity and specificity of our approaches to identify advanced cancer patients compared to this gold standard. Results: We found that the methods used to identify patients using pattern matching had a specificity of 76% and a sensitivity of 80%. Using our final ICD-10 algorithm we achieved a specificity of 93% and a sensitivity of 68%. We improved our sensitivity to 74% while maintaining our specificity at 92% when we excluded oncologists who predominantly see hematological malignancies. Conclusions: We achieved high specificity and reasonable sensitivity for an advanced cancer quality metric denominator using an ICD-10 algorithm within an academic oncology practice. This will help inform quality improvement efforts locally and beyond.

Metropolitan Forensic Anthropology Team (MFAT) case studies in identification: 2. Identification of a Vietnamese trophy skull

A Vietnamese trophy skull, apparently a victim of the Vietnam war, was recently received for analysis in a New York State homicide case. The skull, which is well preserved except for the missing mandible and maxillary dentition, is compared to trophy skulls of Japanese military personnel, also brought back to the United States by American soldiers following wartime duty in Asia.