Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

Colorectal Cancer (CRC) screening continues to be underused with 50- 60% of respondents self-reporting uptodate screening in national surveillance surveys as of 2005-2006 (Holden, et al., 2010). In our systematic review published in 2010, results indicated a need to better ensure patients who are in need of screening (e.g., age 50-74 years) obtain it in an adequate and timely manner, receiving followup for positive findings, but that strategies be developed to more effectively increase screenings among those not receiving it as recommended and decreasing the overuse and misuse of CRC screening tests.

We identified 13 randomized control trials (RCTs) rated as good or fair quality for inclusion in our review to address the key question of identifying effective strategies to increase appropriate use of CRC screening and surveillance. These included 11 studies that targeted the patient much like the study described by Dietrich, et al (this issue)-- only 1 study each for provider or system level interventions was included. At that time (2010), we found high strength of evidence that interventions that provide patient reminders lead to small to moderate increases in screening (percent increases ranged from 6.3-15 percentage points). For the current study reported by Dietrich, et al., the telephone outreach intervention delivered by the clinic staff "increased CDC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention" (p. 335). What was particularly important about this study is the population the authors attempted to reach- patients receiving care from Medicaid managed care organizations (MMCOs). As we found in our review, patients covered by Medicaid only were just as likely (AOR, 27.6; 95% CI, 21.1-35.2) as patients without insurance (AOR, 24.1, 95% CI, 19.2- 29.7) to be uptodate in their CRC screening (Shapiro, et al., 2008). This population is more likely to have a lower income and be less educated and have poorer access to regular care, all factors which have been consistently associated with lower CRC screening rates (Holden, et al., 2010). Since providing patients with reminders, as with this study, is a fairly inexpensive intervention for increasing screening, it is an important finding that this strategy is successful in significantly increasing screening rates among this population of women.

Findings from our review called for additional RCTs of interventions to improve the use and quality of appropriate CRC screening. It is perplexing to determine what strategies will increase CRC screening to a level more like that for breast cancer. In the Dietrich, et al., study, they found more effect in one practice than in others but it is unclear why this would be the case. More research to determine the provider and system level factors that best facilitate appropriate use of screening-- an area we found lacking in our review--will be critical to obtaining higher overall screening rates.

Competing interests: ?? None declared

Dr. Dietrich et al have advanced the field of improving colorectal cancer (CRC) screening among vulnerable patient populations in two important ways. First, they have conducted a dissemination and implementation study, as opposed to yet another randomized controlled trial. They have demonstrated that telephone outreach delivered in the "real world"--e.g. in Medicaid Managed Care Organizations (MMCOs) -- can increase CRC screening in a potentially sustainable way. Second, they have shown that when Prevention Care Managers provided outreach for three types of cancer screening (breast, cervical, and colorectal), versus focusing exclusively on CRC screening, the intervention effect may have been "diluted." This should serve as a cautionary tale for patient navigation/care management interventions that have care managers and navigators addressing multiple chronic conditions and health maintenance items simultaneously.

As I read the study, I wondered whether the primary care providers at participating practices were aware that their patients were receiving outreach calls about CRC screening from the MMCOs. I was concerned about possible duplication of efforts by practice staff. As practices evolve into patient-centered medical homes they may be developing their own registries and providing outreach to patients who are not up to date with screenings. In addition, primary care providers may have difficulty keeping track of all the different initiatives targeting their patients that are provided by different health plans. Ideally, a care manager that is embedded in a practice would provide telephone outreach to all patients, regardless of payer type. What if each health plan contributed resources to support such an individual at the practice or institution level?

As the Director of Quality Improvement for the Section of General Internal Medicine at a large urban safety-net hospital, I find that Dr. Dietrich's study has raised new questions. With limited resources, are we better off partnering with our MMCO to provide telephone outreach to promote CRC screening? Or should we try to implement the approach used by Jean-Jacques et al,2 mailing a CRC fact sheet and fecal occult blood test (FOBT) kit, followed by telephone outreach by a lay health educator, for those patients who do not return the FOBT kits? As a first step, we have decided to mail fecal immunochemical test kits to unscreened patients who are insured by health plans in alternative quality contracts. In the future, we may consider working with our MMCO, thanks to Dr. Dietrich et al's valuable contribution to the literature.

1. Dietrich AJ, Tobin JN, Robinson CM et al. Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial. Annals of Family Medicine. 2013;11(4):335- 343.

2. Jean-Jacques M, Kaleba EO, Gatta JL et al. Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial. Annals of Family Medicine. 2012;10(5):412- 7.

Competing interests: None declared

This nicely executed study illustrates important findings about what it takes to optimize case management in complex clinical (and study) settings for a screening test that is not typically well received by patients. Even more importantly is their characterizing of the number of contact attempts it takes to reach this high risk underserved population, which can assist in understanding both resource utilization and the need for persistence in providing colon cancer screening.

More studies of this caliber are definitely needed!!

Competing interests:   None declared