Home tests and automated reminders cut colon cancer screening costs

GroupHealth: Sending at-home stool kits through the mail and using automated reminders are part of a cost-effective program to boost screening for colon cancer, according to researchers at Group Health and Kaiser Permanente. Health costs were significantly lower over two years when researchers used electronic health records to identify patients who weren’t screened regularly for colon cancer, and then encouraged these patients to be screened.

The American Journal of Preventive Medicine published “An Economic Evaluation of Colorectal Cancer Screening in Primary Care Practice,” the cost results from a randomized controlled trial called Systems of Support to Increase Colorectal Cancer Screening (SOS).
The SOS trial used electronic medical records to identify more than 4,000 Group Health patients, aged 50 to 73, who weren’t up to date for colorectal cancer screening. They were randomly assigned to one of four stepped groups (usual care or three stepped interventions):

• Usual care: reminders sent to patients and their primary-care clinics;
• Automated care: usual care plus a letter telling patients they were due for colorectal cancer screening and a pamphlet about screening choices;
• Assisted care: a medical assistant calling to ask which screening option patients preferred, if they still had not completed screening; or
• Navigated care: all of the above, plus, if still overdue, a nurse calling to advise patients and facilitate their screening.

“Two of the three interventions—automated and assisted care—cost less per screened patient than usual care,” said lead author Richard T. Meenan, PhD, a senior investigator at the Kaiser Permanente Center for Health Research, in Portland, OR. “That’s because the people in those intervention groups were more likely than those in the usual care group to choose a stool test instead of colonoscopy and colonoscopies are more expensive than stool tests.”
With the testing and intervention costs factored in, the automated intervention saved $159 per patient compared to usual care and the assisted intervention saved $36 per patient compared to usual care; navigated care cost $65 more than usual care.  That doesn’t necessarily mean that automated care is best, because it is also important to take into account how many patients received screening. That number rose with each stepped level of intervention.
“Screening for cancers of the colon and rectum can prevent disease—and death,” said Beverly B. Green, MD, MPH, a family physician at Group Health and an associate investigator at Group Health Research Institute. “But this screening works only if people get it done regularly—and nearly one-third of Americans don’t, even though it’s strongly recommended for everyone age 50 to 75 years.”
The same research team had previous published that SOS’s centralized, automated approach doubled these patients’ rates of on-time screening. And nurse navigators helped the patients to get needed follow-up care after positive screening tests. Thanks to this research, usual care has changed so now Group Health and Kaiser Permanente send automated reminders to patients who are overdue for colon cancer screening, and in many cases these patients also receive an at-home screening test.

What’s next?

Now the researchers are following up with the same patients for up to 10 years to see whether the regular screenings—and cost savings—persist. Stool tests need to be done yearly,  while screening colonoscopy is recommended only once per decade, Dr. Green explained. So it is possible that regular screening and cost savings in the intervention groups might decline over time.
Dr. Green and Kaiser Permanente researcher Gloria Coronado, PhD, have also shown that systematically mailing stool tests to patients in community health clinics is a promising way to help prevent disparities in colon cancer screening.