Effects of Standardized Outreach for Patients Refusing Preventive Services: A Quasiexperimental Quality Improvement Study

Educational outreach did not seem to be a promising strategy to promote preventive services use among patients who refused services recommended by their physician.
Published Online: July 13, 2011
Stephen D. Persell, MD, MPH; Elisha M. Friesema, BA; Nancy C. Dolan, MD; Jason A. Thompson, BA; Darren Kaiser, MS; and David W. Baker, MD, MPH

Objective: To determine the effect of standardized outreach on the receipt of preventive services for patients whose physicians record that the patient refused the service.


Study Design: Prospective observational study of a quality improvement intervention using a nonrandomly assigned comparator group.


Methods: Patients from a large internal medicine practice with recorded refusals to preventive services were included. A nonclinician care manager mailed plain-language educational brochures, attempted telephone contact, and provided logistical assistance. The primary patient outcome was the time from refusal to first receipt of a refused service (colorectal cancer screening, breast cancer screening [mammography], cervical cancer screening, osteoporosis screening [bone density testing], or pneumococcal vaccination). We compared the time to completion of refused sevices during the period when outreach was performed (February 8, 2008, to November 25, 2008 [outreach cohort]), and during a subsequent period when refusals were recorded but no outreach was performed (November 26, 2008, to December 1, 2009 [nonintervention cohort]), using Cox proportional hazards regression models adjusted for patient characteristics. We recorded the time spent performing outreach.


Results: In total, 407 patients refused 520 preventive services in the outreach cohort, and 378 patients refused 510 services in the nonintervention cohort. After 6 months of follow-up, 6.1% of the outreach cohort and 4.8% of the nonintervention cohort had received a refused service (adjusted hazard ratio, 1.3; 95% confidence interval, 0.7-2.5). The care manager spent 214 hours performing the outreach.


Conclusions: Standardized educational outreach was not a promising strategy for improving preventive services use among patients who have refused services recommended by their physician. The amount of time required to perform the outreach was substantial.

(Am J Manag Care. 2011;17(7):e249-e254)

This study examined the effects of standardized outreach on the receipt of preventive services for patients whose physicians record that the patient refused the service. A prospective observational study design included a nonrandomly assigned comparator group.

  • This intervention, which included mailed plain-language educational brochures, attempted telephone contact, and assistance with scheduling, led to few patients (6.1%) obtaining the refused service over 6 months.


  • The receipt of refused services did not significantly differ between the outreach cohort and the nonintervention cohort.


  • The care manager time required to perform this outreach was substantial.
Interventions that increase healthcare providers’ recommendations to patients to obtain preventive services have been proved to increase the use of these services.1 However, some patients refuse effective preventive services when they are offered.2-4 How the healthcare delivery system should address these refusals is unclear. Clinicians must respect patient autonomy even when patients make choices to forgo beneficial tests or treatments.5 However, if patients lack adequate information about why a test or treatment is recommended, their voiced refusal may indicate a spurious preference, meaning it is not the choice they would make if they had better information. Concerns have been raised that brief office visits may not provide adequate opportunity for clinicians to educate patients about the host of services that may be of benefit to them.6-8 The information provided by clinicians during office visits may be difficult for some patients to understand, particularly those with lower literacy or socioeconomic status.6,9-12 Patients may hold misconceptions about preventive services that lead them to believe that the services are undesirable, would not benefit them, or may be harmful.13-15 Patients may refuse a medical service if they think that a perceived barrier has not been addressed.11,14-17 Standardized educational outreach and care facilitation could address these concerns and lead some patients who initially refused a service to accept it.

As part of a larger multifaceted quality improvement intervention,18,19 we sought to implement a system of care to ensure that the following goals were met among patients who had refused a recommended preventive service: (1) the patients received clear educational material that provided the essential rationale justifying the need for the preventive service, (2) the information was written at a low-literacy level, (3) some common misconceptions about the service were specifically addressed, and (4) patients had the opportunity to discuss barriers to receiving the service with a nonclinician care manager. This study compares the receipt of refused preventive services among patients receiving care during the period when outreach was conducted at this practice site and during a subsequent period when no outreach was performed.


Setting and Eligible Patients

We performed this study at a large academic primary care inter-nal medicine practice in Chicago, Illinois, using a commercial electronic health record (EHR) (EpicCare, spring 2007 version; Epic Systems Corporation, Verona, WI). Northwestern University’s institutional review board approved the study. Thirty-nine attending physicians, 1 nurse practitioner, and more than 120 residents worked at the clinic during this time.

We previously reported the details of the overall quality improvement context within which this study took place.18 Physicians received quarterly reports of the quality of care received by their primary care patients and had point-of-care reminders provided by the clinical decision support system in the EHR. Physicians were encouraged to record preventive services that patients reported receiving from other providers. Physicians were asked to record standardized exceptions that explained why a service that seemed to be indicated was not performed. We suggested that physicians record a medical exception when a service was not recommended because of a contraindication, an intolerance, or a suspected lack of clinical benefit because of a patient’s clinical condition. We encouraged physicians to record a patient refusal when they recommended a test or treatment but the patient actively refused. We advised physicians not to record an exception when there was a transient reason for not performing a service or if the patient intended to obtain the service elsewhere. Because recording of exceptions turned off computerized reminders, physicians were advised that they should not record an exception if they wanted to be reminded to address a preventive care issue again at the patient’s next visit.

Patients were eligible for inclusion in this study if a physician entered standardized documentation in the EHR that the patient had refused a preventive service that the physician recommended. The preventive services we examined included colorectal cancer screening, breast cancer screening (mammography), cervical cancer screening, osteoporosis screening (bone density testing), and pneumococcal vaccination; the numbers of patients in the practice eligible for each of these services at the start of the study were 7067, 3539, 7462, 2966, and 1816, respectively, approximately 12,000 patients overall.18 Patients with refusals documented between February 8, 2008, and November 25, 2008, constituted the outreach cohort. We stopped performing outreach after 10 months because the ongoing resources that were required did not seem justified. We selected patients who had refusals documented during the period immediately following the intervention, November 26, 2008, to December 1, 2009, as a comparator nonintervention cohort (excluding patients who were already included in the outreach cohort). This group was selected for comparison in a quasiexperimental design to assess whether there was an underlying rate at which patients who refused services but received no other structured intervention were obtaining these services.20 We selected a longer period for the nonintervention cohort to increase the size of the population available and to raise the statistical power for comparisons.

Outreach Intervention

During the outreach period, we performed an automated search of the EHR each week to identify patients with any new refusals recorded to electronic reminders for the 5 preventive services aforelisted. A nonclinician care manager (EMF) performed the following task: She reviewed the EHR to determine if any specific barriers to obtaining the refused service were documented and to assess if outreach for a preventive service seemed inappropriate. Patients who had substantial active medical or psychosocial stressors described in the EHR or for whom the preventive service seemed medically contraindicated were deemed inappropriate for outreach, and no physician contact was performed. These reasons were reviewed at weekly meetings with physician team members (SDP, NCD, DWB), who helped decide when outreach should not be performed. The care manager then sent e-mails within the EHR to patients’ primary care physicians notifying them that patients would receive outreach unless the physician indicated that outreach should not be performed, mailed patients brief materials that included plain-language educational brochures relevant to each topic, attempted telephone contact 3 times, and left a callback number when possible. When telephone contact was successful, the care manager attempted to identify and resolve any barriers to obtaining the service by providing education and, when appropriate, by offering needed referrals, facilitating the scheduling of necessary appointments, or referring the patient back to the practice clinicians if questions arose.


All measurements were obtained using automated searches of EHR-derived data. The primary outcome for each patient was the time from refusal to receipt of any refused preventive service (colorectal cancer screening, breast cancer screening, cervical cancer screening, osteoporosis screening, or pneumococcal vaccination). This included (1) the result of a test or vaccination performed at this center or (2) clinician documentation in a standard field of the EHR that the test had been performed elsewhere. For patients with recorded refusals of more than 1 preventive service, the one with the shortest time from refusal to completion was used in the primary analysis. We also examined completion of the individual preventive service separately. We recorded the time spent by the care manager performing outreach.

Statistical Analysis

We compared time to receipt of the refused sevice for the outreach cohort and for the nonintervention cohort using curves obtained using the Kaplan-Meier method. We used Cox regression models to calculate proportional hazards adjusted for patient characteristics (age, sex, race/ethnicity, and insurance type as categorized in Table 1 when appropriate). Analyses used commercially available statistical software (STATA version 10; StataCorp LP, College Station, TX).

The study was funded by the Agency for Healthcare Research and Quality. The funder had no role in the design, conduct, or analysis of the study or in the decision to submit the manuscript for publication.


Patients Refusing Preventive Services

The characteristics of patients who refused preventive services in both cohorts are listed in Table 1. In the outreach cohort, 407 patients had 1 or more refusals documented for 520 preventive services. This represented approximately 3.4% of the practice population that was eligible for 1 or more preventive services. In the nonintervention cohort, 378 patients had 1 or more refusals documented for 510 preventive services. Compared with the nonintervention cohort, the outreach cohort was slightly older, was more likely to have Medicare insurance, and more frequently had refused colorectal cancer screening or pneumococcal vaccination.

Execution of the Outreach Intervention

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