Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening
Published Online: September 16, 2013
Roger Luckmann, MD, MPH; Mary E. Costanza, MD; Milagros Rosal, PhD; Mary Jo White, MS, MPH; and Caroline Cranos, MPH
Colorectal cancer (CRC) is the second-leading cause of cancer-related deaths in the United States for men and women.1 Evidence from randomized trials and observational studies suggests that screening can reduce CRC mortality 15% to 70% or more, depending on the type of test and screening program.2 The US Preventive Services Task Force and other organizations recommend CRC screening for adults 50 years and older who are at average risk for CRC at least until age 75 years.3 The most commonly recommended screening options are annual fecal occult blood test (FOBT), sigmoidoscopy every 5 years, and colonoscopy every 10 years.4 Although the CRC tests are among the most effective of all cancer screening tests, utilization is low. In 2008, only 53.2% of those 50 years or older were up-to-date with screening, and screening rates in minority groups were even lower.4
The main responsibility for promoting CRC screening rests with primary care providers (PCPs),5,6 who face several barriers to promoting CRC screening, including the short duration of encounters and competing demands to provide other clinical and preventive services.7,8
The US Community Preventive Services Task Force recommends widespread implementation of 2 interventions to increase CRC screening: 1) prompts for PCPs at patient visits to offer screening9 and 2) mail and phone reminders for patients to complete mailed FOBT kits.10 Recent studies support the use of mail and telephone counseling interventions to promote colonoscopy.11-15 Telephone interventions may be most effective when the caller is a known representative of the patient’s PCP and facilitates scheduling of the test. Costanza and colleagues reported that counselor calls did not increase screening when the PCP had not personally recommended the counseling, when the counselor was unfamiliar to the patient, and when the counselor did not facilitate test scheduling.16 Based on findings from that study and from other studies cited above, we developed a hybrid intervention that includes PCP prompting to personally recommend CRC screening and counseling, mailed educational materials, and PCP referral of patients to an educational and motivational telephone intervention that offered facilitated scheduling of colonoscopy and support for FOBT testing.
The study was implemented in 3 Family Medicine practices affiliated central Massachusetts. Two practices (Worcester A, Worcester B) are on the urban campuses of an academic medical center and serve a population diverse in race/ethnicity and socioeconomic status. The third practice (Barre) serves a rural and less diverse population. One of the urban practices included 9 PCPs, 7 part time, and the other included 11 PCPs, all but 1 part time. The Barre practice included 7 PCPs, 4 part time. The University of Massachusetts Medical School Institutional Review Board approved the study, which took place from February 2006 to May 2007.
To maximize the number of referrals for counseling, we asked PCPs to refer patients at any type of visit. Study staff used an electronic scheduling system to identify patients aged 50 to 79 years scheduled for a visit with a study PCP during the upcoming week for 14 months. Clinic staff attached study referral forms to patient paper charts, which prompted PCPs to discuss CRC screening. Providers were to document on the form whether they addressed CRC screening, and if they did, the patient outcome: 1) up-to-date with screening, 2) not a candidate for screening (eg, limited life expectancy), 3) counseling not needed (eg, patient fully understands CRC screening), or 4) referred for counseling and 5) patient acceptance of the referral. Referred patients received a card with instructions to contact the counseling office to set up an appointment. If a provider indicated that he or she did not discuss CRC screening, a patient did not arrive for the scheduled appointment, or if the encounter form was not returned, additional study encounter forms were generated for any future appointments.
Referred patients who did not call the study office received up to 5 call attempts from study staff. At the first phone contact the patient was screened for study eligibility, and if eligible, was asked to schedule an appointment with a telephone counselor. Patients were eligible if they did not report any rectal bleeding that would be an indication for a diagnostic colonoscopy and did not report a screening colonoscopy in the last 10 years. Those who agreed to counseling were administered a brief survey and were mailed an educational booklet and a letter to remind them of the date and time of the counseling appointment. Survey questions addressed readiness for CRC screening.
The intervention had 3 components: 1) a booklet mailed to patients that reviewed CRC and CRC screening, followed by 2) a telephone counseling call during which the key educational messages in the booklet were reviewed and motivational interviewing was used to promote acceptance of CRC screening, and 3) for those accepting screening, counseling to address logistical barriers to screening and facilitation of scheduling colonoscopy or mailing an FOBT kit to the patient.
The study team and a health literacy consultant edited an educational booklet developed for a previous CRC screening study to make it more accessible to patients with lower reading levels and/or low health literacy. The booklet reviewed the nature, risk, and natural history of CRC and the role of polyps in the evolution of CRC. It included an illustrated guide to completing 3 CRC screening tests (FOBT, flexible sigmoidoscopy, and colonoscopy) and a comparison of the benefits and risks of each test. The book was translated into Spanish.
Counseling Protocol and Script
PDF is available on the last page.