Ronald E. Myers, PhD

 Examine association of comprehensiveness of colorectal cancer (CRC) screening discussion by primary care physicians (PCPs) with completion of CRC screening.

Observational study in Kaiser Permanente Northwest, a group-model health maintenance organization.

 A total of 883 participants overdue for CRC screening received an automated telephone call (ATC) between April and June 2009 encouraging CRC screening. Between January and March 2010, participants completed a survey on PCPs’ discussion of CRC screening and patient beliefs regarding screening. Primary outcome measure: receipt of CRC screening (assessed by electronic medical record [EMR], 9 months after ATC). Primary independent variable: comprehensiveness of CRC screening discussion by PCPs (7-item scale). Secondary independent variables: perceived benefits of screening (4-item scale assessing respondents’ agreement with benefits of timely screening) and primary care utilization (EMR; 9 months after ATC). The independent association of variables with CRC screening was assessed with logistic regression.

 Average scores for comprehensiveness of CRC discussion and perceived benefits were 0.4 (range 0-1) and 4.0 (range 1-5), respectively. A total of 28.2% (n = 249) completed screening, 84% of whom had survey assessments after their screening date. Of screeners, 95.2% completed the fecal immunochemical test. More comprehensive discussion of CRC screening was associated with increased screening (odds ratio [OR] = 1.51, 95% confidence interval [CI] = 1.03-2.21). Higher perceived benefits (OR = 1.46, 95% CI = 1.13-1.90) and 1 or more PCP visits (OR = 5.82, 95% CI = 3.87-8.74) were also associated with increased screening.

 More comprehensive discussion of CRC screening was independently associated with increased CRC screening. Primary care utilization was even more strongly associated with CRC screening, irrespective of discussion of CRC screening.

 More comprehensive discussion of CRC screening by PCPs was associated with higher screening rates among adults aged 51 to 80 years who were overdue for screening.

 Higher perceived benefits of CRC screening by patients was also associated with increased CRC screening.

 1 or more PCP visits was strongly associated with increased CRC screening, irrespective of discussion of CRC screening.

Colorectal cancer (CRC) is the third-most common cancer and the second-leading cause of cancer-related death in the United States.

 Recent estimates suggest that CRC will be newly diagnosed in about 112,340 people annually, resulting in over 52,180 deaths per year.

Total direct costs associated with treating CRC are $17 billion annually, with 9.8 million work days lost annually to hospitalization for colon cancer.

The early detection of high-risk lesions, or CRC itself, through appropriate screening is associated with decreased incidence of and mortality from CRC.

 The US Preventive Services Task Force recommends that men and women of average risk begin screening for CRC starting at age 50 years,

 and specialty care guidelines provide recommendations for higher-risk groups.

 Currently, recommended CRC screening modalities for average-risk patients include annual fecal occult blood testing (FOBT), colonoscopy every 10 years, or flexible sigmoidoscopy every 5 years, with or without interval FOBT.

 In addition, as a result of improved test performance and usability, in 2008 multiple professional societies endorsed the use of 4 types of fecal immunochemical tests (FITs) for CRC screening to replace FOBT.

Despite the proven benefits of CRC screening, screening rates remain suboptimal. Although more than half of adults 50 years and older in the United States have ever received a CRC screening test, less than half receive screening tests at recommended intervals.

and specific health-system characteristics are associated with receipt of CRC screening (having usual sources of care,

 and assistance with scheduling of colonoscopy),

 less is known about how providerpatient interactions and comprehensiveness of CRC discussion by primary care physicians (PCPs) influence CRC screening. Previous studies indicate that physician recommendation for screening

 may increase CRC screening. However, less is known about how the comprehensiveness of discussion by PCPs about testing options, screening intervals, and potential test complications may influence actual CRC screening. Study of the association of the comprehensiveness of CRC discussion by PCPs with receipt of CRC screening can inform the development of quality-improvement interventions.

The primary objective of this study was to determine the independent association of comprehensiveness of CRC screening discussion by PCPs, as reported by patients, with receipt of CRC screening.

The protocol for this study was approved by the institutional review board within the study health maintenance organization (HMO).

Study Site, Survey, and Electronic Data Sources

The study was conducted at Kaiser Permanente Northwest (KPNW), a not-for-profit HMO with about 485,000 members in southwest Washington and the Portland, Oregon, metro area. The members’ demographic characteristics (age, gender, race/ethnicity) are similar to those of the area population.

KPNW regional electronic databases provided data on patient membership, demographics, primary care assignment, clinical data (including weight and height, laboratory results, and other healthcare utilization, including CRC screening), and clinician data. These data capture over 95% of all medical care and pharmacy services members receive, and data are linked through each member’s health record number.

We included HMO members aged 50 to 80 years who were at average risk for developing CRC, were overdue for CRC screening, and received an automated telephone call as part of a CRC screening-outreach program between March and June 2009.

 The specifics of the automated call program, including the definition of “average risk,” have been described previously.

 Essentially, the average-risk population includes those who are overdue for CRC screening and do not meet any of the following

criteria: (1) active colon cancer/risk factors that would indicate need for non-routine screening, (2) ever diagnosed with adenomatous polyps or human immunodeficiency virus/acquired immunodeficiency syndrome, (3) referred for colonoscopy or sigmoidoscopy in previous 3 months, or (4) receipt of plavix or warfarin medications in previous 4 months that may increase risk of false-positive FIT. The brief automated telephone calls (ATCs) included information about the benefits of CRC screening, encouraged FOBT as a relatively simple and lowrisk method of screening, and allowed patients to request an FOBT by pushing a number on their telephone. The date of the telephone call was defined as the intervention index date.

Of the population receiving automated telephone calls, a random sample of 2000 adults were mailed a survey in January 2010. We chose to begin survey outreach efforts in January 2010 in order to have the most time for those efforts, while still ensuring that sufficient time elapsed (6-9 months) for patients who received ATCs between March and June 2009 to complete screening.

The process flow of the survey administration process is described in the 

 We sent initial surveys to study respondents on January 15, 2010. Next, we sent a reminder postcard to non-responders 2 weeks after the initial mailing. Finally, we mailed the survey a second time to non-responders about 3 weeks after the reminder postcard. Survey enrollment was completed by March 31, 2010. Of the whole population, 1816 (90.8%) were contacted. A total of 184 participants were not contacted due to incorrect addresses. Of those contacted, 883 completed the survey, for a response rate of 48.6% (883/1816). Compared with non-respondents, respondents were more likely to be white (respondents = 95.3% vs non-respondents = 87.5%, 

<.0001), female (respondents = 58.3% vs non-respondents = 48.4%, 

<.0001), and taking more medications (respondents [mean ± standard deviation (SD)] = [3.1 ± 3.8]). Responders and non-responders did not differ in age or length of health plan membership.

This survey was designed to better understand the barriers and facilitators that patients encountered in their efforts to complete CRC screening. We focused on 2 patient-reported domains: (1) patients’ perceptions of clinician-patient counseling, such as comprehensiveness of CRC screening discussion by the PCP, and (2) patient beliefs; namely, perceived benefits of CRC screening. Comprehensiveness of CRC discussion was the primary independent variable, while primary care utilization and perceived benefits of CRC screening were the secondary independent variables.

Comprehensiveness of CRC Screening Discussion, Based on Patient Self-Report

Comprehensiveness of CRC screening discussion.

 These items were based on previous work from Braddock and colleagues

 that assessed levels of informed decision making occurring during patient-provider communications regarding CRC screening. Informed decision making, a means for facilitating patient participation in decision making, includes (1) providing relevant information about the clinical situation, alternatives, and risks and benefits; (2) assessing the patient’s understanding; and (3) giving the patient a clear opportunity to voice a preference.

 Seven yes/no items measured the content of patients’ discussions with their PCPs. We asked patients whether their PCPs did each of the following at any time in the 2 years prior to survey: (1) explained benefits of CRC screening, (2) discussed how often each screening test should be done, (3) provided information on how to do various tests, (4) explained the accuracy of each screening test, (5) explained potential test complications from screening tests, (6) asked if the patient understood or had any questions about CRC screening, and (7) asked if the patient had the information he or she wanted about CRC screening. These 7 items had high internal consistency (Cronbach’s alpha = 0.92). To calculate an average score, each of the 7 items was summed together (0.0 = no, 1.0 = yes) and divided by 7. A score of 1 indicates that patients answered “yes” to all 7 questions, while a score of 0 indicates a “no” answer to all 7 questions. Only the responses of patients who answered all 7 questions were included in the variable describing this scale.

Perceived Benefits of CRC Screening, Based on Patient Self-Report

Four items measured perceived benefits of CRC screening, scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Similar to the scale for comprehensiveness of CRC discussion, the perceived-benefits scale also had good internal consistency (Cronbach’s alpha = 0.80). To calculate an average score, each of the 4 items was summed together (1 = strongly disagree, 5 = strongly agree) and divided by 4. A score of 5 indicates that the respondent answered “strongly agree” to all 4 questions, and a score of 1 indicates an answer of “strongly disagree” to all 4 questions. Only the responses of patients who answered all 4 questions were included in the variable describing this scale. These questions were adapted from Myers and colleagues28-30 and measured general agreement with the following statements: (1) CRC screening is necessary even if no family history exists, (2) getting screening for CRC can protect health, (3) when colon polyps are found and removed, CRC can be prevented, and (4) when CRC is found early, it can be cured. The rationale for selecting perceived benefits is that beliefs about colon cancer have been identified in the literature as an important characteristic associated with CRC screening.

All patients were due for screening at the time of the ATC; the primary outcome measure was whether the patient completed CRC screening in the 9 months following the ATC. CRC screening included any of the following: 1 sample FIT, receipt of colonoscopy, and receipt of flexible sigmoidoscopy. The distribution of first completed CRC screening test for this study population was FIT (95.2%), colonoscopy (2.8%), and sigmoidoscopy (2.0%).

We identified patient age in relation to the intervention index date, and we identified gender from member eligibility files. We also determined length of KPNW membership. Individual racial categories were obtained from electronic databases for 267 (30.4%) participants, and missing data were imputed using the census tract block corresponding to each subject’s mailing address. Patient race was categorized as white or non-white (African American, Pacific Islander, Asian, and Native American). In addition, as a measure intended to reflect disease burden,

we determined the mean number (± SD) of unique generic drugs dispensed within the 6 months prior to index date for each participant. We also determined whether survey respondents had any primary care visits (internal medicine, family practice; >1 visits vs none) in the 9 months after the intervention index date.

We used logistic regression to model CRC screening during the 9 months following index date (receipt of ATC). Final variables were entered simultaneously and included age (continuous, by 10 years), gender (female vs male), number of medications (continuous), comprehensiveness of CRC discussion scale (continuous), perceived benefits scale (continuous), and having any primary care visit during the follow-up period. With the exception of age and gender, all variables with significant bivariate associations with CRC screening completion were included in the final multivariable model. Although not significant in bivariate analysis, age and gender were retained in final logistic models to adjust for demographics, given that age and gender have been associated with CRC screening in previous research. We lacked complete data on some of the central variables (ie, PCP discussion scale, perceived benefits scale), and we imputed missing data by multiple imputation (MI). Multiple imputation is considered a scientifically rigorous approach to handle missing data.

The MI and MIANALYZE procedures in SAS used 5 replications. All analyses were conducted using SAS version 9.2 (SAS Institute, Cary, North Carolina).

 presents the population characteristics of patients who completed the patient survey. The mean age was 59 years, nearly 60% were female, 95% were white, and the average number of years with KPNW was 14. The average number of medications taken at baseline was 3.1. The average score on the comprehensiveness of CRC discussion scale was less than 0.5 (mean = 0.4, SD = 0.4, possible range 0 to 1), indicating that patients, on average, answered “yes” to fewer than 4 of the 7 screening discussion questions. In addition, the average score on the perceived benefits scale was high (mean = 4.0, SD = 0.7; possible range 1 to 5), suggesting that most believed in the benefits of CRC screening. Most (60%) reported 1 or more primary care visits in the 9 months after the intervention index date.

presents unadjusted and adjusted logistic regression results. Patients’ perceptions of the comprehensiveness of CRC screening discussions and perceived benefits had independent significant (

 <.05) associations with completion of CRC screening, after simultaneous adjustment. A higher score on the comprehensiveness of CRC screening discussion scale was associated with greater odds of completing CRC screening in both unadjusted (OR, 1.84; 95% CI, 1.20-2.81, 

 = .005) and adjusted (OR, 1.51; 95% CI, 1.03-2.21, 

 = .035) analyses. A higher score on the perceived benefits scale was associated with greater odds of completing CRC screening in both unadjusted (OR, 1.70; 95% CI, 1.32-2.18, 

<.0001) and adjusted (OR, 1.46; 95% CI, 1.13-1.90,

Of patient-demographic and clinical-characteristic covariates, 1 or more primary care visits in the follow-up period (9 months after ATC) was associated with greater odds of completing CRC screening in both unadjusted (OR, 6.16; 95% CI, 4.16-9.14, 

 <.0001) and adjusted (OR, 5.82; 95% CI, 3.87- 8.74, 

 <.0001) analyses. Having more medications (OR, 1.05; 95% CI, 1.01-1.09, 

= .012) was associated with greater odds of completing CRC screening in the unadjusted analysis; however, this finding did not remain significant in multivariable analysis.

Articles

More comprehensive discussion of colorectal screening by primary care physicians was associated with higher screening rates among adults aged 51 to 80 years who were overdue for screening.

More Comprehensive Discussion of CRC Screening Associated With Higher Screening

To estimate the cost-effectiveness of an automated telephone intervention for colorectal cancer screening from a managed care perspective, using data from a pragmatic randomized controlled trial.

Intervention patients received calls for fecal occult blood testing (FOBT) screening. We searched patients’ electronic medical records for any screening (defined as FOBT, flexible sigmoidoscopy, double-contrast barium enema, or colonoscopy) during follow-up. Intervention costs included project implementation and management, telephone calls, patient identification, and tracking. Screening costs included FOBT (kits, mailing, and processing) and any completed screening tests during follow-up. We estimated the incremental cost-effectiveness ratio (ICER) of the cost per additional screen.

 At 6 months, average costs for intervention and control patients were $37 (25% screened) and $34 (19% screened), respectively. The ICER at 6 months was $42 per additional screen, less than half what other studies have reported. Cost-effectiveness probability was 0.49, 0.84, and 0.99 for willingness-to-pay thresholds of $40, $100, and $200, respectively. Similar results were seen at 9 months. A greater increase in FOBT testing was seen for patients aged 

70 years (45/100 intervention, 33/100 control) compared with younger patients (25/100 intervention, 21/100 control). The intervention was dominant for patients aged 

70 years and was $73 per additional screen for younger patients. It increased screening rates by about 6% and costs by $3 per patient.

At willingness to pay of $100 or more per additional screening test, an automated telephone reminder intervention can be an optimal use of resources.

Colorectal cancer screening has been shown to be a cost-effective intervention, but uncertainty remains over the most efficient methods for increasing screening rates.

Automated phone calling increased screening rates by about 6% and costs by $3 per patient.

The incremental cost-effectiveness ratio per additional screen of $40 is less than half what other studies have reported.

At a willingness to pay of $100 or higher per additional screening test, our study suggests an automated telephone reminder intervention can be an optimal use of resources.

Colorectal cancer (CRC) is a common and often lethal disease with a lifetime risk of about 1 in 20; it causes more than 51,000 deaths annually in the United States. When diagnosed at late stages the 5-year survival rate is less than 12%, but patients with localized tumors have a 5-year survival rate greater than 90%.

 Early detection is clearly a key to improving survival, and screening has been shown to be cost-effective (eg, at a commonly used threshold of $50,000 per year of life gained), with some analyses even suggesting that screening is cost-saving.

 While CRC screening rates have increased in recent years, they are still below 60% for people aged 

Because the favorable cost-effectiveness of CRC screening is now established, attention has shifted to optimizing methods for increasing adherence with CRC screening. The cost-effectiveness of several intervention types has been reported, including mailing stool cards with and without targeted calls, where the cost per additional patient screened has ranged from about $100 to more than $6000 depending on the intensity of the intervention

 where the cost per additional patient screened has ranged from about $100 to $1000.

Automated telephone calls have been used to remind and inform patients about a wide range of preventive and therapeutic healthcare interventions.

 A recently reported pragmatic trial by our group showed that automated telephone reminders significantly improved CRC screening rates.

 Using data from that randomized control trial, this report focuses on the cost-effectiveness of telephone reminders compared with usual care per additional patient screened.

We used findings from a practical randomized control trial that enrolled patients due for CRC screening (as defined by the National Council for Quality Assurance) to estimate the cost-effectiveness of an automated telephone intervention for CRC screening relative to usual care. The cost analysis focused on replication costs

 from the perspective of a health maintenance organization (HMO) and included any method of screening rather than just fecal occult blood testing (FOBT). Our follow-up was less than 1 year, so costs and effects were not discounted; costs were inflated to reflect 2008 dollars.

A complete description of the trial has been reported elsewhere.

 The trial was conducted at Kaiser Permanente Northwest, a not-for-profit, group-model HMO, and was approved by its institutional review board. 

 details how patients were selected in the randomized control trial; 6000 patients (out of 32,320) were randomly allocated to automated telephone contact or usual care. Consistent with US Preventive Services Task Force CRC screening guidelines in place at the time of trial initiation,

we selected average-risk patients aged 51 to 80 years who were eligible for screening (eg, had no evidence of relevant screening in the HMO’s records and did not have risk factors indicating need for disease monitoring).

Intervention group patients were exposed to calls prompting FOBT screening (call type 1) and FOBT return reminder calls (call type 2); while these calls were not personalized, they were directed toward specific individuals. 

details the timing of these calls. Call type 1 was brief (1 minute), provided information about the benefits of CRC screening, and encouraged FOBT as a relatively simple and low-risk method of cancer screening. Recipients who answered could immediately request a mailed FOBT kit by touch-tone. A detailed message that included a telephone number to call for FOBT kit requests was left via voice mail for unanswered calls. Patients who did not get CRC screening received up to 2 “general” automated reminder calls, 6 weeks apart. One additional reminder call (call type 2) was made to patients who had requested an FOBT kit but did not return it within 5 weeks from the date of request; those patients were given the opportunity to request an additional FOBT kit. All FOBT kits used the guaiac method (Hemoccult II; Beckman Coulter, Inc, Brea, California), which requires samples from 3 consecutive stools, and were delivered via standard mail.

Patients randomized to usual care did not receive the telephone contact intervention. Their CRC screening, if any, occurred via normal care processes. At the time of the study, clinicians had access to national guidelines, Intranetbased screening guidelines, and a “panel support tool” (an electronic prompt system embedded in the electronic medical record that informed clinicians which patients were due for preventive services, including CRC screening). For usual care patients, FOBT kits were obtained after a clinician order by picking the kit up either from the laboratory at the clinic where they received their care or from the HMO’s influenza immunization service, located in primary care clinics.

We used the HMO’s electronic data systems to identify patient outcomes. We specified 2 outcomes for the analysis: the cost per any completed screen and the cost per positive FOBT screen. Even though the intervention promoted FOBT, we defined a completed screen as a record of any US Preventive Services Task Force—recognized screening test (FOBT, flexible sigmoidoscopy, double-contrast barium enema [DCBE], or colonoscopy) during follow-up. For both outcomes, a patient was counted as screened only once, even if he or she had multiple tests; but as detailed below, costs for all screening tests during follow-up were included. We used the term “nonfecal tests” to collectively refer to those more invasive testing methods including flexible sigmoidoscopy, DCBE, and colonoscopy. We examined the effect of the intervention on both FOBT and nonfecal tests separately.

We estimated staff costs associated with the intervention from clinical trial records and study staff time estimates. These costs included project management time to oversee the entire process and computer programming efforts for patient identification, electronic file preparation for the automated telephone call vendor, and patient tracking (eg, for repeat calls to nonresponders). To improve generalizability to other systems, salary costs were taken from the US Bureau of Labor and Statistics.

 To fully allocate the costs we added a fringe benefit rate of 30% and overhead rate of 20%. The cost of the calls and their content was based on vendor charges. The cost of developing and maintaining the automated telephone system was embedded in the vendor charge to the HMO. FOBT kit mailing costs were estimated based on bulk mailing rates.

For patients in both groups, the costs associated with the FOBT testing kit, processing, and reporting was estimated from the HMO’s laboratory charges to nonmembers. Clinician time and cost associated with FOBT laboratory result review and follow-up with patients was estimated from a previous economic evaluation in laboratory medicine

 and from interviews with those doing the work. Costs for other types of testing, including DCBE, flexible sigmoidoscopy, and endoscopy, came from the HMO’s accounting database. While a patient was counted as screened only 1 time, all CRC testing-related costs during the follow-up were enumerated and assigned to that patient. We did this because the intervention may have had knock-on effects for other types of CRC testing, including both diagnostic (eg, following a positive FOBT) and screening (eg, encouraging a patient to request colonoscopy screening), and we wanted to more fully account for the economic consequences of the intervention. For example, if a patient was screened with FOBT at month 1 and then subsequently had a colonoscopy during month 8, the cost of both tests was counted in the 9-month analysis. We made no attempt to discern the clinical rationale for a given screening test (eg, a screening vs a diagnostic colonoscopy); rather, we conservatively included all tests for both outcomes and costs. Usual care patients may have gotten their screening advice at an office visit, but we assumed CRC screening advice was unlikely to be the chief reason for the visit, so we did not attempt to include those costs. Any resulting bias from that decision would make usual care appear less costly.

In the clinical trial, the mean age in both groups was about 60 years, with an even female/male split. There were 2943 patients in the intervention group, and 2962 patients in the usual care group. In the intervention group, 22.5% completed FOBT within 6 months, compared with 16.0% in the usual care group. Screening by any method was completed for 23.9% in the intervention versus 17.6% in the usual care group. In the intervention group, 2943 (100%) received the initial call type 1 (general reminder), 2406 (81.8%) received a second type 1 call, and 1632 (55.5%) received a total of 3 calls of type 1. Call type 2 (FOBT return reminder) was made to 18.3% of the intervention group.

We calculated the incremental cost-effectiveness ratio (ICER) as (cost

 = control, and effect = number of patients with a screening test. We used net benefit regression methods

 to estimate the intervention’s probability of being cost-effective. We report the probability of the intervention being cost-effective at several relevant thresholds of willingness to pay for an additional outcome (eg, additional screen) to aid decision makers’ translation of the results to their own setting and specific considerations. We also computed bootstrapped 95% confidence intervals on total costs using the percentile method.

The parent clinical trial revealed a significant intervention effect that depended on patient age, so we undertook a similar subgroup analysis. As was done in the clinical trial, we followed patients for 6 months in our primary analysis. Since fecal screening is recommended annually, the health plan encourages screening on that basis; therefore, we also wanted to examine a time period more compatible with that interval. To accomplish this goal and to avoid the potential overlapping effects from the next annual screening efforts, we undertook a secondary analysis and followed patients for completed tests up to 9 months after their index date. SAS version 9.1 (SAS Institute, Cary, North Carolina) and STATA versions 10 and 11 (STATA Corporation, College Station, Texas) were used for all analyses.

enumerates the resources necessary to implement and sustain the automated calling program in the intervention arm and to carry out all types of CRC screening tests in both arms. 

 shows the resource use and average cost per person in both groups at 6 and 9 months and by age. Accounting for the staff time associated with project management, computer programming, patient tracking and reporting, and the calls themselves, the intervention cost was about $4.20 per person.

For patients of all ages, the average cost per patient for FOBT testing (kits and their processing) was slightly higher in the intervention group, while the per patient cost associated with nonfecal tests (endoscopy, DCBE, and flexible sigmoidoscopy) was slightly higher in the usual care group. We found that the number of FOBT tests completed at 9 months was markedly higher in the intervention group (ie, 812 vs 669). On the other hand, we observed similar overall proportions of patients with nonfecal tests (3.2% intervention and 3.0% usual care, data not shown). But there were differences by age; intervention patients aged 70 years or older had 5.6 nonfecal tests per 100 persons compared with 7.8 per 100 persons in usual care. However, for patients younger than 70 years, nonfecal test use was similar in both groups (7.9 and 8.0 nonfecal tests per 100 persons in the intervention and usual care groups, respectively). FOBT testing increased in both age groups, but the FOBT increase was greater in the older age group (45/100 intervention patients and 33/100 control patients) than in the younger age group (25/100 intervention patients and 21/100 control patients). As shown in Table 2, these observed differences by age in the use of FOBT and nonfecal tests translated into notable differences in costs at both 6 and 9 months. For example, at 9 months the average costs of FOBT and nonfecal tests were similar for patients younger than 70 years in the intervention and usual care groups. However, at 9 months, for patients 70 years or older, the costs of FOBT were 25% higher in the intervention group ($1.50 vs $1.20), while the costs for nonfecal tests were more than 40%

 in the intervention group ($34.60 vs $48.70). While these component costs showed some variation, total costs were similar in both groups, as evidenced by the overlapping confidence limits.

 shows the cost-effectiveness at 6 and 9 months by age using each of the 2 measures of effectiveness: any completed screen and the positive FOBT screen. Overall, we found that the cost for an additional screened patient was $42 at 6 months and $40 at 9 months. At 6 months, the chance of the intervention being cost-effective was about 50% at a willingness to pay of $40 for an additional patient screened. It increased to 84% for a willingness to pay of $100 and 99% for a willingness to pay of $200.

The intervention was dominant (ie, lower costs with a greater proportion of patients screened) at 6 months for patients 70 years or older, but it had an ICER of $73 for younger patients. In both age groups the intervention had a high probability (

95%) of being cost-effective at a willingness to pay of $200 for an additional screened patient at 6 months, but cost-effectiveness was markedly different at willingness-to-pay thresholds of $100 (0.97 and 0.64 for older and younger patients, respectively) and $40 (0.75 and 0.35 for older and younger patients, respectively). We found a similar pattern of results at 9 months.

The cost per additional positive FOBT screen was $1156 at 9 months. The probability of cost-effectiveness was 0.47 at a willingness to pay of $1000 and increased to 0.70 at a willingness to pay of $7000.

Depending on one’s willingness to pay for an additional screen, we found that automated telephone calls can be costeffective. For example, at a willingness to pay of $100 per additional screen, the probability of cost-effectiveness is 0.84 and increases to near-certainty (0.99) at a willingness to pay of $200 per additional screen. But at lower willingness-to-pay levels (ie, $40 per additional screen), there is considerable uncertainty about the cost-effectiveness (probability of being cost-effective was 0.49).

A recent systematic review noted that, compared with no screening, all types of CRC screening are cost-effective at common thresholds (eg, $50,000 per year of life gained) and some are even estimated to be cost-saving.

 Our study focused on the cost and cost-effectiveness of using automated telephone calling to promote FOBT screening relative to usual care. We found that automated calls were low cost and compared favorably with other reported CRC screening programs at about $40 per additional patient screened with any test. For example, a recent report reviewed several studies that analyzed the cost-effectiveness of comparable interventions to increase CRC screening.

 Those authors noted that the cost per additional patient screened ranged from more than $6000 to $94 for a range of interventions including physician communication training and patient education, physician feedback, and patient mailings.

Our intervention differed from previous interventions in several important ways that may have had a direct effect on the differential program costs. First, we did not send stool cards unless the patient requested the kit. By requiring a patient request before mailing a kit (and thus before incurring associated costs), a relatively costly component of the intervention was avoided by presumably targeting those patients most likely to complete testing. Additionally, by requiring a patient commitment (ie, a positive response to the call), the intervention potentially further enhanced patient follow-through. Our results suggest that future reviews on this topic might usefully compare the costs and cost-effectiveness of patient-directed versus provider-directed interventions and consider whether automated systems are more cost-effective, perhaps in a stepped approach.

Automated telephone calls can increase colorectal cancer screening rates at a cost of about $40 per additional screen.

Automated Telephone Calls to Enhance Colorectal Cancer Screening: Economic Analysis

: To determine the effect of Healthcare Effectiveness Data and Information Set (HEDIS) measurement of colorectal cancer (CRC) screening on insurance plans in Pennsylvania.

: Natural experiment tracking changes in CRC screening policies.

: Survey data were collected in 2006 on screening policies of 13 Pennsylvania commercial insurers offering 37 plans. All companies that met the inclusion criteria were surveyed. Medical directors answered questions about how HEDIS measures affected plan benefit designs. Responses were analyzed using descriptive statistics.

: All companies responded and focused their responses on a particular plan as requested, including 2 health maintenance organizations, 3 point-of-service plans, 2 fee-for-service plans, and 6 preferred provider organizations. The survey results indicated that 39% of plans revised their screening guidelines, 46% established new or updated reminder systems, and 46% established new systems for tracking screening rates. Although only the health maintenance organization plans were linked to HEDIS with formal reporting, all types of plans reported changes that they attributed to the HEDIS measure.

: The establishment of the new HEDIS measure on screening for CRC has been associated with changes in health plan policies and practices in Pennsylvania.

The addition of screening for colorectal cancer to the publicly reported Healthcare Effectiveness Data and Information Set (HEDIS) measures in 2006 is associated with changes implemented by Pennsylvania health plans that have been shown to increase screening rates, such as the following:

Revised screening guidelines that shape physician recommendations for screening 

These changes were implemented even by plans that did not have a formal reporting relationship with the National Committee for Quality Assurance, which collects and reports the HEDIS data.

Screening for colorectal cancer (CRC) is a beneficial and costeffective way to advance the public&#8217;s health by reducing the incidence and mortality of CRC, the nation&#8217;s second leading cause of cancer deaths.

 Colorectal cancer screening was designated as one of the highest priority preventive services by the National Commission on Preventive Priorities after 2 years of deliberation and analysis; the commission&#8217;s choice rested on 2 criteria, the burden of disease that could be prevented and the cost-effectiveness.

Yet, the national screening rate of approximately 57% remains less than optimal.

 A nationwide survey of health plans conducted in 1999-2000 showed deficiencies in insurance coverage for recommended CRC screening tests and in the organizational systems that encourage enrollees to make use of such coverage where it exists.

 Only 57% offered coverage for colonoscopy, 41% had any system for monitoring delivery or outcome of screening, fewer than 25% had patient reminder systems, 16% had provider reminder systems, and 11% had tracking systems to determine whether invited enrollees completed screening. Only 5% tracked to determine whether individuals with positive screens received proper follow-up: 5% tracked the results of the follow-up tests, and 10% tracked adverse events related to the follow-up tests.

Evidence is strong that lack of insurance coverage is an impediment to the use of preventive services, including CRC screening tests.

 There is also considerable evidence supporting the usefulness of patient reminder systems and of tracking and feedback as effective approaches to raising screening rates.

In 2003, in an effort to improve the country&#8217;s screening record, the National Committee for Quality Assurance

 (NCQA) added the CRC screening rate to the measures it requests from its health maintenance organization (HMO) member plans and announced that it would begin reporting these rates to the public in 2006. Given the earlier national survey, 

 this initiative on the part of the NCQA created the basis for a natural experiment in which it became possible to document the changes associated with this new public policy.

The NCQA is a voluntary organization with the mission of improving the quality of healthcare by creating accountability through application of measurement tools and transparency.

The organization publishes measures and report cards that reflect the quality of care offered by managed care plans.

Until recently, only HMOs were part of the NCQA reporting system. Preferred provider organizations (PPOs) subsequently became eligible in 2007. The Healthcare Effectiveness Data and Information Set (HEDIS) is a group of measures that has been published annually by the NCQA to provide information to employers and to other purchasers of health services about the performance of managed care (HMO) plans. The approach of the NCQA and other organizations that promote measurement, transparency, and accountability has been endorsed by the Institute of Medicine in its reports on quality and the healthcare system.

The transparency achieved through public reporting of CRC screening rates was predicted to stimulate accountability that would raise screening rates among NCQA members. Whether there would also be an effect on non-HMO health plans that do not participate in the NCQA reporting was another question.

Pennsylvania is the sixth largest state, with a population of 12.4 million people (or 4% of the US population according to US census data). In 2006, the Pennsylvania General Assembly sought to gather information that would inform policy making in the area of CRC screening. The assembly was considering the establishment of a state mandate on insurers for the provision of CRC screening coverage that included the full range of options recommended by national consensus panels. An earlier effort to pass such legislation in 2002 was opposed by the insurance industry based on the claim that such screening coverage was already universal and that a mandate was unnecessary. In 2006, an assembly standing committee funded a survey of health insurance companies to provide unbiased information regarding CRC screening coverage. The survey included questions on the effect of HEDIS measurement of screening rates on plan policies. The findings of the survey are reported herein.

Insurance companies that market health plans in Pennsylvania were identified from a listing in the Directory of Health Plans published by Atlantic Information Systems, Inc.

 The listing included all health plans offered by each company with business in the state. There were 37 plans in all. The listing included the size of the enrollment in each plan type and the name of the medical director and his or her contact information.

The following 2 inclusion criteria applied to insurance companies: (1) the insurance company had to offer at least 1 commercial health plan in the state (non-Medicare and non-Medicaid) and (2) at least 1 of its plans had to have a significant enrollment in Pennsylvania, defined as more than 25,000 enrollees. A minimum of 25,000 enrollees was chosen because only 5 plans had fewer than 25,000 enrollees, which added together produced a combined enrollment of less than 1% of the total enrollment, and the next smallest enrollment was 4 times that large. Plans designated for Medicare or Medicaid enrollees were excluded because their policies are determined at the state or federal level and not by the insurance company and because they would not have been affected by a proposed state insurance mandate. The study was given an expedited review and was approved by the Thomas Jefferson University Institutional Review Board.

Thirteen companies met the inclusion criteria. The companies insured 8.3 million people. Eleven of 13 companies offered several types of plans, for a total of 37 plans. Two companies offered only HMOs; the rest offered several types of plans. Every company offered at least 1 HMO, 11 companies offered PPOs, 9 companies offered POS plans (an HMO or a PPO plus an indemnity plan), and 8 companies offered FFS plans. Although HMO was the most common plan type in the state, the enrollment in PPOs exceeded that of HMOs.

All 13 companies responded to the survey with answers based on the policies for the plan type that was identified by the research team, including 2 HMOs, 3 POS plans, 2 FFS plans, and 6 PPOs. The responses about a particular plan type offered by a particular company did not mean that all policies of that plan type (ie, all PPO plans sold by a single company) were uniform. A company could have a plan type (PPO, POS, or FFS) with different features depending on the purchaser of the plan. 

Across all insurance companies that participated in our survey, enrollment in PPOs was the largest, accounting for 71% of the enrollees. Health maintenance organizations and POS plans had the next highest enrollment with 16% and 12% of the enrolled population, respectively, followed by FFS plans with 11% of the enrolled population. Compared with statewide distribution across plan types (61% PPO, 35% HMO, and 4% FFS and POS), this sample overselected for PPO, FFS, and POS plans, none of which had a formal reporting relationship with the NCQA. The median enrollment was 350,000.

Ten of 13 respondents (77%) had guidelines or protocols regarding CRC screening for individuals at average risk. Seven plans (54%) also had guidelines or protocols for individuals at increased risk or high risk. Only 3 medical directors (23%) reported having no guidelines or protocols regarding CRC screening (

Five respondents (39%) reported that they revised their guidelines specifically as a result of the new HEDIS CRC measure; although 7 (54%) revised their guidelines after 2003. The question read, &#8220;Has your plan implemented any of the following in response to the HEDIS CRC screening measure&#8221; and then listed choices, including revised guidelines.

In response to a question about which practice guidelines influenced the plan screening policies, the US Preventive Services Task Force guidelines were the most influential (very) with 92% of plans. Other guidelines and sources were very or somewhat influential, including guidelines of the American Cancer Society, clinical evidence published in the literature, Medicare policy, and technology assessment reports.

Respondents were asked whether the plan measured the CRC screening rate and whether they measured the HEDIS rate specifically. The first question read, &#8220;Does your plan measure colorectal cancer screening tests?&#8221; A subsequent question asked, &#8220;Has your plan implemented the HEDIS measure on colorectal cancer screening?&#8221; (the measure is a rate based on enrollees aged >50 years).

Nine respondents (69%) measured CRC screening tests, although only 8 gave a specific starting date for doing so. Nine respondents (69%) implemented the HEDIS measure, although only 8 attested in response to another question that they measured the HEDIS rate (

). Three more respondents anticipated that they would implement the HEDIS measure in the next 12 months. The 9 plans included every type of plan (HMO, PPO, POS, and FFS). One plan began measuring CRC screening before 2003, and 7 plans began during or after 2003. All but 1 plan (which started later) began measuring the HEDIS rate in 2004, the first year the measure was reported. 

Screening Recruitment, Reminders, and Tracking

Most plans reported recruitment and reminder activities. For recruitment, 9 plans (69%) distributed printed information about screening directly to enrollees; 8 plans (62%) provided information over the Internet on Web sites.

Nine plans (69%) reminded individual enrollees that they were due for screening. Six plans (46%) implemented new or updated reminder systems in response to the HEDIS measure (

). The most common form of reminder was regular mail, used by all 9 plans. Two plans used other approaches as well, including verbal prompts, e-mails, telephone calls, and personalized Web pages.

Six plans (46%) implemented new or updated data systems to track CRC screening in response to the HEDIS measure. Seven plans (54%) counted the number of eligible enrollees who received reminders, 4 plans (31%) routinely gave lists of enrollees who were not up-to-date to their primary care providers, 5 plans (39%) tracked the number of reminded enrollees to see who completed the tests, and 2 plans (15%) recontacted enrollees directly if they were not screened after the initial contact.

Of 12 respondents to a question about the level of implementation of recruitment and tracking activities (plan or provider level), 5 (39%) engaged in these activities at the plan level only, 5 (39%) at provider and plan levels, and 2 (15%) at the provider level only.

Health plans initiated other steps as a part of their response to the HEDIS measure. Three plans (23%) covered more types of CRC screening tests, and 1 plan (8%) lowered out-of-pocket charges for CRC screening (Table 3). One plan (8%) provided financial incentives to physicians for achieving performance measures on CRC screening (pay for performance).

Three plans (23%) conducted quality improvement studies (&#8220;Has your plan conducted any quality improvement studies of colorectal cancer screening?&#8221;). The activities included studies of mailed reminders, interactive voice recognition calls, barrier analyses regarding obstacles to screening, and quality assessment for plan members older than 65 years. One plan had implemented these activities in 2004 and 2 plans in 2005 or later.

Our findings indicate that Pennsylvania insurers and health plans took specific actions in response to the new HEDIS measure on CRC screening. Nine plans (69%) implemented the HEDIS measure, 5 plans (39%) revised their screening guidelines, 6 plans (46%) established new or updated enrollee or provider reminder systems, 6 plans (46%) established new or updated data systems to track CRC screening, 1 plan (8%) provided new financial incentives to physicians, and 1 plan (8%) lowered out-of-pocket payments. No plans tracked whether follow-up procedures were obtained after screening; however, 1 plan tracked the results of the follow-up procedure, and 1 plan tracked adverse events associated with the follow-up procedure.

Colorectal cancer is the second leading cause of cancer mortality nationwide. It is largely preventable through regular screening and polyp removal, and morbidity and mortality could be reduced through early detection. It is clear that a rise in screening rates associated with efforts to improve awareness of and access to preventive services will reduce the clinical burden of CRC.

 The addition of a measure on CRC screening to the HEDIS reporting system of the NCQA was intended to improve accountability in the delivery of preventive services through reporting and transparency within those plans for which HEDIS reporting is required. This study provides preliminary evidence that the presence of the measure has contributed to insurer policy changes in the state of Pennsylvania. Assessment of the developments associated with the new HEDIS measure on a nationwide basis will provide a fuller picture.

2. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI.

 Priorities among effective clinical preventive services: results of a systematic review and analysis. 

4. Klabunde CN, Riley GF, Mandelson MT, Frame PS, Brown ML.

 Health plan policies and programs for colorectal cancer screening: a national profile. 

 Interventions targeted toward patients to increase mammography use. 

8. Myers RE, Ross EA,Wolf TA, Balshem A, Jepson C, Millner L.

 Behavioral interventions to increase adherence in colorectal cancer screening. 

10. Balas EA,Weingarten S, Garb CT, Blumenthal D, Boren SA, Brown GD.

 Improving preventive care by prompting physicians. 

 Quality in the delivery of preventive services: the National Colorectal Cancer Roundtable. 

14. Schneider EC, Riehl V, Courte-Wienecke S, Eddy DM, Sennett C.

 Enhancing performance measurement: NCQAâ€™s road map for a health information framework: National Committee for Quality Assurance. 

16. Committee on Quality of Health Care in America, Institute of Medicine

. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; June 2004. 

. AISâ€™s Directory of Health Plans: 2006.Washington, DC: Atlantic Information Services Inc; 2006.

 National surveys of colorectal cancer screening policies and practices. 

http://healthservices.cancer.gov/surveys/colorectal/

22. Vogelaar I, van Ballegooijen M, Schrag D, et al.

 How much can current interventions reduce colorectal cancer mortality in the U.S.? Mortality projections for scenarios of risk-factor modification, screening, and treatment. 

In 2006, the NCQA began reporting colorectal cancer screening rates of member plans as a HEDIS measure, which is associated with Pennsylvania health system changes.

Ronald E. Myers, PhD

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