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The American Journal of Managed Care September 2013
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Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening
Roger Luckmann, MD, MPH; Mary E. Costanza, MD; Milagros Rosal, PhD; Mary Jo White, MS, MPH; and Caroline Cranos, MPH
Risk-Stratification Methods for Identifying Patients for Care Coordination
Lindsey R. Haas, MPH; Paul Y. Takahashi, MD; Nilay D. Shah, PhD; Robert J. Stroebel, MD; Matthew E. Bernard, MD; Dawn M. Finnie, MPA; and James M. Naessens, ScD
Out-of-Pocket Costs and Prescription Reversals With Oral Linezolid
Margaret K. Pasquale, PhD; Anthony M. Louder, PhD, RPh; Michael C. Deminski, MS, RPh; Richard B. Chambers, MSPH; and Seema Haider, MSc
FDA Warning and Removal of Rosiglitazone From VA National Formulary
Sherrie L. Aspinall, PharmD, MSc; Xinhua Zhao, PhD; Chester B. Good, MD, MPH; Roslyn A. Stone, PhD; Kenneth J. Smith, MD, MS; and Francesca E. Cunningham, PharmD
Emerging and Encouraging Trends in E-Prescribing Adoption Among Providers and Pharmacies
Meghan H. Gabriel, PhD; Michael F. Furukawa, PhD; and Varun Vaidya, PhD
Improving Pneumococcal and Herpes Zoster Vaccination Uptake: Expanding Pharmacist Privileges
Michael S. Taitel, PhD; Leonard E. Fensterheim, MPH; Adam E. Cannon, MPH; and Edward S. Cohen, PharmD
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John Beshears, PhD; James J. Choi, PhD; David Laibson, PhD; Brigitte C. Madrian, PhD; and Gwendolyn Reynolds, MTS
Outpatient Parenteral Antimicrobial Therapy at Large Veterans Administration Medical Center
Andrew Lai, MD; Thuong Tran, PharmD; Hien M. Nguyen, MD; Jacob Fleischmann, MD; David O. Beenhouwer, MD; and Christopher J. Graber, MD, MPH
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Kimberly Tsai, PharmD; Sara C. Erickson, PharmD; Jianing Yang, MS; Ann S. M. Harada, PhD, MPH; Brian K. Solow, MD; and Heidi C. Lew, PharmD

Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening

Roger Luckmann, MD, MPH; Mary E. Costanza, MD; Milagros Rosal, PhD; Mary Jo White, MS, MPH; and Caroline Cranos, MPH
In this pilot study, primary care providers refer patients to a telephone counselor who provides education about colorectal cancer screening and performs motivational interviewing as needed to promote screening.
Objective: To determine the feasibility, acceptability, and outcomes of a telephone counseling intervention promoting colorectal cancer (CRC) screening when patients are referred for counseling by primary care providers (PCPs).

Study Design: Interventional cohort study with no formal control group.

Methods: PCPs in 3 practices were prompted to address CRC screening in patient encounters and, if appropriate, to recommend referral for telephone counseling. A telephone counselor called referred patients, made an appointment for a counseling call, and mailed an educational booklet to patients. Counseling included education about CRC and screening tests, motivational interviewing, barrier counseling, and facilitated referral for colonoscopy or mailing of a fecal occult blood testing kit. About 7 months following counseling, electronic records were searched for evidence of colonoscopy.

Results: PCPs addressed CRC screening with 1945 patients, most of whom were up-to-date with CRC testing, recommended counseling referral to 362, and of these 180 (49.7%) accepted the referral. A total of 140 (77.8%) of referred patients were contacted and 67 (37.2%) received counseling. After counseling 93.9% were planning on CRC screening compared with 54.6% at the beginning of the call. Of those planning a colonoscopy, 53.2% received one within 7 months.

Conclusions: Referring patients for telephone counseling to promote CRC screening may be feasible and acceptable to PCPs and to some patients, and may increase CRC screening. Further evaluation of the intervention may be warranted to compare the rate of screening associated with the intervention to rates related to usual care and to other interventions.

Am J Manag Care. 2013;19(9):702-708
Provider referral of patients for telephone counseling to promote use of colorectal cancer (CRC) screening may increase screening, but many patients may not accept or follow through with the referral. Further research is needed to determine how to maximize patient participation in this type of intervention and to compare its effectiveness with usual care.
  • Primary care providers are willing and able to refer patients for telephone counseling during many types of patient encounters.

  • Even patients who accept referrals may refuse or not be available to complete counseling.

  • Some patients not planning on screening change their minds after learning about CRC screening.
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.


Study Settings

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.

Referral Process

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

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.

Educational Booklet

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

The counseling protocol and script were informed by the Precaution Adoption Process Model (PAPM)17 and by motivational interviewing methods and drew on a protocol and script previously developed by Costanza and colleagues. 18 The PAPM, like other stage-based theories of behavior change (eg, the Transtheoretical Model19), has roots in social learning theory and the health belief model. The PAPM predicts that counseling tailored to a subject’s stage of adoption of a preventive measure will be more effective than nontailored counseling. The PAPM stages that we used to tailor the protocol and script are: 1) unaware (never heard of CRC risk or CRC screening), 2) unengaged (aware, not appreciative of the personal relevance of screening), 3) undecided on screening, 4) decided no, 5) decided yes (planning).

The counseling protocol was represented as a series of blocks of script with associated statements and questions. Movement from one block to the next was governed by a subject’s PAPM stage and response to the counselor’s questions. We developed a computer-assisted telephone interview (CATI) system for guiding counselors through the protocol. The protocol included the following modules: 1) identifying the patient’s PAPM stage, 2) evaluation of individual cancer risk and current colon symptoms, 3) basic education on CRC and screening, 4) motivational interviewing for patients not planning on getting screened, 5) educational counseling about the specific screening tests as needed, 6) assessment of and counseling about patient confidence and barriers to completing screening, 7) facilitated test scheduling. When a subject agreed to colonoscopy during a counseling call, his/ her PCP received a request to complete a referral form, and endoscopy center staff called the patient to schedule an appointment. When a patient requested an FOBT, counseling staff mailed out an FOBT kit with instructions.

The counseling was provided by a single counselor with a master’s degree in public health who had substantial experience in telephone interviewing and counseling. She had recently been a telephone counselor for another study of CRC screening for which she had received 32 hours of training about CRC and related screening tests, as well as training in motivational interviewing. Because of the similarity of the counseling protocol in this study to the one in the previous study, little additional training was needed. The counselor used a telephone interpretation service for patients whose preferred language was not English.

Determination of Screening Completion

Seven months following the completion of calls we searched records of colonoscopies at the local endoscopy center for subjects who had received a colonoscopy during or after the study period. All PCPs in the study referred patients to a single center for colonoscopy. We did not identify patients with a completed FOBT during the study period because this would have required hand searching of paper charts.

Data Analysis and Statistics

The frequency of reasons for not referring patients and the frequency of referrals by practice were calculated and P values comparing rates of referral and the frequency of reasons for not referring patients were determined using the χ2 test or Fisher’s exact test. The proportion of patients completing colonoscopy was compared across categories of acceptance of referral for counseling and across categories of completion of counseling for patients who had accepted a referral. P values were calculated for these comparisons with the χ2 test, and 95% confidence intervals [CIs] on selected measures were calculated. To estimate the independent effect of accepting a referral and completing counseling on completion of colonoscopy we created a logistic regression model that included health center, gender, and age as possible confounders. All statistical analyses were conducted with Stata software.20


Referral and Patient Contact Outcomes

During the recruitment period 2261 encounters were documented involving 1945 patients. Healthcare maintenance was the focus of 588 (26.0%) encounters. CRC screening was discussed at 1635 (72.3%) out of the 2261 encounters with 1613 patients. Discussions occurred twice with 22 patients. The Figure shows the interventions and outcomes for the 1613 patients. A total of 603 patients were eligible for CRC screening and of these the providers determined that 241 (40.0%) patients were adequately informed about and motivated for CRC screening and would not benefit from counseling, and the providers recommended counseling to 362 (60.0%). Table 1 shows characteristics of patients with a completed encounter form and those eligible for and due for CRC screening. A majority of subjects eligible for screening were women. More than half of the subjects were between the ages of 50 and 59 years, and 93.5% were English speaking.

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