Primary care clinicians take a “whole person” approach and are responsible for a wide range of preventive healthcare efforts.

Maximizing the benefits of screening for cancer requires efforts to ensure everyone is screened and those with abnormal results are followed up, explains Steven J. Atlas, MD, MPH. “However, timely follow-up of abnormal cancer screening results is not always achieved,” he says.

For a study published in JAMA, Dr. Atlas and colleagues assessed nearly 12,000 patients who completed follow-up in 44 primary care practices due to an overdue abnormal screening test result for breast, cervical, colon, or lung cancer. The primary care intervention supplemented usual care, Dr. Atlas notes, therefore additional time beyond the due date was added to allow for completion of recommended follow-up before patients were enrolled.

EHR Provides Reminders to Patients & Clinicians

“For breast, cervical, and lung cancer screening results, relevant guideline recommendations and specialist input were used to create automated EHR algorithms to identify eligible patients and determine the recommended diagnostic follow-up and the appropriate time interval,” Dr. Atlas says. “For short-interval colonoscopy results, the follow-up timeframe was determined by the gastrointestinal specialist performing the procedure.”

After enrollment, patients in the intervention arms received screening reminders from the EHR that identified the type of abnormal result and recommended follow-up. Both patients and clinicians could view these EHR reminders any time they accessed the record, most commonly around the time of an office visit. Completing recommended follow-up led to closure of the EHR reminder.

Patients in the two outreach intervention arms received reminder letters. For overdue reminders, patients received a phone call. “Patients in the intervention arm that included patient navigation were called to assess social barriers to care such as family caregiving, transportation, and financial costs of tests and treatments,” Dr. Atlas notes. “Navigators used an online network of verified social service programs to help connect patients with services available in their community.”

Primary & Secondary Outcome Results

In the primary outcome, adjusted 120-day completion proportions were significantly higher in arms 3 and 4 (overall P<0.001; absolute difference compared with usual care is shown in parentheses):

• Arm 1: Usual care: 22.9%
• Arm 2: EHR reminders: 22.7% (-0.2%)
• Arm 3: EHR reminders and outreach: 31.0% (+8.1%)
• Arm 4: EHR reminders, outreach, and patient navigation: 31.4% (+8.5%)

In the secondary outcome, adjusted 240-day completion proportions also were significantly higher in arms 3 and 4 (overall P <0.001; absolute difference compared with usual care is shown in parentheses):

• Arm 1: Usual care: 34.1%
• Arm 2: EHR reminders: 34.7% (+0.6%)
• Arm 3: EHR reminders and outreach: 42.6% (+8.5%)
• Arm 4: HER reminders, outreach, and patient navigation: 43.8% (+9.7%)

Over time, Dr. Atlas and colleagues observed that most patients were more likely to achieve recommended follow-up for abnormal cancer screening test results. “Despite this overall improvement, patients in the two outreach intervention groups continued to have better outcomes than patients in the usual care or EHR reminder only groups as far out as 240 days (8 months) (Figure).

A Large Gap in Care Remains

“Such systems are best based in primary care because primary care clinicians take a ‘whole person’ approach and are responsible for a wide range of preventive healthcare efforts, which include cancer screening and test result follow-up,” Dr. Atlas says. “Primary care clinicians and specialists involved in cancer screening need to work together to develop systems to identify and track abnormal cancer screening test results and implement outreach efforts to ensure timely follow-up.”

Despite the success of the interventions, Dr. Atlas and colleagues agree that there continues to be large gaps in care that need addressing before the full benefits of preventive cancer screening are realized. “To implement these findings requires healthcare networks to invest in the information technology infrastructure and coordinate outreach efforts among primary care clinicians and specialists involved in cancer screening and abnormal result follow-up,” Dr. Atlas says.