Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests | Breast Cancer | JAMA Network Open | JAMA Network
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1.
Centers for Disease Control and Prevention. Leading causes of death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed March 1, 2019.
2.
Wilt  TJ, Harris  RP, Qaseem  A; High Value Care Task Force of the American College of Physicians.  Screening for cancer: advice for high-value care from the American College of Physicians.  Ann Intern Med. 2015;162(10):718-725. doi:10.7326/M14-2326PubMedGoogle ScholarCrossref
3.
Cokkinides  VE, Chao  A, Smith  RA, Vernon  SW, Thun  MJ.  Correlates of underutilization of colorectal cancer screening among U.S. adults, age 50 years and older.  Prev Med. 2003;36(1):85-91. doi:10.1006/pmed.2002.1127PubMedGoogle ScholarCrossref
4.
Meester  RG, Doubeni  CA, Lansdorp-Vogelaar  I,  et al.  Colorectal cancer deaths attributable to nonuse of screening in the United States.  Ann Epidemiol. 2015;25(3):208-213.e1. doi:10.1016/j.annepidem.2014.11.011PubMedGoogle ScholarCrossref
5.
Bromley  EG, May  FP, Federer  L, Spiegel  BM, van Oijen  MG.  Explaining persistent under-use of colonoscopic cancer screening in African Americans: a systematic review.  Prev Med. 2015;71:40-48. doi:10.1016/j.ypmed.2014.11.022PubMedGoogle ScholarCrossref
6.
McGinnis  E, Meyerson  BE, Meites  E,  et al.  Cervical cancer screening and prevention in 78 sexually transmitted disease clinics—United States, 2014-2015.  Sex Transm Dis. 2017;44(10):637-641. doi:10.1097/OLQ.0000000000000659PubMedGoogle ScholarCrossref
7.
US Preventive Services Task Force. Colorectal cancer: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2. Accessed March 1, 2019.
8.
US Preventive Services Task Force. Final recommendation statement: breast cancer: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening1. Accessed March 1, 2019.
9.
White  A, Thompson  TD, White  MC,  et al.  Cancer screening test use—United States, 2015.  MMWR Morb Mortal Wkly Rep. 2017;66(8):201-206. doi:10.15585/mmwr.mm6608a1PubMedGoogle ScholarCrossref
10.
Patel  MS, Volpp  KG, Asch  DA.  Nudge units to improve the delivery of health care.  N Engl J Med. 2018;378(3):214-216. doi:10.1056/NEJMp1712984PubMedGoogle ScholarCrossref
11.
Patel  MS, Volpp  KG, Small  DS,  et al.  Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.  Healthc (Amst). 2016;4(4):340-345. doi:10.1016/j.hjdsi.2016.04.005PubMedGoogle ScholarCrossref
12.
Patel  MS, Kurtzman  GW, Kannan  S,  et al.  Effect of an automated patient dashboard using active choice and peer comparison performance feedback to physicians on statin prescribing: the PRESCRIBE cluster randomized clinical trial.  JAMA Netw Open. 2018;1(3):e180818. doi:10.1001/jamanetworkopen.2018.0818PubMedGoogle Scholar
13.
Patel  MS, Volpp  KG, Small  DS,  et al.  Using active choice within the electronic health record to increase influenza vaccination rates.  J Gen Intern Med. 2017;32(7):790-795. doi:10.1007/s11606-017-4046-6PubMedGoogle ScholarCrossref
14.
Black  AD, Car  J, Pagliari  C,  et al.  The impact of eHealth on the quality and safety of health care: a systematic overview.  PLoS Med. 2011;8(1):e1000387. doi:10.1371/journal.pmed.1000387PubMedGoogle Scholar
15.
van der Sijs  H, Aarts  J, Vulto  A, Berg  M.  Overriding of drug safety alerts in computerized physician order entry.  J Am Med Inform Assoc. 2006;13(2):138-147. doi:10.1197/jamia.M1809PubMedGoogle ScholarCrossref
16.
Avery  AJ, Savelyich  BS, Sheikh  A,  et al.  Identifying and establishing consensus on the most important safety features of GP computer systems: e-Delphi study.  Inform Prim Care. 2005;13(1):3-12. doi:10.14236/jhi.v13i1.575PubMedGoogle Scholar
17.
Kim  RH, Day  SC, Small  DS, Snider  CK, Rareshide  CAL, Patel  MS.  Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination.  JAMA Netw Open. 2018;1(5):e181770. doi:10.1001/jamanetworkopen.2018.1770PubMedGoogle Scholar
18.
Hsiang  EY, Mehta  SJ, Small  DS,  et al.  Association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening.  JAMA Netw Open. 2019;2(5):e193403-e193403. doi:10.1001/jamanetworkopen.2019.3403PubMedGoogle ScholarCrossref
19.
Dimick  JB, Ryan  AM.  Methods for evaluating changes in health care policy: the difference-in-differences approach.  JAMA. 2014;312(22):2401-2402. doi:10.1001/jama.2014.16153PubMedGoogle ScholarCrossref
20.
Shadish  WR, Cook  TD, Campbell  DT.  Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, MA: Houghton Mifflin; 2001.
21.
Zeger  SL, Liang  KY, Albert  PS.  Models for longitudinal data: a generalized estimating equation approach.  Biometrics. 1988;44(4):1049-1060. doi:10.2307/2531734PubMedGoogle ScholarCrossref
22.
Charlson  ME, Pompei  P, Ales  KL, MacKenzie  CR.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.  J Chronic Dis. 1987;40(5):373-383. doi:10.1016/0021-9681(87)90171-8PubMedGoogle ScholarCrossref
23.
Efron  B, Tibshirani  R.  An Introduction to the Bootstrap. New York, NY: Chapman & Hall; 1993. doi:10.1007/978-1-4899-4541-9
24.
Davison  AC, Hinkley  DV.  Bootstrap Methods and Their Application. New York, NY: Cambridge University Press; 1997. doi:10.1017/CBO9780511802843
25.
Meyer  BD.  Natural and quasi-experiments in economics.  J Bus Econ Stat. 1995;13(2):151-161. doi:10.2307/1392369Google Scholar
26.
Mehta  SJ, Khan  T, Guerra  C,  et al.  A randomized controlled trial of opt-in versus opt-out colorectal cancer screening outreach.  Am J Gastroenterol. 2018;113(12):1848-1854. doi:10.1038/s41395-018-0151-3PubMedGoogle ScholarCrossref
27.
Rat  C, Pogu  C, Le Donné  D,  et al.  Effect of physician notification regarding nonadherence to colorectal cancer screening on patient participation in fecal immunochemical test cancer screening: a randomized clinical trial.  JAMA. 2017;318(9):816-824. doi:10.1001/jama.2017.11387PubMedGoogle ScholarCrossref
28.
Singal  AG, Gupta  S, Skinner  CS,  et al.  Effect of colonoscopy outreach vs fecal immunochemical test outreach on colorectal cancer screening completion: a randomized clinical trial.  JAMA. 2017;318(9):806-815. doi:10.1001/jama.2017.11389PubMedGoogle ScholarCrossref
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    Original Investigation
    Oncology
    November 15, 2019

    Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests

    Author Affiliations
    • 1Department of Medicine, University of California, San Francisco
    • 2Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 3Wharton School, University of Pennsylvania, Philadelphia
    • 4Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
    • 5Department of Medicine, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
    JAMA Netw Open. 2019;2(11):e1915619. doi:10.1001/jamanetworkopen.2019.15619
    Key Points español 中文 (chinese)

    Question  Is an active choice intervention in the electronic health record directed to medical assistants during primary care visits associated with improved rates of breast and colorectal cancer screening?

    Finding  In this quality improvement study of 25 primary care practices and 69 916 patients, the active choice intervention was associated with a significant increase in clinician ordering of both breast and colorectal cancer screening tests over time when compared with a control group of practices. However, the intervention was not associated with a significant change in patient completion of either type of cancer screening test during a 1-year follow-up.

    Meaning  Nudges facilitated by the electronic health record can increase clinician ordering of cancer screening tests but may need to be combined with other interventions to improve patient completion.

    Abstract

    Importance  Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused.

    Objective  To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests.

    Design, Setting, and Participants  A retrospective quality improvement study was conducted among 69 916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019.

    Interventions  From 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit.

    Main Outcomes and Measures  The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit.

    Results  The sample eligible for breast cancer screening comprised 26 269 women with a mean (SD) age of 60.4 (6.9) years; 15 873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43 647 patients with a mean (SD) age of 59.4 (7.5) years; 24 416 (55.9%) were women, 19 231 (44.1%) were men, 29 029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P < .001) but no change in patient completion (0.1 percentage points; 95% CI, −4.0 to 4.3 percentage points; P = .45). For colorectal cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (13.7 percentage points; 95% CI, 8.0-18.9 percentage points; P < .001) but no change in patient completion (1.0 percentage points; 95% CI, −3.2 to 4.6 percentage points; P = .36).

    Conclusions and Relevance  An active choice intervention in the electronic health record directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests. However, it was not associated with a significant change in patient completion of either cancer screening test during a 1-year follow-up.

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