Multilevel Follow-up of Cancer Screening (mFOCUS)

In the United States, the second-leading cause of death is cancer. Some cancers can be prevented or detected early through screening. When patients are screened and abnormal results are found, timely follow-up care for diagnostic testing and treatment is needed to ensure the best patient outcomes. Nevertheless, one in four adults are not up to date with breast, cervical, or colorectal cancer screening based on recommendations. In addition, some people who participate in screening do not receive follow-up care after receiving an abnormal screening result. One study found that 50 percent of people with an abnormal result on an at-home colorectal cancer screening did not get follow-up testing. Evidence-based interventions are needed to help improve timely follow-up care for abnormal results following breast, cervical, colorectal, and lung cancer screening.

The Multilevel Follow-up of Cancer Screening (mFOCUS) program is designed to improve timely follow-up (within 120 days) for overdue abnormal screening results for breast, cervical, colorectal, and lung cancer screening. The program uses electronic health record (EHR) systems—programmed with algorithms based on clinical guidelines and specialist input—to identify patients due for follow-up care, share reminders, and send messages. The program aggregates data from the EHRs of individual patients to allow hospital systems to effectively manage a large volume of abnormal test results without increasing clinician burden.

The intervention components include an EHR reminder, outreach, and navigation, with outreach and navigation added sequentially as described below if the patient has not scheduled the recommended follow-up:

-- EHR Reminder: For a patient with an abnormal screening result, a reminder is added to the patient record that can be accessed in the EHR by the primary care provider and in the patient portal by the patient. The reminder, which is visible until the patient completes the outstanding follow-up visit, specifies the type of abnormal test result, the recommended follow-up test or procedure, and the specified time interval for completing follow-up. These alerts can be seen at any time but are mostly viewed around the time of an office visit. 

-- Outreach: A patient overdue for follow-up 2 weeks after their abnormal test result is posted in the patient’s record is sent a reminder letter through the EHR portal or via postal mail. If the patient is still overdue at 4 weeks, a clinic staff member calls the patient to inform them of the test result and provide contact information to schedule the recommended follow-up.

-- Navigation: A patient still overdue at week 8 receives a phone call from a trained patient navigator. The navigator attempts to facilitate scheduling the recommended follow-up by using a script that assesses social barriers to care across nine domains: housing insecurity, food insecurity, paying for basic utilities, family caregiving, legal, transportation, financial compensation for treatment, education, and employment. For patients with identified barriers, navigators provide referral information using an online network of verified social service programs to help connect patients with services available in their community. After the completion of the call, the navigator tracks the patient to determine whether the referred resources provided support to the patient. 

-- Variable time is required to set up the EHR alert system (e.g., to identify patients past due for follow-up, reminders, outreach, and navigation).
-- Variable time is required for calling patients to schedule appointments and to provide patient navigation.

The intervention is intended for patients who are past due for follow-up for their abnormal screening results for breast, cervical, colorectal, and lung cancer.

The program is suitable for implementation in clinical settings with an EHR system.

Required resources to implement the program include the following:

-- Navigator and Study Coordinator Training Book
-- Navigator Script
-- EHR Alert Example in Online Portal
-- Patient Outreach Letter

Costs associated with this program have not yet been determined. 

This pragmatic cluster randomized clinical trial enrolled 44 primary care practices within three health networks in the United States: Brigham and Women’s Hospital (15 practices), Dartmouth Health (12 practices), and Massachusetts General Hospital (17 practices). Participants were women aged 40 to 80 years with an abnormal mammogram; women aged 21 to 65 years with an abnormal Papanicolaou test with or without a human papillomavirus test; men and women aged 40 to 80 years with a positive fecal immunochemical test or an abnormal short-interval colonoscopy (1 to 5 years); and men and women aged 55 to 80 years who currently or formerly smoked and had an abnormal low-dose computed tomographic result. Individuals who were unable to speak English or Spanish, or who had a history of cancer for the organ associated with the abnormal test result, were ineligible to participate. Among those with abnormal colorectal cancer screening results, individuals with inflammatory bowel disease also were excluded, but those undergoing short-interval colonoscopy screening for high-risk family history alone were included because they were difficult to identify in the EHR. 

Primary care practices were randomized to one of four groups: (1) usual care, (2) mFOCUS reminder, (3) mFOCUS reminder+outreach, or (4) mFOCUS reminder+outreach+navigation.

The study enrolled 11,980 patients. The median age was 60 years; 64.8% were women, and 83.3% were White. Patients were overdue for follow-up for colorectal cancer (69%), cervical cancer (22%), breast cancer (8%), and lung cancer (1%).

The primary outcome, measured using EHR data, was completion of the recommended follow-up within 120 days of study enrollment. The study also examined secondary outcomes (not reviewed for the EBCCP program summary), which included completion of the recommended follow-up within 240 days of enrollment.

• At 120 days following study enrollment, follow-up rates were higher in the mFOCUS reminder+outreach+navigation group than in either the mFOCUS reminder group or the usual care group (p<.001 for both comparisons). Likewise, follow-up rates were higher in the mFOCUS reminder+outreach group than in either the mFOCUS reminder group or the usual care group (p<.001 for both comparisons). No differences were found between the mFOCUS reminder+outreach+navigation group and the mFOCUS reminder+outreach group or between the mFOCUS reminder group and the usual care group.