Automated Telephone Calls Improve Completion of Fecal Occult Blood Testing

Colorectal cancer (CRC) is the third most common type of cancer and the second leading cause of cancer death in the United States.  Despite the availability of effective screening, CRC screening remains underused. In 2005, only 50% of adults aged 50 or older in the United States reported undergoing a sigmoidoscopy or colonoscopy within the previous 10 years or using a fecal occult blood test (FOBT) home kit within the preceding year, according to findings from the National Health Interview Survey administered by the Centers for Disease Control and Prevention (CDC).  The CDC estimates that as many as 60% of deaths from CRC cancer could be prevented if everyone aged 50 and older were screened regularly.  To reduce CRC mortality rates in adults aged 50-75 at average risk for the disease, the U.S. Preventive Services Task Force recommends three screening technologies: annual high-sensitivity FOBT, sigmoidoscopy every 5 years with FOBT between exams, and optical colonoscopy every 10 years.

Automated Telephone Calls Improve Completion of Fecal Occult Blood Testing is an automated telephone intervention to increase CRC screening using an FOBT home test kit.  Staff at health maintenance organizations (HMOs) identify patients in an electronic database who will receive the automated calls.  The criteria used to define the need for routine screening are as follows: (1) no completed FOBT screening within the past 12 months; (2) no flexible sigmoidoscopy or double-contrast barium enema (DCBE) within the past 5 years; (3) no colonoscopy within the past 10 years; and (4) no clinician order or referral for FOBT, or colonoscopy in the past 3 months.  The intervention consists of a general reminder telephone call (type 1) that provides a brief overview of CRC, including the benefits of colorectal screening, and encourages use of a home FOBT kit as a relatively simple and low-risk method of CRC screening.  Recipients of reminder calls can request an FOBT kit with instructions for completion by pressing a number on a touch-tone telephone.  Patients who do not complete FOBT screening receive up to two additional reminder calls (type 1) at 6 and 12 weeks after the initial call. One additional FOBT return reminder call (type 2) targets patients who initially request an FOBT stool card kit but fail to return it within 4-5 weeks of the request.  Automated calls to FOBT non-returners reiterate the benefits of CRC screening and remind to return a completed FOBT card.  Non-returners are also given the opportunity to request an additional FOBT card if needed. 

- Up to three, automated, type 1, general reminder calls, each 1 minute long - an initial call with follow-up calls at 6 and 12 weeks later if no FOBT has been completed
- One additional, automated, type 2, FOBT return call, approximately 1 minute long at 4-5 weeks following an initial patient request for an FOBT kit, if a completed FOBT has not been submitted

The intervention targets adults aged 51-80 years at average risk for CRC and due for routine screening. 

The intervention can be delivered through a group-model HMO or other clinical settings. 

-    Implementation guide
-    Automated calling system
-    Call scripts
-    Mailed FOBT materials
-    FOBT

A randomized clinical study evaluated the effects of an HMO-based, automated, telephone contact intervention on completion of FOBT screening for CRC in patients aged 51-80 at average risk for CRC and due for routine screening.  Of a total of 45,558 HMO members aged 51-80 who were due for routine CRC screening, 6,063 were excluded for medical conditions that precluded their appropriateness for CRC screening through FOBT, and another 7,175 patients were excluded because continuous HMO medical coverage was not maintained for a minimum duration of 2 years before randomization.  This left a total eligible patient population of 32,320.  From these individuals, 6,000 patients were randomly chosen for study participation and then randomly assigned to either the telephone contact intervention (3,000 patients) or usual care (3,000 patients) condition (i.e., no telephone contact).  However, usual care patients may have been referred for CRC screening by their clinicians during the course of routine medical care procedures since the HMO uses a prompt system for ordering needed services embedded in the electronic medical record of each patient to inform physicians which patients are overdue for preventive services at primary care visits. 

A stratified randomized approach balanced study conditions on age, gender, and prior CRC screening. After randomization, but prior to the start of the intervention, 95 patients (38 from usual care and 57 from the intervention group) had either dis-enrolled from the HMO or received CRC screening and were excluded from the analyses.  The final study sample of 5,905 patients had a mean age of about 60, with nearly equal proportions of men and women, 92% of whom were White.  Nearly 40% of the study sample was obese, about 30% of patients assigned to each condition had a history of prior CRC screening, and almost 92% of the study sample had an assigned primary care physician.  A similar proportion of patients in each condition had received one prior CRC screening telephone call prior to study entry (intervention group = 13.4% versus usual care = 12.4%) as part of an ongoing quality improvement effort throughout the HMO that started 4 months before the study began but did not target non-responders for reminder calls. 

All randomized study patients were assessed for completion of FOBT screening during the 6 months following the initiation of study telephone contact.  Statistical modeling of the intervention effect on completion of FOBT included controlling for the potential mediating effects of age, gender, prior receipt of CRC screening, race or ethnicity, diagnosed obesity status, and receipt of a prior CRC screening call before the start of the study.

• Six months after initiating study telephone contact, 22.5% of the intervention patients compared with 16.0% of the usual care patients had completed FOBT (p<.001); intervention patients were 1.31 times more likely than usual care patients to complete FOBT during the 6-month follow-up period after adjusting for age, gender, and prior receipt of CRC screening.