Effect of a Mailed Brochure on Appointment Keeping for Screening Colonoscopy

As of 2004, almost 45% of adults aged 50 years or older were not up to date with colorectal cancer (CRC) screening. In community settings, a key barrier to screening is the absence of a primary care physician who would recommend screening. Nonetheless, previous work has demonstrated that adherence to referrals is low even when patients have face-to-face discussions with their primary care physicians and receive referrals for screening. This finding is particularly true for colonoscopy, a high-intensity procedure requiring considerable advance preparation. Non-adherence to referrals for colonoscopy represents a missed opportunity both for individual patients and for realizing public health goals. Mailed brochures have been shown to be effective in promoting other types of cancer screening tests.

In an effort to reduce non-adherence to screening colonoscopy, the referring physician's office mails patients a one-page, two-sided brochure shortly after they receive referrals for a colonoscopy procedure. The brochure aims to educate patients about CRC and colonoscopy, address most common questions and concerns, and remind them to schedule a procedure. A secondary objective is to clearly inform patients ahead of time about bowel preparation and the risk of bleeding and perforation associated with the procedure. The introductory paragraph of the brochure is personalized to include the name of the patient's primary care physician. The brochure format makes use of color and large font and includes a diagram of the large intestines and colonoscopy. Written at an eighth-grade reading level, the brochure provides the following information:

• The similar lifetime risk for CRC for men and women at average risk
• The concept of cancer prevention and early detection
• The nature of polyps and early-stage cancer
• How screening may help prevent death
• The colonoscopy procedure
• Alternatives to colonoscopy
• The risk of colon perforation
• Preparation for a colonoscopy

Those implementing the intervention spend a negligible amount of time to prepare and send the brochure in the mail. Because the brochure is printed on one double-sided page and makes use of a large font size, a diagram, and text written at the eighth-grade reading level, time required for patients to read the brochure is expected to be minimal.

The brochure is intended for asymptomatic men and women, aged 50 or older, who are receiving referrals for screening colonoscopy. 

Suitable settings include ambulatory primary care practices (e.g. family and general internal medicine).

The only required resource is the educational brochure, which costs approximately $1 per patient to produce and send in the mail.

The investigators conducted a randomized, controlled trial to test the hypothesis that adherence to colonoscopy referrals is greater among patients who receive a mailed brochure with a description of a colonoscopy and a reminder to schedule a procedure than among patients who do not. Patients in the intervention condition received both usual care (face-to-face discussions with primary care physicians, referrals for colonoscopy, and written instructions to call to schedule a procedure) and the mailed brochure. Patients in the comparison condition received only usual care.

A total of 781 patients were included in the analyses, as follows: 38% men and 62% women; 77% were between the ages of 50 and 64; 23% were aged 65 or older; 57% were White, non-Latino; 9% were African American, non-Latino, and 4% were Latino; 31% self-identified as "other or unknown."

A hospital claims record was generated within an average of 4 weeks for each colonoscopy procedure completed. If no claims record was generated within a minimum of 4 months following referral, the procedure for that patient was coded as not completed. 

Key Finding

• The overall adherence rate for colonoscopy screening was 11.7 percentage points greater in the intervention group than in the control group (70.7% vs. 59.0%; p=.001).