Client (Patient) Reminder Planning Guide

Introduction

The four Evidence-Based Intervention Planning Guides provide tips to help clinic staff, and those who provide technical assistance to them, implement evidence-based interventions to increase screening for breast, cervical, and colorectal cancer.

Patient reminders can be written messages (letter, postcard, email, or text) or a telephone call made by a person or an automated service. The goal is to prompt patients to schedule an appointment for screening. See the Community Guide recommendation.

Process flow

Implement and integrate a patient reminder system into the clinic workflow

When a reminder is sent and received, the patient is prompted to action.

Output: Increased screening prompts to patients

Measure: Delivery of reminders.

Example: Number of patients given reminders divided by the number of patients due for screening.

Example: Number of patients who received reminders divided by the number of patients due for screening.

Patient schedules and keeps an appointment for cancer screening

Potential challenges include a limited electronic health record (EHR) system, limited staff time if reminders are not automated, and incomplete records or incorrect contact information.

Output: Increased screening appointments by patients

Measure: Appointments among eligible patients.

Example: Number of patients scheduled for screening appointments divided by the number of patients receiving reminders.

Example: Number of patients showing up for screening appointments divided by the number of patients scheduled.

Patient completes cancer screening

Potential challenges include inconvenient clinic hours, limited capacity or resources to follow-up on abnormal screening results, patient fear, cost, and lack of transportation.

Outcome: Increased screening and diagnostic tests completed by patients

Measure: Screening completion.

Example: Number of patients completing screening divided by the number of patients referred for screening.

Example: Number of patients completing diagnostic follow-up divided by the number of patients with positive screening tests.

Increased cancer screening

Outcome: Increased clinic-level rates of cancer screening

Measure: Age-eligible clinic population up-to-date with recommended cancer screening.

Example: Uniform Data System (UDS), Healthcare Effectiveness Data and Information Set (HEDIS), National Quality Forum (NQF) 12-month measure used to calculate screening rate.

Components of the intervention

Identify patients due for screening tests

• Was a priority population defined?
• Were the characteristics of the priority population and their barriers assessed?
• Have patients who are due for screening been identified using the EHR or other patient record system?

Develop and send reminder

• Will the reminder be a phone call, email, letter, postcard, or text message?
• Was the date that determined screening eligibility included? In other words, is screening due based on aging into eligibility or the date of the patient's last test?
• Is up-to-date contact information for the patients available? Is the type of contact information appropriate for the mode of reminder selected?
• Is the language used for the reminder appropriate for the recipient?
• Have administrative staff been told when the reminders will be sent so they can prepare for increased call volume? Have they been trained on any new processes?

Track outcomes

• Are there means and data available to track patients through screening and diagnostic test completion?
• Have methods and tools for tracking been identified or created?
• Have appropriate and feasible performance measures been selected for process and outcome evaluation?

Resources to support implementation

Partnerships

• Internal: Across and within clinics, with departments such as billing, claims, radiology, and information technology (IT).
• External: Patient registries, laboratories, community health workers, volunteers, and academics.

Staff

Administrative support to identify patients due for screening, draft the content of the reminder, send the reminders (if the process is not automated), collect data, and track reminders and test results.

Tools

• Computerized patient registry or EHRs to identify patients due for screening and record responses to reminders.
• Reminder content can include responses to common screening barriers.
• Appointment scheduling system.
• Assessments of effectiveness.

Lessons learned from the literature¹

• The effect was larger for telephone reminders than for written reminders for breast and cervical cancer.
• When used as part of a multicomponent approach to increase cancer screening rates, the median increase across multiple studies attributed to the patient reminders was 5.0 percentage points for breast cancer, 3.7 percentage points for cervical cancer, and 10.9 percentage points for colorectal cancer.
• Simple reminders were more effective for patients who had been screened before.
• Reminder letters were less effective when multiple barriers to screening existed.
• The reminder system can range from simple to highly complex. More complex systems require greater coordination of staff and processes.
• Funds may be required to start systems and generate and deliver reminders, but programs implemented on a large scale may decrease the cost per person.
• Interviews about barriers and facilitators to screening in priority populations can inform effective messaging for follow-up reminders.
• In one longer-term study, the effect achieved after year 1 diminished over time and disappeared by year 3, suggesting that systems may need periodic adjustment or enhancement to maintain effectiveness.

Ways to strengthen performance or sustainability

• Assess the priority population to inform message development and refinement.
• Send additional follow-up reminders.
• Provide additional information about cancer, screening tests, and resources to overcome screening barriers.
• Help schedule appointments.

Community Guide recommendation

The Community Preventive Services Task Force recommends the use of patient (client) reminders to increase screening for breast, cervical, and colorectal cancer.²

Settings where the intervention was studied¹

• Rural, urban, and suburban areas in the United States and Australia.
• Primary care clinics and hospitals, Veterans Administration clinics, health maintenance organizations, local health departments, mobile mammography units, and patients' homes.

Outcomes from the systematic review of effectiveness¹

Screening

• Completed mammography for breast cancer screening increased by a median of 12.3 percentage points; 6.0 percentage points for repeat (re-screening) mammography.
• Completed cervical cancer screening tests increased by a median of 10.2 percentage points; 2.8 percentage points for a repeat test.
• Completed fecal occult blood tests (FOBTs) for colorectal cancer screening increased by a median of 11.5 percentage points.

Cost of the intervention per participant

• For mammography, the average cost per participant was less than $1.50.
• For FOBT, the average cost per participant was less than $3.50 for mailed reminders and less than $60 for telephone reminders.

References

¹Sabatino SA, Lawrence B, Elder R, et. al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. Am J Prev Med. 2012;43(1):97–118.

²Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2012;43(1):92–96.