Does access to a colorectal cancer screening website and/or a nurse-managed telephone help line provided to patients by their family physician increase fecal occult blood test uptake?: results from a pragmatic cluster randomized controlled trial

Abstract

Background: Evaluation of the effectiveness of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website), distributed to patients by their family physician, in improving fecal occult blood test (FOBT) colorectal cancer screening rates.

Methods: A pragmatic, two arm, cluster randomized controlled trial in Winnipeg, Manitoba, Canada (39 medical clinic clusters; 79 fee-for-service family physicians; 2,395 average risk patients). All physicians followed their standard clinical screening practice. Intervention group physicians provided a fridge magnet to patients that facilitated patient decision aid access. Primary endpoint was FOBT screening rate within four months.Multi-level logistic regression to determine effect of cluster, physician, and patient level factors on patient FOBT completion rate. ICC determined.

Results: Family physicians were randomized to control (n = 39) and intervention (n = 40) groups. Compared to controls (56.9%; n = 663/1165), patients receiving the intervention had a higher FOBT completion rate (66.6%; n = 805/1209; OR of 1.47; 95% confidence interval 1.06 to 2.03; p < 0.02). Patient aid utilization was low (1.1%; 13/1,221) and neither internet nor telephone access affected screening rates for the intervention group. FOBT screening rates differed among clinics and physicians (p < 0.0001). Patients whose physician promoted the FOBT were more likely to complete it (65%; n = 1140/1755) compared to those whose physician did not (51.1%; n = 242/470; p < 0.0001; OR of 1.54 and 95% CI of 1.23 to 1.92). Patients reporting they had done an FOBT in the past were more likely to complete the test (70.6%; n = 1141/1616; p < 0.0001; 95% CI 2.51 to 3.73) than those who had not (43%; n = 303/705). Patients 50-59 years old had lower screening rates compared to those over 60 (p < 0.0001). 75% of patients completing the test did so in 34 days.

Conclusion: Despite minimal use of the patient aid, intervention group patients were more likely to complete the FOBT. Powerful strategies to increase colorectal cancer screening rates include a recommendation to do the test from the family physician and focusing efforts on patients age 50-59 years to ensure they complete their first FOBT.

Trial registration number: clinicaltrials.gov identifier NCT01026753.

Figure 1

CONSORT flow diagram for family physician recruitment⁵.¹Representing 30 community-based medical clinics. ²Representing 23 medical clinics (of which 3 contained both control and intervention clusters). Each family physician was asked to enroll 30–35 patients. Total number of patients was n = 2,395; 915 males, 1473 females. ³Control group represented by 13 clinics and 19 clusters; intervention group represented by 12 clinics and 20 clusters. See Table 5 for detailed description of clusters. ⁴Number of patients analyzed; control (n = 1,174) and intervention (n = 1,221). ⁵Based on the CONSORT flow diagram [23].

Figure 2

Screening rate for individual family physicians in the control group by gender and cluster. There were significant differences in FOBT screening rates among the clusters in the control group (p < 0.0001). Average screening rate for control group is 57%; range 33.8 to 81.5%. F = Female, M = Male. See text for further details.

Figure 3

Screening rate for individual family physicians in the intervention group by gender and cluster. There were significant differences in FOBT screening rates among the clusters in the intervention group (p < 0.0001). Average screening rate for intervention group is 66.6%; range 20 to 78.8%. F = Female, M = Male. See text for further details.