Patients Are Untapped Resource for Improving Care

FINDINGSA study looking at over 21,000 patients from 11 health centers finds that patients who receive mailed reminders for scheduling colorectal cancer screenings are more likely to comply than those who don't. Forty-four percent of patients who received a reminder in the mail were screened, versus 38 percent who did not—an effect that increased with age. However, electronic reminders targeting physicians yielded no significant increase.

RELEVANCEMuch of the debate around health care IT focuses on physicians, with counter-arguments often pointing out that many primary care physicians are overwhelmed with administrative work to begin with. But in this study researchers find that when mailed reminders are sent to patients—reminders generated by electronic data—rates of screening increase. These findings suggest that the debate around health care IT should include ways to empower patients to become more proactive in their health care.

INVESTIGATORSJohn Ayanian, professor of medicine and health care policy at Harvard Medical School; professor of health policy and management at the Harvard School of Public Health; director of the Harvard Fellowship in General Medicine and Primary Care.http://www.hcp.med.harvard.edu/people/hcp_core_faculty/john_ayanian

Thomas Sequist, assistant professor of medicine and of health care policy at Harvard Medical School and Brigham and Women's Hospitalhttp://www.hcp.med.harvard.edu/people/hcp_core_faculty/thomas_sequist

JOURNALArchives of Internal Medicine

FUNDINGThe National Cancer Institute

Newswise — As the United States transitions to a new administration, and as the health care crisis mounts, the debate about how to buttress primary care delivery with information technology is getting louder. While much of the attention—and controversy— is focused on how to better equip physicians, little focus appears to be aimed at how to better equip patients to improve their health care.

A 15-month study looking at 21,860 patients and 110 primary care physicians from 11 Harvard Vanguard health centers found that patients who received mailed reminders that they were due for colorectal cancer screenings were more likely to schedule screenings than those who didn't. Forty-four percent of patients who received a reminder in the mail got screened, versus 38 percent who did not—a 16 percent relative increase in screening rate. In an interesting twist to the findings, electronic reminders to physicians during office visits indicating that these same patients were due for screenings yielded no significant increase.

"We had a large group of people who needed to be screened for a very important condition. If we provided them with basic information about colon cancer and their need for screening, this approach was more effective than simply leaving it all up to the doctor," says Harvard Medical School professor of medicine and health care policy John Ayanian.

These findings are published in the February 23 issue of Archives of Internal Medicine.

For this study, Ayanian, who is also a professor of health policy and management at the Harvard School of Public Health, and Thomas Sequist, assistant professor of medicine and of health care policy at Harvard Medical School and Brigham and Women's Hospital, looked at a group of patients aged 50 to 80. Using data generated by an electronic health record, they were able to isolate a large group who were overdue for colorectal cancer screening.

One group of patients was randomly chosen to receive in the mail a personalized letter indicating their history of colon cancer screening exams, education literature on colon cancer, plus a fecal occult blood test kit and instructions for scheduling either a sigmoidoscopy or colonoscopy. The remaining patients received their usual care without this extra information. Not only did 44 percent of the first group get screened, but the effect increased with age; the older, the more compliant. In fact, among patients between 70 and 80 years old, screening rates increased from 37 percent to 47 percent among those who received mailed reminders to be screened—a 27 percent relative increase.

Some physicians were also chosen at random to receive electronic reminders during office visits indicating that their patients were overdue for screening. The fact that up to one third of the patients did not visit their physician during this 15-month period may very well have contributed to the overall negligible results (42 percent versus 40 percent). Still, the effectiveness of such reminders increased with patients who visited their doctor three or more times during the study period. Among these patients with frequent visits, nearly 60 percent of those whose physicians received reminders were screened, compared with 52 percent of patients whose doctors did not receive reminders.

"Getting something in the mail might seem low tech, but it was only possible because in these health centers electronic medical records already existed," says Sequist. "People speak of primary care being in crisis and that there's too much for physicians to get done in a regular workday. But here we see that patients can take a more active role in their health care. We often don't give enough credit to patients for their ability to own their health care. But here's some evidence that patients can better manage their health care if we arm them with the right information."

The authors comment at the end of the paper, "Our findings underscore that informed patients can play an active role in completing effective preventive services."

This research was funded by the National Cancer Institute

Full Citation

Archives of Internal Medicine, Vol. 169, No. 3, February 9, 2009

Patient and Physician Reminders to Promote Colorectal Cancer Screening: A Randomized Controlled Trial

Thomas D. Sequist, MD, MPH(1,2,3); Alan M. Zaslavsky, PhD (2); Richard Marshall, MD(3); Robert H. Fletcher, MD(4); John Z. Ayanian, MD, MPP(1,2)

1-Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston MA2-Department of Health Care Policy, Harvard Medical School, Boston, MA3-Harvard Vanguard Medical Associates, Boston, MA4-Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA

Harvard Medical School http://hms.harvard.edu has more than 7,500 full-time faculty working in 11 academic departments located at the School's Boston campus or in one of 47 hospital-based clinical departments at 18 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children's Center, Immune Disease Institute, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.