Capsule Commentary on Fortuna et al., Get Screened: A Randomized Trial of the Incremental Benefits of Reminders, Recall, and Outreach on Cancer Screening

Abstract

Fortuna et al.1 assess and compare the effectiveness of phone, mail, and personal reminders as methods to improve rates of breast and colorectal cancer screening in an underserved population. Compared to reminder letters alone, cancer screening rates were increased with the addition of reminders at the point of care or a personalized phone call. However, no benefit was shown with the addition of an automated phone call to a reminder letter, compared to the letter alone. This study is well-written, well-designed, and shows promising findings. Unfortunately, this study might lack relevance for the practice environments of many, perhaps most, physicians currently practicing in the United States, in which electronic medical records (EMRs) are widely available and capable of ever-wider functionality. A survey done in 2011–2012 showed that greater than 40 % of physicians are currently using EMRs.2 Of course, the authors made extensive use of EMRs in their study in retrieving patient data and ascertaining their screening status. However, today’s EMRs make possible automated reminders to both physicians and patients regarding their screening.3 This issue affects the generalizability of the study results. If we accept the results that letter+autodial+prompt and letter+personal call are better than letter alone (note that these first two options do not appear statistically different, though they are not compared explicitly), then we must ask what the equivalent to “letter+autodial+[paper] prompt” is in current EMRs. Is a computer prompt of equivalent effectiveness to a paper prompt? What about a prompt delivered in real time to the provider, so that the prompt can be personally delivered during the visit? Another point to raise is the choice of American Cancer Society (ACS) cancer-screening guidelines. It is unclear which screening guidelines are most widely followed by physicians (if indeed any guidelines, as a set, are consistently followed at all,4) but clearly there are several competing possibilities, including United States Preventive Services Task Force (USPSTF) guidelines. A separate analysis to determine the sensitivity of the results to guidelines might be useful. This study serves as evidence that reminders work. The next step is to implement such reminders according to the most current practice environments.