Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals

Abstract

Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be reevaluated. We tested three outreach approaches for transitioning patients to the 10-year interval recommendation. Design: 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. Kaiser Permanente Northern California, a large integrated healthcare system. Patients aged 54-70 years with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all three outreach modalities. Patients were randomly assigned to outreach arm (telephone [n=200], secure message [n=203], and mailed letter [n=201]) stratified by age, sex, race, and ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval. 60-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) versus mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared to mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% CI: 8.3%, 27.9%) and secure message outreach (13.1%; 97.5% CI: 3.5%, 22.7%) versus mailed letter outreach. Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting.