Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests

Esther Y Hsiang, Shivan J Mehta, Dylan S Small, Charles A L Rareshide, Christopher K Snider, Susan C Day, Mitesh S Patel, Esther Y Hsiang, Shivan J Mehta, Dylan S Small, Charles A L Rareshide, Christopher K Snider, Susan C Day, Mitesh S Patel

Abstract

Importance: Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused.

Objective: To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests.

Design, setting, and participants: A retrospective quality improvement study was conducted among 69 916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019.

Interventions: From 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit.

Main outcomes and measures: The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit.

Results: The sample eligible for breast cancer screening comprised 26 269 women with a mean (SD) age of 60.4 (6.9) years; 15 873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43 647 patients with a mean (SD) age of 59.4 (7.5) years; 24 416 (55.9%) were women, 19 231 (44.1%) were men, 29 029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P < .001) but no change in patient completion (0.1 percentage points; 95% CI, -4.0 to 4.3 percentage points; P = .45). For colorectal cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (13.7 percentage points; 95% CI, 8.0-18.9 percentage points; P < .001) but no change in patient completion (1.0 percentage points; 95% CI, -3.2 to 4.6 percentage points; P = .36).

Conclusions and relevance: An active choice intervention in the electronic health record directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests. However, it was not associated with a significant change in patient completion of either cancer screening test during a 1-year follow-up.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Patel reported being supported by career development awards from the Department of Veterans Affairs Health Services Research and Development and the Doris Duke Charitable Foundation; being founder of Catalyst Health LLC, a technology and behavior change consulting firm; receiving research funding from Deloitte, which is not related to the work described in this article; receiving personal fees from and owning equity in Catalyst Health LLC; receiving stock options from LifeVest Health; receiving personal fees and stock options from HealthMine Services; and receiving personal fees from Holistic Industries outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Breast Cancer Screening Rates by…
Figure 1.. Breast Cancer Screening Rates by Practice Group and Year
A, The percentage of patients who were eligible for breast cancer screening and left their primary care visit with an order for screening. B, The percentage of patients who had screening completed within 1 year after the visit. The active choice intervention was implemented at the intervention site during the period from 2016 to 2017. The vertical dashed black line separates the 2 preintervention years from the postintervention year.
Figure 2.. Colorectal Cancer Screening Rates by…
Figure 2.. Colorectal Cancer Screening Rates by Practice Group and Year
A, The percentage of patients who were eligible for colorectal cancer screening and left their primary care visit with an order for screening. B, The percentage of patients who had screening completed within 1 year after the visit. The active choice intervention was implemented at the intervention site during the period from 2016 to 2017. The vertical dashed black line separates the 2 preintervention years from the postintervention year.

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