Journal of General Internal Medicine

, Volume 23, Issue 6, pp 762–767

Physician Reminders to Promote Surveillance Colonoscopy for Colorectal Adenomas

A Randomized Controlled Trial
  • John Z. Ayanian
  • Thomas D. Sequist
  • Alan M. Zaslavsky
  • Richard S. Johannes
Original Article

Abstract

Background

Most colorectal cancers develop from adenomatous polyps. National guidelines recommend surveillance colonoscopy within 5 years after such polyps are removed.

Objective

To determine whether surveillance colonoscopy can be increased among overdue patients by reminders to their primary physicians.

Design

Randomized, controlled trial of patient-specific reminders mailed to 141 physicians in 2 Massachusetts primary care networks during April, 2006.

Patients

Seven hundred seventeen patients who had colorectal adenomas removed during 1995 through 2000 and no follow-up colonoscopy identified via automated review of electronic records through March, 2006.

Measurements and Main Results

The use of colonoscopy and detection of new adenomas or cancer were assessed at 6 months by a blinded medical record review in all patients. Among 358 patients whose physicians received reminders, 33 (9.2%) patients underwent colonoscopy within 6 months, compared with 16 (4.5%) of 359 patients whose physicians did not receive reminders (P = 0.009). In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, elderly and nonelderly patients, or women and men (all P > 0.60 by Breslow–Day test). New adenomas or cancer were detected in 14 (3.9%) intervention patients and 6 (1.7%) control patients (P = 0.06), representing 42.4% and 37.5% of patients who underwent colonoscopy in each group, respectively. Despite using advanced electronic health records to identify eligible patients, 22.5% of enrolled patients had a prior follow-up colonoscopy ascertained only by visual record review, and physicians reported 27.9% of intervention patients were no longer active in their practice.

Conclusions

Among patients with prior colorectal adenomas, physician reminders increased the use of surveillance colonoscopy, but better systems are needed to identify eligible patients (ClinicalTrials.gov ID number NCT00397969).

KEY WORDS

colorectal neoplasms adenomatous polyps colonic polyps colonoscopy quality of health care primary health care randomized controlled trials Massachusetts 

References

  1. 1.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–30.PubMedCrossRefGoogle Scholar
  2. 2.
    Toribara NW, Sleisenger MH. Screening for colorectal cancer. N Engl J Med. 1995;332:861–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–81.PubMedCrossRefGoogle Scholar
  4. 4.
    Citarda F, Tomaselli G, Capocaccia R, Barcherini S, Crespi M. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut. 2001;48:812–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Winawer SJ, Zauber AG, O’Brien MJ, et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med. 1993;328:901–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124:544–60.PubMedCrossRefGoogle Scholar
  7. 7.
    Yabroff KR, Washington KS, Leader A, Neilson E, Mandelblatt J. Is the promise of cancer-screening programs being compromised? Quality of follow-up care after abnormal screening results. Med Care Res Rev. 2003;60:294–331.PubMedCrossRefGoogle Scholar
  8. 8.
    Maviglia SM, Teich JM, Fiskio J, Bates DW. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines. J Gen Intern Med. 2001;16:531–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12:431–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Shah NR, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc. 2006;13:5–11.PubMedCrossRefGoogle Scholar
  11. 11.
    Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Intern Med. 2006;166:1374–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Pereira AG, Kleinman KP, Pearson SD. Leaving the practice: effects of primary care physician departure on patient care. Arch Intern Med. 2003;163:2733–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Sequist TD, Adams A, Zhang F, Ross-Degnan D, Ayanian JZ. Effect of quality improvement on racial disparities in diabetes care. Arch Intern Med. 2006;166:675–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH. Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med. 2006;166:2237–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–51.PubMedGoogle Scholar
  16. 16.
    Yabroff KR, Kerner JF, Mandelblatt JS. Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening. Prev Med. 2000;31:429–39.PubMedCrossRefGoogle Scholar
  17. 17.
    Bastani R, Yabroff KR, Myers RE, Glenn B. Interventions to improve follow-up of abnormal findings in cancer screening. Cancer. 2004;101:1188–200.PubMedCrossRefGoogle Scholar
  18. 18.
    Myers RE, Hyslop T, Gerrity M, et al. Physician intention to recommend complete diagnostic evaluation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev. 1999;8:587–93.PubMedGoogle Scholar
  19. 19.
    Jha AK, Ferris TG, Donelan K, et al. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood). 2006;25:w496–507.CrossRefGoogle Scholar
  20. 20.
    Simon SR, Kaushal R, Cleary PD, et al. Physicians and electronic health records: a statewide survey. Arch Intern Med. 2007;167:507–12.PubMedCrossRefGoogle Scholar
  21. 21.
    Persell SD, Wright JM, Thompson JA, Kmetik KS, Baker DW. Assessing the validity of national quality measures for coronary artery disease using an electronic health record. Arch Intern Med. 2006;166:2272–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Baker DW, Persell SD, Thompson JA, et al. Automated review of electronic health records to assess quality of care for outpatients with heart failure. Ann Intern Med. 2007;146:270–7.PubMedGoogle Scholar
  23. 23.
    Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med. 2004;141:264–71.PubMedGoogle Scholar
  24. 24.
    Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal screening after polypectomy: a national survey study of primary care physicians. Ann Intern Med. 2006;145:654–9.PubMedGoogle Scholar
  25. 25.
    Brown ML, Klabunde CN, Mysliwiec P. Current capacity for endoscopic colorectal cancer screening in the United States: data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices. Am J Med. 2003;115:129–33.PubMedCrossRefGoogle Scholar
  26. 26.
    Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130:1872–85.PubMedCrossRefGoogle Scholar
  27. 27.
    Noshirwani KC, van Stolk RU, Rybicki LA, Beck GJ. Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy. Gastrointest Endosc. 2000;51:433–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Saini SD, Kim HM, Schoenfeld P. Incidence of advanced adenomas at surveillance colonoscopy in patients with a personal history of colon adenomas: a meta-analysis and systematic review. Gastrointest Endosc. 2006;64:614–26.PubMedCrossRefGoogle Scholar
  29. 29.
    Gross CP, McAvay GJ, Krumholz HM, Paltiel AD, Bhasin D, Tinetti ME. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med. 2006;145:646–53.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • John Z. Ayanian
    • 1
    • 3
    • 4
  • Thomas D. Sequist
    • 1
    • 3
    • 5
  • Alan M. Zaslavsky
    • 3
  • Richard S. Johannes
    • 2
    • 6
  1. 1.Division of General Medicine and Primary Care, Department of MedicineBrigham and Women’s HospitalBostonUSA
  2. 2.Division of Gastroenterology, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Health Care PolicyHarvard Medical SchoolBostonUSA
  4. 4.Department of Health Policy and ManagementHarvard School of Public HealthBostonUSA
  5. 5.Harvard Vanguard Medical AssociatesBostonUSA
  6. 6.Cardinal HealthWestboroughUSA

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