May 19, 2015

Home tests and automated reminders cut colon cancer screening costs

With Kaiser Permanente colleagues, Group Health finds cost savings for two years 

SEATTLE—Sending at-home stool kits through the mail and using automated reminders are part of a cost-effective program to boost screening for colon cancer, according to researchers at Group Health and Kaiser Permanente. Health costs were significantly lower over two years when researchers used electronic health records to identify patients who weren’t screened regularly for colon cancer, and then encouraged these patients to be screened.

The American Journal of Preventive Medicine published “An Economic Evaluation of Colorectal Cancer Screening in Primary Care Practice,” the cost results from a randomized controlled trial called Systems of Support to Increase Colorectal Cancer Screening (SOS).

The SOS trial used electronic medical records to identify more than 4,000 Group Health patients, aged 50 to 73, who weren’t up to date for colorectal cancer screening. They were randomly assigned to one of four stepped groups (usual care or three stepped interventions):

  • Usual care: reminders sent to patients and their primary-care clinics;
  • Automated care: usual care plus a letter telling patients they were due for colorectal cancer screening and a pamphlet about screening choices;
  • Assisted care: a medical assistant calling to ask which screening option patients preferred, if they still had not completed screening; or
  • Navigated care: all of the above, plus, if still overdue, a nurse calling to advise patients and facilitate their screening.

“Two of the three interventions—automated and assisted care—cost less per screened patient than usual care,” said lead author Richard T. Meenan, PhD, a senior investigator at the Kaiser Permanente Center for Health Research, in Portland, OR. “That’s because the people in those intervention groups were more likely than those in the usual care group to choose a stool test instead of colonoscopy and colonoscopies are more expensive than stool tests.”  

With the testing and intervention costs factored in, the automated intervention saved $159 per patient compared to usual care and the assisted intervention saved $36 per patient compared to usual care; navigated care cost $65 more than usual care.  That doesn’t necessarily mean that automated care is best, because it is also important to take into account how many patients received screening. That number rose with each stepped level of intervention.

“Screening for cancers of the colon and rectum can prevent disease—and death,” said Beverly B. Green, MD, MPH, a family physician at Group Health and an associate investigator at Group Health Research Institute. “But this screening works only if people get it done regularly—and nearly one-third of Americans don’t, even though it’s strongly recommended for everyone age 50 to 75 years.”

The same research team had previous published that SOS’s centralized, automated approach doubled these patients’ rates of on-time screening. And nurse navigators helped the patients to get needed follow-up care after positive screening tests. Thanks to this research, usual care has changed so now Group Health and Kaiser Permanente send automated reminders to patients who are overdue for colon cancer screening, and in many cases these patients also receive an at-home screening test.

What’s next?

Now the researchers are following up with the same patients for up to 10 years to see whether the regular screenings—and cost savings—persist. Stool tests need to be done yearly,  while screening colonoscopy is recommended only once per decade, Dr. Green explained. So it is possible that regular screening and cost savings in the intervention groups might decline over time.

Dr. Green and Kaiser Permanente researcher Gloria Coronado, PhD, have also shown that systematically mailing stool tests to patients in community health clinics is a promising way to help prevent disparities in colon cancer screening.

Award R01 CA121125 from the National Cancer Institute (NCI) of the NIH supported the SOS study, which is registered at (NCT00158639).

Drs. Meenan and Green’s coauthors include Associate Investigator Jessica Chubak, PhD, MBHL, Senior Biostatistician Melissa L. Anderson, MS, and Analyst Programmer Sharon Fuller, all of Group Health Research Institute. Dr. Green has a joint appointment as an assistant clinical professor at the University of Washington School of Medicine, and Dr. Chubak is also at the University of Washington School of Public Health. Their other co-authors are Ching-Yun Wang, PhD, a member of the Public Health Sciences Division at the Fred Hutchinson Cancer Research Center, in Seattle; and Sally W. Vernon, PhD, chair of health promotion & behavioral sciences at The University of Texas School of Public Health in Houston.

HMO Research Network

The HMO Research Network includes 19 research centers, each associated with a health care delivery system. Researchers at the centers collaborate on multi-site studies in real-world health care settings across the United States and in Israel. With access to information on more than 16 million ethnically and geographically diverse patients, these researchers are finding solutions for common and rare health problems. Since 1994, the Network has been answering pressing questions about keeping people healthy and delivering effective care.

About Kaiser Permanente

Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 12.4 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal Permanente Medical Group physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to:

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Melissa L. Anderson, MS

Principal Collaborative Biostatistician
Kaiser Permanente Washington Health Research Institute

Jessica Chubak, PhD

Senior Investigator
Kaiser Permanente Washington Health Research Institute