Opt-out breast cancer screening approach more likely to worsen administrative burden
Key takeaways:
- An opt-out approach to breast cancer screening led to similar mammography completion but many more cancellations.
- Practices should consider staff burden and the potential effects when deciding on a strategy.
When all eligible patients were automatically referred for breast cancer screening, mammography completion did not improve, but staff burden worsened, according to the results of research published in JAMA Internal Medicine.
Just 66% of the 280,000 people who receive care from the Veterans Health Administration (VHA) and are eligible for breast cancer screening are up to date, Leah M. Marcotte, MD, MS, an assistant professor at the University of Washington, and colleagues wrote. Barriers to screening include wait times, lack of on-site mammography, scheduling and more.
“Population-based outreach for preventive care (in which patients due for screening are notified outside a primary care visit) may help to address barriers to breast cancer screening,” they wrote. “However, these strategies can be time intensive and have yielded mixed results both in and outside the VHA. Considering the null or modest results from these studies, optimal strategies for population-based outreach for breast cancer screening remain unknown.”
So, Marcotte and colleagues conducted a pragmatic randomized clinical trial to investigate the impacts of an opt-out automatic mammography referral strategy on breast cancer screening compared with an opt-in strategy.
They included 883 women aged 45 to 75 years enrolled in VA primary care who were eligible for breast cancer screening. The researchers randomly assigned the participants in a 1:1 ratio to receive either an opt-in or opt-out approach.
In the opt-in arm, 442 participants received an automated call and were given the option for a mammography referral, to discuss screening with their PCP or decline the service. In the opt-out arm, which included 441 women, primary care nurses reviewed all patients’ records and placed referrals for all eligible patients.
Comparing the two approaches, Marcotte and colleagues observed no significant differences in mammography completion. However, there were many more canceled referrals in the opt-out group (23.6% for the out-out group vs. 5.4% for the opt-in group), which they said increased staff burden.
The intention-to-treat analysis revealed that, at 100 days, 15.2% in the opt-out group completed mammography vs. 14.9% of the opt-in group. Also, 24% of the opt-in group completed or scheduled mammography, compared with 19% for the opt-out group.
An analysis that excluded veterans who were unable to be reached by telephone or who were found to be ineligible after randomization showed similar results, except more participants scheduled or completed mammography within 100 days in the opt-out group vs. the opt-in group (26.3% vs. 19.3%, respectively).
“The findings suggest that health systems should consider both potential effects and excess administrative burden when deciding between opt-out and opt-in outreach strategies,” Marcotte and colleagues wrote. “The administrative burden of the opt-out approach, including medical record review of all veterans prior to outreach ... likely outweighs any potential added benefit.”
Perspective
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Effective interventions to increase patient compliance with health care screening opportunities are a perennial need. A resource-heavy intervention did not effectively improve breast cancer screening rates compared with an automated system. A preprogrammed digital phone call offering referral for breast cancer screening resulted in similar rates of completed mammography compared with a nurse-driven chart review, referral and in-person phone call. The latter ultimately proved overwhelming for staff and led to significantly more mammography cancellations.
Although limited in their generalizability (particularly because the study specifically analyzed veterans from a single medical center), these data seem to affirm a ubiquitous phenomenon of the information age, namely, that a computerized product advertisement can be successful without straining personnel resources. Selling targeted options through automated means is the norm whenever we turn to our smartphones or any computer. Leaning into this digital trend to advertise health care screening opportunities may be the most efficient way to educate the public about options to prevent and effectively detect disease while simultaneously freeing clinicians to commit resources to other projects. As technology advances at a dizzying rate, perhaps collaboration between clinicians, health care scientists and digital advertising experts — including those across social media — could be a key component for augmenting public health.
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