Effect of Patient Portal Messaging Before Mailing Fecal Immunochemical Testing Kit on Colorectal Cancer Screening Rates
Condition: Colorectal Cancer; Colorectal Neoplasms; Colorectal Cancer Screening
MeSH terms: Colorectal Neoplasms
Study type: Interventional

Summary: 
      Behavioral economics principles have increasingly been shown to improve health outcomes in
      the United States. They offer the ability to implement simple, low-cost and effective
      interventions to address key health issues without sacrificing the autonomy of patients.
      Colorectal cancer (CRC) screening is a key area where behavioral economics principles can
      help improve health outcomes. Despite being the second leading cause of cancer related death,
      the rate of CRC screening remains well below national targets. Interventions to address these
      issues, and improve screening rates at our institution have including implementing a Mailed
      FIT outreach program, and adding an informational letter that utilizes behavioral economic
      principles. To further improve our screening rates, this project builds upon our previous
      efforts to include a randomized electronic message primer via patients electronic patient
      portal, to help alert them of incoming FIT Kit and complete screening. This study will
      contribute to the growing literature of behavioral economics in medicine, while addressing an
      important health issue.
    

Detailed description: 
      Colorectal cancer (CRC) is the second leading cause of death from cancers affecting both men
      and women in the United States. One in 17 Americans will suffer from CRC during his/her
      lifetime. Early detection by screening has been shown to reduce CRC mortality. Despite
      screening recommendations, the U.S. screening rate remains well below the national benchmark
      of 80% as established by the National Colorectal Cancer Roundtable. The U.S. Multi-Society
      Task Force (MSTF), however, does recommended FIT and colonoscopy as first line screening
      modalities for CRC in 2017. To help address the issue of suboptimal CRC screening, the
      investigators implemented an intervention utilizing the principles of behavioral economics to
      improve screening rates. Studies in behavioral economics and psychology indicate that how
      information or choice is framed impacts behavior in predictable ways, which has applications
      in health and medicine, including the design of CRC screening strategies. This project builds
      upon our institutions continued quality improvement efforts utilizing behavioral economics
      principles to improve CRC screening, through improving the choice architecture, framing and
      salience of information to incentivize routine screening.

      For this project the investigators will leverage our electronic health records (EHR) patient
      portals to improve CRC screening. Specifically, the investigators developed an electronic
      primer within the EHR patient portal to alert patients due for CRC screening before arrival
      of a mailed FIT Kit. The investigators randomized implementation of the primer at the
      patient-level to determine whether the electronic primer improved CRC screening completion in
      patients enrolled in our mailed FIT program.

      For our analysis, after summarizing our demographic data, the investigators plan to compare
      screening completion in the two study arms using an intention-to-treat analysis and t-tests.
      The investigators then plan a logistic regression and Cox proportional hazards model to
      compare time to screening utilization in the two study arms, controlling for age, sex, race,
      and ethnicity. Following this the investigators use Fisher's exact tests to compare
      completion of individual screening modalities in the two study arms. Lastly, the
      investigators plan a secondary, analysis to determine the impact of opening the portal
      message on screening utilization, using randomization arm as an instrumental variable. In
      this analysis the investigators compare the subset of patients in the intervention group that
      opened the portal primer message to the control group. P-values less than 0.05 are considered
      statistically significant.
    

Intervention name(s): MyChart Priming Message
Intervention type(s): Behavioral
Intervention description(s): In addition to the standard FIT mailer protocol, we will send randomized participants a message via their personal health portal. Patients receive the primer approximately 1-2 weeks prior to arrival of the FIT kit, which informed patients about the incoming FIT Kit and instructed patients to complete and return the kit promptly.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 3880 patients 51-75 years old, within the UCLA Health Managed Care group overdue for average risk CRC screening without prior history of documented FIT or colonoscopy will be randomized into 2 groups, in a 1:1 ratio. The 2 groups represent standard of care, and then the MyChart Message group
Masking: None (Open Label)
Primary purpose: Screening
Keywords: Colorectal Cancer Screening; Colon Cancer; Nudge; Behavior and Behavior Mechanisms; Behavioral Economics; Health Screening