An automated system that reminds both physicians and patients when follow-up colonoscopies are due nearly doubled the rate of completed exams, compared with standard care, Dr. Daniel A. Leffler and his colleagues reported in the April issue of Gastroenterology.
Although there are some up-front costs associated with adoption of the follow-up system, once it is running, it "can function with little additional burden to the physician or administrative staff," said Dr. Leffler of Beth Israel Deaconess Medical Center, Boston, and his associates.
Dr. Daniel A. Leffler
Recommended follow-up colonoscopies often are neglected, which can seriously compromise patient care. "Many practices and institutions currently have systems in place to ensure and document that test results, such as pathology findings after a polypectomy, are communicated to patients. Few institutions or practices, however, have implemented systems to monitor and improve compliance with suggested follow-up" colonoscopies, they noted.
The lack of such a reminder system also raises the risk of malpractice litigation. "Data from a large malpractice carrier show that colorectal cancer is the second most common type of cancer cited as a "missed diagnosis" in malpractice claims, and that many of these claims were related to the lack of adequate follow-up and documentation systems," the researchers said.
Dr. Leffler and his colleagues developed such a reminder system and incorporated it into the electronic medical record system at Beth Israel’s gastroenterology referral center, which performs approximately 10,000 screening colonoscopies per year. They then tested its effectiveness as compared with usual practice in a randomized clinical trial.
When the online pathology report from the index colonoscopy is filed, the system prompts physicians to order follow-up colonoscopies and to list the indication and the recommended time interval. This order also can be made or modified immediately after the initial procedure or at an office visit.
At 4 months before the due date for the follow-up exam, the system queries the patient’s records to see whether the procedure has been done or has at least been scheduled. If not, it notifies the primary care physician that the patient is due for repeat colonoscopy, so that the physician can modify or cancel that order, if necessary.
At 3 months before the due date, if the order has not been changed, the system sends the patient a standard reminder letter. If no colonoscopy is scheduled or completed, a second reminder letter is sent 1 month before the due date.
Finally, if the due date passes, no procedure has been scheduled or completed, and the patient has not responded to the reminder letters, the system alerts the administrative staff to call the patient. Every step of this procedure is documented in the patient’s medical record.
To test this system, the investigators reviewed patient records and identified 830 who had undergone an index colonoscopy 5 years earlier and were now due for a follow-up procedure.
The patients were randomly assigned to usual care (291 control subjects) or to the automated reminder system (539 intervention subjects). The primary end point was the percentage of patients who scheduled or underwent follow-up colonoscopy within 6 months of the recommended due date.
A total of 45% of the patients in the reminder group scheduled follow-up colonoscopy, compared with only 23% of those in the control group. Similarly, 34% of those in the reminder group underwent follow-up colonoscopy, compared with 18% of the control group, the investigators said.
After the conclusion of the study, patients in the control group who had not scheduled or completed follow-up colonoscopy were contacted to do so. A total of 58% said they were unaware that they were due for the procedure.
A random sample of 182 patients from the intervention group was asked to complete a survey of patient satisfaction, and 46 did so. "In general, patients reported that they found the system helpful [and] that letters were the preferred method of contact, and many reported not being aware that they were due for colonoscopy prior to receiving the reminder. No privacy concerns were noted by patients," Dr. Leffler and his associates said.
It was "notable" that nonwhite patients, who often receive lower-quality care, were even more likely than white patients to respond to the reminder intervention. The racial distribution was the same between the two study groups, but 44% of nonwhite patients in the intervention group scheduled follow-up colonoscopies, compared with only 8% of the nonwhite patients in the usual-care group. Thus, this intervention could improve the racial disparity in health care, the authors added.
Primary funding for the study was provided by CRICO–Risk Management Foundation. The authors declared no conflicts of interest.