Methods:Using institutional endoscopy billing records and the practice's FOBT database, we identified 2788 eligible patients who appeared not to be up-to-date with CRC screening. We then performed a controlled trial of a mailed intervention in two waves. In both waves, intervention patients received a letter signed by the patient's physician encouraging CRC screening and instructions allowing the patient to directly schedule screening tests without a provider visit. In wave 1 (n=137), we also included a CRC screening decision aid. In wave 2 (n=194), patients were allowed to request the decision aid. Patients received reminder letters at 1 and 2 months if they did not respond. Controls from both waves received no contact. Outcomes were completion of any CRC screening test and estimated cost per additional patient screened. Screening test completion was determined by a chart and screening database review, completed by two independent reviewers. A preliminary review was done at two months, and a final review at six months. Cost per additional patient screened was measured by estimating costs for mailing, then dividing by the incremental yield of the intervention in terms of additional patients screened.

Results:Two months after the initial mailing, wave 1 showed a 5% difference in screening rates between the intervention and control groups. Wave 2 showed a 3% difference. Estimated cost per additional patient screened at two months was $189 for wave 1 and $46 for wave 2 (p<0.0001). The final chart review for wave 1, at six months, showed a net increase in screening rates between the groups of 11% (CI: 2%, 19%; p=0.02) and estimated cost per additional patient screened of $94. A final chart review for wave 2 will be completed at six months, and compared to wave 1.

Conclusions:Direct mailing of a CRC screening decision aid is an effective, and may be an efficient, method of increasing screening test completion. In this study, mass mailing a letter and direct contact information for screening tests, with the option of requesting the DA, appears to be a less costly method of increasing screening test completion than mailing the decision aid to all potentially eligible patients.