Survey: How to Get Older Patients to Schedule Preventive ServicesMay 27, 2014 by Melissa McCormack
Preventive health is a big component of the shift in U.S. health care from quantity-based medicine to quality outcomes. Preventive services can help doctors head off expensive acute health emergencies among their patients, keeping patients healthier and saving the health system money in the process.
Preventive visits can also be a dependable source of revenue for a practice. Some physician practices receive reimbursement in excess of $375 for a single Annual Wellness Visit: a Medicare-introduced annual exam for older patients that often includes screenings, vaccinations and other preventive services. Additionally, some payers offer financial incentives to physicians for certain preventive services.
Yet according to the CDC, more than half of patients aged 65 and older are not up-to-date on the core set of clinical preventive services recommended by the U.S. Preventive Services Task Force. We surveyed U.S. patients age 55 and over to find out why that is, and what physicians can do to change it.
Many Patients Don’t Realize They’re Not Up-to-Date
The CDC’s latest data indicates that only 46 percent of men and 47 percent of women aged 65 and older are up-to-date on recommended preventive services. But limiting our sample to just patients aged 65 and older respondents, 56 percent of males and 68 percent of females indicated that they were up-to-date on all recommended services for someone of their age, gender and medical history—significantly higher rates than the CDC reports.
Recommended Preventive Services Status of Males Age 65+
Recommended Preventive Services Status of Females Age 65+
It’s worth noting that the CDC’s data also comes from patients self-reporting, in the annual, state-based Behavioral Risk Factor Surveillance survey. But their survey asks patients more granular questions—e.g., “When were you last screened for colon cancer?”—whereas our survey asked a more generic question (“Are you up-to-date on screenings?”).
So, why the discrepancy in results? I hypothesized that patients may be unaware of which screenings are recommended, and how often. Thus, when asked if they’re up-to-date, patients may answer yes; but when asked when their last flu vaccination was, their answer may reveal otherwise.
Dr. Leslie Kernisan, a geriatrician and clinical instructor at the University of California, San Francisco (UCSF), says her experience confirms there is often a lack of awareness among patients. She also suggests that many patients don’t remember precisely when they had their last screening, and thus may think they’re up-to-date when in fact they are not.
Most older patients, Dr. Kernisan says, are at least aware of which cancer screenings they need, but may have forgotten when they last had one performed. And when it comes to non-cancer-related preventive services, such as blood pressure testing and vaccination, patients are less aware of what’s recommended.
Patients Think Preventive Services Require Too Much Time
Among patients who acknowledge not being up-to-date on preventive services, nearly half give “not having enough time” as the reason.
Reasons for Falling Behind on Preventive Services
What can doctors do to get busy older patients to schedule preventive services? One solution is to conduct multiple screenings or services in one visit. Another suggestion Dr. Kernisan mentions is mailing a fecal immunochemical test (FIT) to patients’ homes for colon cancer screenings.
Kaiser Permanente recently reported on a study which found that such mail-in stool tests effectively boosted colon cancer screening rates by nearly 40 percent—an option that saves patients from a time-consuming trip to the doctor’s office. And, as Dr. Kernisan points out, if the test is negative, patients may be saved from an even more time-intensive, often uncomfortable and fairly invasive procedure (and the risks that accompany it): the colonoscopy.
Personal Reminders Would Bring Patients Into the Office
Most patients—77 percent—said they’d be likely to schedule an appointment for preventive services in response to a personal message from their doctor. This makes sense if we’re operating under the assumption that many patients either aren’t sure what’s recommended for them, or don’t remember when they last had a screening or test.
Likelihood of Scheduling Services in Response to Outreach
This puts the impetus on the practice to identify which patients need which screenings, and when. Fortunately, many electronic health record (EHR) systems offer alerts or reminders, or even allow a practice to run reports on a specific patient population (such as female patients between the ages of 50 and 75) to check screening status.
Dr. Jenn Brull relies on her EHR for such alerts: “We put a reminder in the EHR that automatically notifies me [if someone has not had the test],” she says on the HealthIT.gov website. With the help of her EHR and some ensuing proactive outreach, Dr. Brull was able to increase her patients’ colon cancer screening rates from a worrisome 37 percent to 81 percent.
Reach Out by Phone to Get Patients Scheduled
Patients are receptive to reminders for preventive services—but what types of reminders are met with the most success? Nearly half of patients surveyed (48 percent) indicated a phone call would be most effective at getting them to schedule preventive care—perhaps unsurprising, since older adults typically use email and text messaging less frequently than younger adults. Still, email was the second most popular option, with 26 percent of the vote.
Notably, despite being the common go-to of physicians’ offices (and a mode of communication most older patients are familiar with), direct mail such as a letter or postcard weighed in as the least effective method of outreach. Only 11 percent of respondents said direct mail would be their preferred reminder.
Preferred Method of Reminder Outreach
For best results, practices should consider calling patients directly, or in some cases sending an email. This decision could be made based on the type of screening and its urgency. For example, a practice may wish to email a patient who is due for a blood pressure screening in a month, but call a patient who is overdue for a cancer screening.
But whether sending an email or making a phone call, how should the outreach be structured? Dr. Kernisan has some suggestions.
“Generally, offering people fewer choices gets better results,” she says. “It’s called decision fatigue, and it’s very real.”
For example, if you reach out to a patient with a message such as: “Here are the three screenings you need, and here are five options for how you could go about each one; let us know what you want to do,” you’re unlikely to get much response.
Instead, when you remind your patients to schedule preventive care, start by focusing on the single most important screening, and offer an easy (and, ideally, cost-effective) choice for how to go about it. If patients don’t respond to that option, then you might present them with more choices. For example, in the case of colon cancer, start by offering the mail-in test. If a patient doesn’t complete that test, maybe it’s time for a discussion about a colonoscopy.
Patients Are Most Amenable to Colon Cancer Screening
So you want to proactively remind your patients about what services they need, but you don’t want to bombard them with a long list of options. Where do you start?
Our final survey question asked patients which preventive services they’d be most willing to schedule in response to a reminder from their doctor’s office. Nearly 40 percent of patients said that they’d respond most favorably to a reminder for a colonoscopy. This is likely due to the fact that colorectal cancer is the second leading cause of cancer death in the United States, according to the CDC, and it doesn’t discriminate between genders.
Nearly 30 percent said they’d be most responsive to a reminder to schedule an appointment related to testing their blood pressure. Around a quarter of patients said mammograms and prostate-specific antigen (PSA) testing would bring them into the office. Meanwhile, vaccinations had the least favorable response, with only 9 percent of patients indicating they’d be most willing to be immunized in response to a physician office reminder.
Screenings Patients Are Most Likely to Schedule
Here again, the free, mail-in colon cancer test presents a great solution for doctors—it resolves the time and money concerns of patients, and it addresses the type of screening patients are most willing to participate in.
Additionally, as virtual medicine becomes more widespread, patients will increasingly have options to measure vitals such as blood pressure from their own homes and transmit the data electronically to their doctors. For example, the Department of Veterans Affairs (VA) already has such programs in place, allowing older patients with chronic conditions to perform their own blood pressure screenings at home on devices that automatically send the results to the patient’s assigned medical professional.
Our survey found that patients may be unaware that they are not up-to-date with recommended preventive screenings. The good news is that patients are extremely receptive to reminders from their physicians to schedule preventive services. Such reminders should present patients with as few options as possible to increase the likelihood of a response. Patient outreach should also seek to allay patient concerns about spending time and money on screenings.
However, Dr. Kernisan points out an important consideration: while under-screening is problematic, over-screening can also introduce waste. For example, mammograms are no longer recommended annually; they’re now recommended once every two years, and in patients over 75, only when the patient is in good health and has at least 10 years’ life expectancy.
Just as patients may be unaware that they should be receiving a certain screening, Dr. Kernisan says many older patients may be unaware that they shouldn’t be. It’s up to doctors to stay abreast of recommendations and keep their patients informed about why they do or don’t need preventive services.