UCLA Health motivates more patients to take at-home colon cancer screening

UCLA Health is one of a growing number of health systems in the U.S. that sends at-home colon cancer screening tests to patients.

Patients mail a sample of their stool to the hospital using the fecal immunochemical test, or FIT, a kit sent to the patient’s home by their provider that includes the necessary instructions and supplies.

The test is used by health systems that want to boost the number of patients screened for colon cancer, which is the second-most common cause of cancer deaths in the U.S. The cancer is highly treatable if caught early and the U.S. Preventive Services Task Force recommends the screenings begin at age 50.

But a colonoscopy, the traditional screening method, isn’t appealing to patients. It requires patients to fast for 24 hours and take certain liquids to clear their bowels and then be sedated during the procedure. “From the patient perspective, people don’t like to do it—there is a preparation involved … it’s uncomfortable,” said Dr. Nasim Afsarmanesh, chief quality officer of medicine at UCLA Health in Los Angeles.

FIT tests are considered a more convenient alternative since they don’t require the patient to even visit a doctor’s office. The patient will only have to undergo a colonoscopy if the test results show abnormalities.

Despite the convenience, the response rate at UCLA for the at-home test was very low. To motivate more patients to complete the test, Afsarmanesh led an effort to redesign how the kits were presented to patients when delivered to their homes.

The health system attaches a letter with the FIT test that describes what it is, why the patient has received it and how it works. Afsarmanesh said the ini- tial letters weren’t engaging to patients. She described the letters as “wordy” and overly technical. “A lot of healthcare communication nowadays is provider-centered,” Afsarmanesh said. “We write and communicate what we think is educational, but that doesn’t translate well to patients on paper.”

Afsarmanesh partnered with two colleagues in UCLA’s management department to create more patient-friendly letters. The redesigned letters have large text and short sentences split into small paragraphs so patients can understand and read the message quickly. Pictures are used as well, like a clock to indicate the test only takes a few minutes to com- plete. The bold words “You have been selected to complete a colon cancer screening that could save your life” at the top of the letter help draw patients in. People are more likely to respond to a call to action if they are told they were selected specifically, said Suzanne Shu, an associate professor of marketing and behavioral decisionmaking who helped Afsarmanesh craft the new letter.

A deadline—two weeks—to return the test is included in the letter as well. “Putting a deadline, even though it isn’t strict, makes people feel like, ‘I better get this done right away,’” Shu said.

Afsarmanesh said she was inspired to rethink the patient letters while she was completing classes to get her MBA early last year.

“It dawned on me there are things that are very well-developed on the industry side that impact our behavior in our day-to-day lives, but we don’t use them to engage people to have better health habits,” she said.

To test the new design’s effectiveness, Afsarmanesh and her team sent a sample of the new letters and the old letters to 2,000 patients beginning in May 2017. UCLA patients who were due for a colon screening were randomly selected using the health system’s electronic health record and claims data.

The results showed that the redesigned letter motivated more patients to take the test at home and mail it back. Four weeks after the letters were sent, 15% of patients who received the new format responded, compared with 9% who received the old letter. A roughly 5 percentage point difference in response rate persisted for 26 weeks between the 1,000 patients who received the new letters and the 1,000 who received the old version.

“To actually be able to able to impact patient behavior is pretty significant,”

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Afsarmanesh said.