Millions of cancer screenings were missed during the COVID-19 pandemic. And, even with the gradual return to pre-pandemic levels of screenings, those that were postponed still haven't been made up, according to the Centers for Disease Control and Prevention (CDC).
In particular, there have been significant declines in screenings for six major cancers: colorectal, female breast, lung, pancreas, prostate and thyroid. Delays in screenings can subsequently delay a diagnosis or treatment. At the same time, guidelines for recommended screenings are continually evolving, sometimes unbeknownst to patients and even some clinicians.
Cancer is the second leading cause of death in the U.S. Providers, who are concerned that cancer rates are increasing in younger people, are testing out strategies to get more patients into preventive screenings. Among them is leaning on companies specializing in patient engagement—effectively nudging patients to be proactive about their care.
The global patient engagement technology market is expected to grow considerably over the next decade. Here is how providers are tapping that resource to improve cancer screening rates.
Patient prompts with results
Illinois-based OSF HealthCare worked with patient engagement company Upfront Healthcare to educate and motivate more patients to get screenings. Upfront is known for its multipronged approach to delivering personalized, omnichannel communication. This enables the company to be flexible when determining the best modality, language and imagery for a particular patient, Upfront argues.
There are five key barriers and solutions to patient outreach, according to Lindsay Zimmerman, Ph.D., vice president of patient engagement and activation at Upfront. They are:
- Technological: Make the experience frictionless when possible.
- Cultural: Provide multilingual guidance and imagery that’s inclusive.
- Psychological: Tailor to core motivations and address fears.
- Social: Collect social needs data through screenings; connect patients to resources.
- Health literacy: Highlight the importance of a screening in plain language.
It was through this lens that Upfront designed a strategy to reach OSF’s Medicaid population in 2020, leveraging a Medicaid-focused grant. Together, they conducted a study of more than 4,000 women split into two groups: those on Medicaid with identified social determinants of health and those economically advantaged with commercial insurance. All women were 41 years or older and appeared to be overdue for their mammogram.
“It’s a moment when we want to make sure they’re being proactive about their care,” Zimmerman told Fierce Healthcare.
An analysis of the screening rates between the two groups revealed a disparity: The Medicaid cohort had a 2.6% lower breast cancer screening rate than the commercial insurance cohort.
Among the interventions offered to the Medicaid group were personalized text reminders, digital voice calls from community health workers or an invite to a health fair offering on-site mammograms. Upfront also offered microsites to educate patients about the value of preventive screenings with embedded appointment scheduling capabilities. A subset of commercially insured women was randomized to receive no intervention.
By the end of the study, the partners saw the rate of screening more than double for the Medicaid group. In fact, the interventions effectively reversed the disparity in screening rates, with the Medicaid patients screening at a rate 3.7% higher than those in the commercial group who had received no intervention.
“We are focused on driving the end outcome for the patient, so not just ‘did we send communication to help patients get their mammogram,’ but in the end, did the patient get the mammogram?” Zimmerman said.
Soon after, OSF expanded its work with Upfront to the general patient population with open care gaps for breast cancer screenings, rolling it out to an additional 41,500 patients. In 2021, the first year of the larger program, the screening scheduling rate more than doubled to 48%. It has since remained elevated in subsequent years, hovering around 65% in 2022 and 2023. The figures account for a period within 30 days of outreach.
Proactive outreach for a progressive disease like cancer is particularly important, according to Hilary Hatch, Ph.D., chief clinical officer at Phreesia. The company's technology automates and manages patient intake, and it focuses on what it calls patient activation. When patients are activated, the company said, they are more likely to ask questions, practice healthy behaviors and follow their provider’s instructions.
As science has become more advanced, so have treatments and the benefits of early action. “To diagnose someone early didn’t have that incredible value that it has today,” Hatch told Fierce Healthcare.
Phreesia's platform, used by more than 3,600 organizations, can streamline clinical intake and administer screening tools. Its offering for oncology, described on its website, features pre-visit instructions via text, measures how activated a patient is and delivers targeted messages intended to drive follow-up visits and promote supportive care services.
The company recently released data analyzing the reach of some of its engagement efforts. During a breast cancer awareness campaign that reached 268,000 patients in 10 days, more than 80% of patients said the information they saw about the disease and screenings was helpful.
Nonwhite patients were also more likely to consider the content helpful than their white counterparts. This suggests the campaign’s benefit in closing awareness gaps, per Hatch, though it is hard to interpret the findings with certainty.
“The first thing I think is that we’re just closing a racial disparity in awareness on a key topic. We’re getting people that actually haven’t seen this message multiple times or heard from their clinician multiple times,” Hatch said.
One health system asked more than 87,000 patients about mammogram screenings at intake through Phreesia, after which a third requested a mammogram appointment, according to the tech company. Separately, a health system that asked nearly 5,000 women about their cervical cancer screenings during intake found a third said they would discuss their screening options with their provider, Phreesia said.
Meanwhile, surveyed patients between 50 and 80 years old with a history of smoking at intake were 234% more likely to get screened for lung cancer after seeing the campaign when compared to those who didn’t.
In 2021, the recommended age for colorectal screening dropped by five years. In an outreach campaign focused on colorectal cancer screenings by Phreesia, 40% of responding patients identified risk factors that placed them in the “high risk” category for the disease. That helped indicate a need for timely screening and also suggested that risk factors may go uncaptured at appointments.
“Our systems for tracking these things for people are just not as sophisticated and simple as we wish they were,” Hatch said. “There’s a lot of opportunity there to tighten all that up and have people really know where they are.”
"An ongoing strategy"
Patient engagement cannot be one-off program, per Zimmerman. It may also require keeping humans in the loop. “It has to really be embedded in the fabric of the organization,” she said. “You also need to have, potentially, humans to help augment the digital outreach.”
Over the past several years, there has been a growing recognition of disparities and the need to address them in healthcare. Quality measures are one way organizations are increasingly expected to evaluate their data to identify care gaps, Hatch said. There might be a lag between when a screening guideline is changed and when new patients start getting screened, for example.
“The devil is in the details in getting that message out to patients,” Hatch said. “It’s a constant battle to keep people up to guidelines.”
Brandi Clark, VP of digital care at OSF, agrees. “I don’t think it’s ever done,” she said. “This is an ongoing strategy and a different way to outreach to patients that we find to be much more effective than some of those traditional means.”
As part of a larger effort to rebuild trust in science and public health, CDC Director Mandy Cohen, M.D., recently emphasized the need to partner with providers “because people trust their own doctor,” Hatch said. The vast majority of Americans trust their doctor, compared to 66% of Americans who trust the CDC.
“Getting a prompt as you walk into your own trusted doctor and then having a chance to discuss it … is a simple way to massively improve screening rates,” Hatch noted.
However, she cautioned, that can’t come at the expense of already overworked physicians. “It’s kind of like a heroic effort, but that’s the thing I think we can simplify,” Hatch said.