Monday, July 25, 2011

Usual Telephonic Outreach To Get Patients To Change Their Minds About Refusing Preventive Services Doesn't Work

Pick up the phone, will ya?
It's a no brainer, isn't it?  Patients who don't submit to being immunized, mammogramed, pap'd, colonscopied, blood-worked or pricked, poked or imaged by other inconvenient, uncomfortable and icky preventive tests only need to be "educated."  And once they are enlightened, the average person will stampede toward their recommended testings faster than legislators going to the White House for some serious budget scolding, right?

Not so fast.  Stephen Persell and colleagues at Northwestern University culled 407 patients with refusals for 520 recommended preventive services from a large internal medicine clinic in Chicago, Illinois.  In this particular practice, physicians were committed to promoting prevention among their patients and, what's more, they recorded when patients said "no."  Unless the physician refused permission or there was an active medical or psychosocial reason not to, a case manager telephoned (with up to three attempts) the 407 refusniks with some added "education," helped remove any potential barriers, arranged additional referrals if necessary and, if it would help, got the doctor re-involved.

And six months later, what happened?  19% of the patients were not called based on what was written in the medical record, 11% of the patients were not called based on physician feedback and only 11% of the patients answered the phone. Compared to a parallel control group of refusniks who were not called, there was no statistically significant improvement in the receipt of preventive services: 6.1% of intervention group cooperated versus 4.8% in the control group.  While the authors didn't mention it, caller ID probably helped patients to not answer the phone.

While the study may have been statistically hobbled by a low number of observations (making any conclusions about the lack of statistical significance less trustworthy) the authors concluded that one-on-one educational outreach may not sufficient to overcome patient refusals for preventive services.  The DMCB, based on its own professional experience agrees: tracking persons down outside the clinic can be difficult and if patients are willing to say "no" to their doctor, it's unlikely that they'll say "yes" to someone else.

This speaks to the possibility that in any population, there is going to be a percent that refuse preventive services and that there is little that physicians can ultimately do about it.  This has implications for the assumptions that underlie many quality reporting and provider pay-for performance programs.

This also has implications for the population health and disease management service providers.  While this study used a "nonclinician case manager" to provide the education, the DMCB has to wonder if the intervention was hobbled by not using state-of-the-art "engagement" strategies that are configured for behavior change that delivered by credentialed nurse health professionals.  If correct, it's possible that a commercial prevention program would have compared more favorably to the "usual care" telephonic outreach described by Northwestern. 

That's another research study for another day.

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