Stepped reminders lifted annual lung screening from 47% to 76%

Design

Pragmatic 2 x 2 factorial randomised clinical trial

Population

1,837 people with a normal low-dose CT screen at Kaiser Permanente Washington

Primary outcome

Screening CT completed 9 to 15 months after index scan

Effect

Stepped Reminders 75.5% vs 47.4%, RR 1.59 (95% CI 1.47 to 1.72); health communication 59.2% vs 63.3%, RR 0.93 (0.86 to 1.00)

This pragmatic 2 x 2 factorial randomised trial at Kaiser Permanente Washington enrolled 1,837 people (mean age 66.3 years; 47.6% current tobacco users) who had completed lung cancer screening with normal results. Arms were usual care, a health communication intervention (print and video messaging), Stepped Reminders, or both. Stepped Reminders pended the low-dose CT order for the primary care physician and sent outreach to the patient to schedule it. A system-level coordinator used an electronic registry.

The primary outcome was completing a screening or chest CT 9 to 15 months after the index scan. With Stepped Reminders, 75.5% (604 of 800) completed screening, against 47.4% (388 of 819) without: relative risk 1.59 (95% CI 1.47 to 1.72). The health communication intervention did slightly worse: 59.2% vs 63.3% (RR 0.93, 0.86 to 1.00; P=0.04).

Stepped Reminders worked better in current tobacco users (73.0% vs 41.2%) than in former users (77.8% vs 52.9%; P for interaction 0.03).

The trial was conducted in an integrated US health system with a registry and coordinator, so the result applies where such infrastructure exists. The outcome was completion of screening, not cancer detection or mortality.

• If you run a lung screening programme, pend the next annual scan order when the previous scan is read as normal.
• Add patient outreach to book the scan; the combination was what lifted completion.
• Printed and video education alone did not help and slightly reduced adherence.
• Keep a registry or recall list with a named coordinator.
• Current tobacco users gained the most, so prioritise outreach to them.

Why it matters

It shows that the barrier to annual screening is often logistics, not knowledge.

Don't overread it

The outcome was screening completion in one integrated US health system; the trial did not measure cancers found or deaths prevented.

The statistics, in plain English

A relative risk of 1.59 means screening completion was about 1.6 times as likely with reminders; the absolute gain was 28 percentage points, which is the number that matters to a service. The interval for communication (0.86 to 1.00) just touches 1.00, so its slight harm is uncertain.

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