Stepped Reminders Boost Lung Cancer Screening Adherence

Key Takeaways

• Among patients in a primary care-led Kaiser Permanente Washington lung cancer screening program who had completed a normal index screen and were due back for annual screening, stepped reminders were associated with higher adherence.
• Health communication materials alone did not improve repeat screening completion.
• The improvement with stepped reminders was larger among participants currently using tobacco than among former users.

Annual low-dose computed tomography screening only works when patients return after a normal baseline examination, but repeat adherence remains a persistent gap. For patients already engaged in lung cancer screening, a practical question is whether education alone can change return behavior or whether a more active reminder pathway embedded in primary care workflow is needed.

Investigators conducted a pragmatic 2 × 2 factorial randomized clinical trial of health communication and stepped reminders for annual lung cancer screening at Kaiser Permanente Washington among patients who had completed lung cancer screening (LCS) with normal findings and remained eligible for annual screening. The trial randomized 1837 participants across four groups: usual care, 459; health communication, 460; Stepped Reminders, 460; and both interventions, 458.

Health communication used print and video messaging aimed at screening knowledge barriers, whereas Stepped Reminders pended LCS orders for primary care physicians (PCPs) and sent outreach prompting patients to schedule low-dose computed tomography (LDCT). A system-level LCS coordinator used an electronic health record registry to facilitate both interventions. The primary outcome was completion of screening LDCT or chest computed tomography (CT) 9 to 15 months after the index LDCT, analyzed with a modified intent-to-treat approach that allowed censoring for lung cancer diagnosis, death, early imaging, or health-plan disenrollment.

Repeat screening adherence was higher with Stepped Reminders than without them, at 75.5% versus 47.4%; relative risk 1.59; 95% CI 1.47-1.72; P<.001. Health communication showed the opposite pattern, with adherence of 59.2% versus 63.3%; relative risk 0.93; 95% CI 0.86-1.00; P=.04. The absolute improvement with Stepped Reminders was larger among participants currently using tobacco than among former users, with risk differences of 32.3 versus 24.1 percentage points and P for interaction=.03.

These results suggest that improving knowledge alone may be insufficient to increase repeat LCS participation within a primary care-led program. In this pragmatic randomized setting, appropriately timed reminders directed across patient, clinician, and system levels were associated with better annual return for screening after a normal examination.

Clinician Questions

Which patients were included in the trial of reminders for repeat lung cancer screening?

The trial enrolled patients at Kaiser Permanente Washington who had completed lung cancer screening with normal findings and remained eligible for annual screening within a primary care-led program.

What counted as adherence in the stepped-reminder lung cancer screening trial?

Adherence meant completion of screening low-dose computed tomography or chest computed tomography 9 to 15 months after the index low-dose computed tomography examination. The primary analysis was modified intent-to-treat and allowed censoring for lung cancer diagnosis, death, early imaging, or health-plan disenrollment.

How did the stepped-reminder intervention differ from health communication alone in repeat lung cancer screening?

Health communication used print and video messaging to address screening knowledge barriers, whereas Stepped Reminders combined pended scan orders for primary care physicians with outreach reminding patients to schedule scans. Both interventions were delivered through a system-level lung cancer screening coordinator using an electronic health record registry.