Forcing patients to “opt out” of mammography screening does not impact adherence rates, according to the results of a randomized clinical trial published Monday in JAMA Internal Medicine.
Veterans Affairs recently tested this practice change at one of its medical centers, with only about 66% of its patient population up to date on breast cancer screening. Researchers assigned study subjects at a 1:1 ratio, with half automatically mammography referred for imaging while the rest received an automated phone call offering the option of undergoing screening.
Leah M. Marcotte, MD, and colleagues found no significant difference in completed mammography rates at 100 days between the two groups. In fact, a greater number of patients canceled their appointments in the opt-out group (23.6%) compared to the opt-in cohort (5.4%), researchers noted.
“The administrative burden of the opt-out approach—including medical record review of all veterans prior to outreach to confirm [breast cancer screening] eligibility, at least one telephone call to eligible veterans, and an increased number of canceled referrals following outreach—likely outweighs any potential added benefit,” Marcotte, with the Department of Medicine at the University of Washington, Seattle, and co-authors advised. “Notably, following the study, primary care leadership at [VA Puget Sound Health Care System] reported that the opt-out strategy was not sustainable with current staffing.”
Researchers conducted the trial from April 2022 to January, targeting female veterans ages 45 to 75. A total of 883 individuals participated in the trial, at an average age of 59, with 441 assigned to the opt-out group. For the opt-in cohort, veterans received an automated, interactive call offering three options: receive a mammography referral, discuss screening with a primary care physician, or decline imaging. Meanwhile for the opt-out group, a nurse reviewed the individual’s record, placed a referral, and then the individual was contacted by a human caller to schedule their exam.
Between the two study populations, 15.2% of those in the opt-out group completed their screening compared to 14.9% among those who had to opt in. About 19% either completed or scheduled their appointment in the opt-out group compared to 24% in the second cohort.
In a corresponding editorial [2], experts speculated on why the opt-out approach failed to make a dent. For one, the two approaches were handled differently, with the opt-in automated call functioning as a “nudge” to encourage adherence while the opt-out approach required more legwork and a human phone call.
“Even a comparably designed opt-out intervention is vulnerable to the amount of effort that exists on the behavioral pathway,” Kimberly J. Waddell, PhD, and Shivan J. Mehta, MD, MBA, both with the University of Pennsylvania, wrote Sept. 11. “The study location did not offer on-site mammogram screening and had to coordinate scheduling with non-VA healthcare facilities. One can imagine that scheduling and completing a mammogram in a different health system creates additional steps on the behavioral pathway that can hinder mammogram completion.”
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Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.