Opportunity 

Penn Medicine screens thousands of patients for cancer across numerous hospitals and outpatient sites in Pennsylvania and New Jersey each year. Routine cancer screenings such as colonoscopies and mammograms are crucial for long-term health as they can help detect cancer early so that it can be treated effectively.  

At the onset of the COVID-19 pandemic, elective medical procedures, including cancer screenings, were put on hold to reduce the risk of COVID-19 spread in health care settings. Unfortunately, when restrictions were lifted, and elective procedures were reintroduced, screening rates for colonoscopies and mammograms did not return to pre-COVID levels. 

Despite extensive efforts to call patients whose appointments were canceled during the shutdown and those newly due for screening, appointment slots were not booking up. Additionally, clinic staff noted that Black and Medicaid patients were less likely to reschedule. 

Intervention  

To increase colonoscopy and mammography screening rates amid the pandemic, we had to find a way to make patients feel comfortable returning for in-person care. It was also imperative that we reduced the burden on clinical staff as new pre-procedure COVID-19 testing protocols, increased scheduling duties, and space constraints for social distancing were making it difficult to maintain operational efficiency. We ran a series of pilots to explore what might move the needle. 

We tested different modes of outreach, including text messaging, email, and mail, and experimented with various framing strategies. For example, some messages affirmed the rationality of patient decisions to delay and defer care during the shutdown, while others positioned information about increased safety protocols in the forefront. 

We also tested new workflows. For example, we leveraged bulk ordering and automated text-based outreach to enable patients to easily self-schedule mammography appointments. Similarly, we tried automating the first portion of the scheduling call for colonoscopy patients, allowing them to share their medical history via text message so that schedulers only had to jump in to finish the process for “qualified leads” via phone call. 

Impact  

Bulk ordering and self-scheduling doubled the rate of mammography appointments scheduled. And the automated text outreach and streamlined scheduling process for colonoscopy procedures resulted in time savings that would enable the existing clinic staff to schedule an additional 2,000 appointments per year. 

Both interventions improved patient experience by reducing frustrating phone tag scenarios and decreasing time on hold. We also observed that there was higher participation across age and race when we leveraged more accessible and asynchronous channels like text or email. For example, we saw a drop in the screening disparities between Black and White patients in the colonoscopy pilot. Outcomes like this indicate that particular modes of outreach can reduce disparities in cancer screening.

Based on these pilot results, the clinical team we worked with is partnering with Penn Medicine Information Services to develop a pre-screening questionnaire that can be sent electronically to patients and allow call center staff to identify patients ready for scheduling and minimize the amount of time on the phone.

The bulk ordering and text messaging interventions were subsequently tested among patients eligible for breast cancer screening in pragmatic randomized clinical trials. As a result of this body of work, the Centralized Mammogram Outreach program is now implemented widely across Penn Medicine Primary Care.