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Opt-Out Framing and Incentives to Increase Liver Cancer Screening Rates

Doctor performing an abdominal ultrasound

Opt-Out Framing and Incentives to Increase Liver Cancer Screening Rates

Project status

Pilot/study with results


Kenneth Rothstein, MD 

Shivani Kastuar, MD 

Tessa Cook, MD 

David Goldberg, MD 


National Institute of Aging


Hepatocellular carcinoma (HCC) is a major cause of cancer death in the United States. Approximately 10,000 active patients are at risk for HCC at Penn Medicine at any given time. Such patients should be screened every six months with an abdominal ultrasound to catch this cancer at a treatable stage. Despite the benefits of screening, HCC surveillance rates are low. Applying strategies from behavioral economics may increase ultrasound completion. 


We ran a randomized controlled trial to test whether opt-out framing with or without a financial incentive could increase the ultrasound completion rate among eligible patients. Adults with cirrhosis or advanced fibrosis who were overdue for screening were eligible, and 562 participated in the trial.  

The study had two intervention arms and a control arm. To the first group, we mailed an order slip for an abdominal ultrasound along with a letter that described the importance of HCC surveillance, explained that an ultrasound order had already been placed for them, and provided instructions to schedule a screening. Patients in the second intervention group received the mailed letter and order slip plus an unconditional $20 incentive. Patients in the “usual care” arm did not receive any study-related outreach. 


The order and mailed letter – with or without the $20 – doubled ultrasound completion, with rates at 54 percent for the interventions versus 28 percent for usual care after six months. Abnormal results were found in nearly 5 percent of patients who had imaging done within this timeframe, and 1 percent of all patients screened were diagnosed with HCC and referred for treatment. 

The study results show that direct outreach with opt-out framing effectively increased the HCC surveillance rate. A handful of patients in the intervention groups received an HCC diagnosis that otherwise might not have been caught until the cancer had progressed further. Preordering also reduced the effort required by patients, who must typically complete an office visit to obtain an order slip, and by clinicians, who typically sign orders individually. The financial incentive did not improve screening rates, perhaps because the amount was too small or because it was offered regardless of ultrasound completion. 

The trial participants included high percentages of Black and Medicaid-insured patients, groups who typically experience disparities and worse outcomes for liver disease. Notably, the interventions were effective across sociodemographic groups.