An Apple iPad application that allowed patients to self-order screening tests for colorectal cancer (CRC) increased the number of completed screenings compared to standard care, according to a study published in the Annals of Internal Medicine.
More than half of American adults own a tablet device, more than three quarters own a smartphone, and 95% own a cell phone (consistent across major sociodemographic groups). This creates new opportunities to develop digital health interventions.
The randomized clinical trial, led by David P Miller, Jr., MD, MS, from the Wake Forest School of Medicine in Winston-Salem, NC, examined the effect of an app that allowed patients to order their preferred screening test during a primary care visit.
To leverage patients’ familiarity with mobile devices, the investigators developed the app to address patient, provider, and system barriers. The intervention, called Mobile Patient Technology for Health-CRC (mPATH-CRC), informs patients of the need for screening, helps them make a decision regarding the type of test they prefer, and allows them to “self-order” a test. It also sends automated reminders.
The study was conducted in six community-based primary care practices affiliated with a large academic health system; three served urban and suburban patients and three served rural populations.
Patients due for CRC screening were contacted and invited to participate in the study prior to a scheduled visit to their primary care provider.
The participants were randomly assigned to either mPATH-CRC or a control group. A research assistant met with members of the mPATH-CRC group and launched the application on the iPad, handed it to the participant, and waited outside the door while they viewed an 8.6 minute information aid about CRC screening and the two most commonly used tests: fecal testing for blood and colonoscopy. The patients were then allowed to order their preferred screening test. A series of electronic messages was sent at specific times to help them complete the screening procedure.
The program for the control group included a 4.3-minute video about diet and exercise. They were not given the option to self-order screening tests or receive follow-up messages.
One day after the visit, a research assistant called all participants to determine if they had discussed CRC screening with their provider, as well as their satisfaction with decisions made. A final telephone survey was made 24 weeks later to determine if CRC screening had been ordered and completed.
The primary outcome was chart-verified completion of a CRC screening test within 24 weeks of enrollment.
Secondary outcomes were assessed for all participants. They included patient ability to state a screening preference and intention to receive screening as measured on the post-program iPad survey, participant discussions of CRC screening with their provider (from the next-day telephone survey), and screening tests ordered (from chart review).
Of the 450 patients enrolled, 223 were assigned to the mPATH-CRC group, and 227 were assigned to the control program. All participants completed the assigned iPad program, and almost all completed the 24-week follow-up (86% and 90% for mPATH-CRC and control, respectively).
The enrolled participants were racially and socioeconomically diverse: the median age was 57 years, 38% of participants self-identified as African American, 37% had limited health literacy, and more than half (53%) had annual household incomes less than $20,000. There was no statistically significant interaction between the intervention and health literacy, income, or race/ethnicity.
Results were generally consistent across clinics. Test ordering was higher in the mPATH-CRC group compared to the control group (69% vs 32%), and participants in the mPATH-CRC group were twice as likely as control participants to complete a screening test (30% vs 15%).
The investigators explained that the gap between the number of tests ordered and completed indicates that sending text messages or emails to help patients complete screening had a smaller effect than tools such as the informational decision aids.
The post-program survey revealed that 97% of mPATH-CRC participants could state a screening preference, compared with 71% of control participants. Patients in the mPATH-CRC group were more likely than controls to prefer fecal testing over colonoscopy (53% vs 28%).
The authors believed that two components of mPATH-CRC directly encourage screening orders: the decision aid, which increases patients' intention to receive screening, and the ability to self-order tests, which decreases barriers to order entry.
“In this randomized controlled trial, the mPATH-CRC digital health program doubled the proportion of patients who completed CRC screening, primarily because of an increase in test orders,” they concluded.
The authors acknowledge that the study had limitations. For most of the study, the clinics used an older, more complicated fecal test, and patient-level randomization could have resulted in higher screening rates in the control group. In addition, study participants agreed to arrive early to the appointment, which could have resulted in selection bias. The study was also limited to patients who spoke English.
To read more about this study, click here.