Opt-In vs Opt-Out Patient Outreach Programs Yield Similar Mammography Completion Rates

Of the over 280,000 individuals who are enrolled in health plans offered by the Veterans Health Administration and are eligible for breast cancer screening, only 66% are up to date on screening. Patient outeach programs can help address barriers to screening.

Although automated opt-in and opt-out patient outreach programs for breast cancer screening (BCS) yielded similar rates of mammography completion, differences were observed in the number of canceled mammography referrals, according to a recent study.

The randomized controlled study, published in JAMA Internal Medicine, assessed the differences between the 2 outreach strategies within a single Veterans Affairs (VA) medical center to see which strategy was more effective at encouraging eligible patients to get up to date on their BCS.

Of the over 280,000 individuals who are enrolled in health plans offered by the Veterans Health Administration (VHA) and are eligible for BCS, only 66% are up to date on screening. Additionally, since the COVID-19 pandemic, screening rates have been persistently lower within the VHA compared with before the public health crisis. Many veterans face barriers to screening, including long wait times, scheduling challenges, and lack of on-site capabilities for mammography.

Population-based outreach for preventative care can help address barriers to BCS; however, current strategies can be time intensive and yield mixed results inside and outside of the VHA, suggesting that more research in identifying optimal strategies for population-based outreach for BCS is needed. Applying behavioral economics principles, such as the status quo bias, in population-based outreach can influence decision-making. Opt-out programs, where services are automatically provided unless declined, have proven effective in increasing vaccination and cancer screening rates compared with opt-in approaches. However, the effectiveness of opt-out vs opt-in approaches for BCS outreach in the VHA has not yet been assessed.

In the present analysis, female veterans aged 45 to 75 years who were due for BCS were identified using the VA Breast Care Registry. The participants were randomized 1:1 to receive either an automatic mammography referral (opt-out arm) or an automated telephone call with an option for mammography referral (opt-in arm). The primary outcome was completed mammography 100 days post outreach, and secondary outcomes were scheduled or completed mammography by the 100-day post outreach mark and referrals canceled if mammography was not scheduled within 90 days.

Of the 883 veterans due for screening (mean [SD] age, 59.13 [8.24] years), 442 were randomized to the opt-in group and 441 to the opt-out group. During the intention-to-treat analysis, no significant differences in the primary outcome were identified between the opt-out and opt-in groups (n = 67 [15.2%] vs 66 [14.9%], respectively; P = .90). There were also no significant differences in completed or scheduled mammography (n = 84 [19%] vs 106 [24%], respectively; P = .07).

However, the opt-out group experienced a higher number of referrals compared with the opt-in group (n = 104 [23.6%] vs 24 [5.4%], respectively; P < .001). The results from the restricted analysis revealed that more veterans in the opt-out group completed or scheduled a mammogram within 100 days compared with the opt-in group (n = 102 [26.3%] vs 80 [19.3%]; P = .02).

The study had some limitations, including an insufficient nursing staff time to complete medical reviews for veterans who did not select BCS in the opt-in group, which led to more individuals being excluded from the opt-out group than from the opt-in group in the restricted analysis. Additionally, The opt-out group did not receive a message preceding the scheduling call, which could have made the intervention more effective.

“The administrative burden of the opt-out approach, including medical record review of all veterans prior to outreach to confirm BCS eligibility, at least 1 telephone call to eligible veterans, and an increased number of canceled referrals following outreach, likely outweighs any potential added benefit…. The automated telephone outreach received by those in the opt-in group required little staffing or administrative burden,” the authors explained. "While our results did not indicate greater effectiveness of an opt-out strategy for BCS compared with an opt-in strategy, the comparable results for a less burdensome outreach approach may be valuable to VA operational leaders interested in a population-based BCS outreach.”

Reference

Marcotte LM, Deeds S, Wheat C, et al. Automated opt-out vs opt-in patient outreach strategies for breast cancer screening. JAMA Intern Med. Published online September 11, 2023. doi:10.1001/jamainternmed.2023.4321