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Durable Improvements in Prostate Cancer Screening from Online Spaced Education

A Randomized Controlled Trial
  • B. Price Kerfoot
    Correspondence
    Address correspondence to: B. Price Kerfoot, MD, EdM, V.A. Boston Healthcare System, 150 South Huntington Avenue, 151DIA, Jamaica Plain MA 02130
    Affiliations
    Veterans Affairs Boston Healthcare System, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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  • Elizabeth V. Lawler
    Affiliations
    Veterans Affairs Boston Healthcare System, Boston, Massachusetts

    Harvard School of Public Health, Boston, Massachusetts

    Pharmacoepidemiology Research Group, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, Massachusetts

    Brigham and Women's Hospital, Boston, Massachusetts
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  • Galina Sokolovskaya
    Affiliations
    Veterans Affairs Boston Healthcare System, Boston, Massachusetts

    Pharmacoepidemiology Research Group, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, Massachusetts
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  • David Gagnon
    Affiliations
    Veterans Affairs Boston Healthcare System, Boston, Massachusetts

    Pharmacoepidemiology Research Group, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, Massachusetts

    Boston University School of Public Health, Boston, Massachusetts
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  • Paul R. Conlin
    Affiliations
    Veterans Affairs Boston Healthcare System, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts

    Brigham and Women's Hospital, Boston, Massachusetts
    Search for articles by this author

      Context

      Prostate cancer screening with prostate-specific antigen (PSA) is frequently performed, counter to clinical practice guidelines.

      Background

      It was hypothesized that an e-mail–based intervention termed “spaced education” could reduce clinicians' inappropriate screening for prostate cancer.

      Design

      The study was conducted as an RCT.

      Setting/participants

      The study involved 95 primary care clinicians in eight Veterans Affairs medical centers from January 2007 to February 2009.

      Intervention

      Participants were randomized into two cohorts: spaced education clinicians received four isomorphic cycles of nine e-mails over 36 weeks (zero to two e-mails per week), whereas control clinicians received no intervention. Each e-mail presented a clinical scenario and asked whether it was appropriate to obtain a PSA test. Participants received immediate feedback after submitting their answers.

      Main outcome measures

      The primary outcome was the number and percentage of inappropriate PSA screening tests ordered. Inappropriate testing was defined as use of PSA for prostate cancer screening in patients aged >76 or <40 years. Appropriateness of screening was dichotomized based on patient age at time of screening. Patients with PSA testing for non-screening reasons were excluded using a validated protocol. Logistic regression with adjustment for patient clustering by clinician was performed. Analyses were conducted in 2009.

      Results

      During the intervention period (Weeks 1–36), clinicians receiving spaced education e-mails ordered significantly fewer inappropriate PSA screening tests than control clinicians (10.5% vs 14.2%, p=0.041). Over the 72-week period following the intervention (Weeks 37–108), spaced education clinicians continued to order fewer inappropriate tests compared to controls (7.8% vs 13.1%, respectively, p=0.011), representing a 40% relative reduction in inappropriate screening.

      Conclusions

      Spaced education durably improves the prostate cancer screening behaviors of clinicians and represents a promising new methodology to improve patient care across healthcare systems.
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