Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial

Am J Prev Med. 2010 Nov;39(5):472-8. doi: 10.1016/j.amepre.2010.07.016.


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.

Trial registration: ClinicalTrials.gov NCT01168323.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Early Detection of Cancer / methods
  • Early Detection of Cancer / standards*
  • Education, Medical, Continuing / methods*
  • Electronic Mail
  • Female
  • Guideline Adherence
  • Hospitals, Veterans
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • New England
  • Practice Guidelines as Topic
  • Primary Health Care / methods
  • Primary Health Care / standards*
  • Prostate-Specific Antigen / blood
  • Prostatic Neoplasms / blood
  • Prostatic Neoplasms / diagnosis*


  • Prostate-Specific Antigen

Associated data

  • ClinicalTrials.gov/NCT01168323