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

Abstract

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.

Figure 1

Structure of the RCT

Figure 2

CONSORT flow chart of the RCT. All 95 participants were included in the intention-to-treat analysis.

Figure 3

Percentage scores on tests and spaced education cycles. Bars represent SE.

Figure 4

Impact of spaced education on inappropriate PSA screening. The percentages of inappropriate PSA screening during and after the spaced education intervention are represented by the gray and black triangles, respectively. The USPSTF released its recommendation statement in Week 82 of the trial. PSA, prostate-specific antigen; USPSTF, U.S. Preventive Services Task Force