Timed EHR Reminders to Physicians and Patients Raise Annual Lung Cancer Screening Adherence by 28 Percentage Points

The mortality benefit of annual low-dose CT lung cancer screening requires patients to actually come back every year. The USPSTF recommends annual LDCT for adults aged 50–80 with a 20+ pack-year smoking history who currently smoke or quit within the past 15 years — and the evidence that screening saves lives when done annually is robust. But there are two separate failure modes in screening programs: the first is that too few eligible patients get screened at all; the second is that patients who have been screened once fail to return annually. This trial addresses the second problem. National real-world adherence to repeat LDCT screening ranges from just 22% to 50% across health systems — far below the rates sustained in the landmark trials that established screening's mortality benefit.[1, 2]

The JAMA Internal Medicine RCT enrolled 1,837 patients at Kaiser Permanente Washington who had previously completed LDCT screening with normal or benign findings and were due for their next annual scan. Enrolled from November 2022 through April 2024, participants were randomized to one of four conditions: (1) health communication alone — educational portal messages, videos, and mailed letters about why annual screening matters and when to return; (2) Stepped Reminders alone — an EHR system that pended a lung cancer screening scan order for each patient's primary care physician four weeks before that patient's annual due date, combined with direct outreach to the patient to schedule the scan; (3) both interventions combined; or (4) neither. The primary outcome was LDCT or chest CT completion within 9–15 months of the prior scan.[1]

Stepped Reminders increased annual screening completion by 27.7 percentage points: 75.5% of patients who received the reminder-based intervention completed their annual scan, compared with 47.4% who did not (RR 1.59; p < 0.001). Health communication alone showed no benefit — patients who received educational messaging were slightly less likely to complete screening than those who received nothing (59.2% versus 63.3%; p = 0.04). The benefit of Stepped Reminders was larger for current tobacco users (73.0% versus 41.2%; +32.3 percentage points) than for former smokers (77.8% versus 52.9%; +24.1 percentage points), suggesting the intervention is particularly valuable for the highest-risk patients who most struggle with follow-through.[1]

Clinical Context

The mortality benefit of annual LDCT lung cancer screening in high-risk current and former smokers is established at the highest level of evidence. The National Lung Screening Trial (NLST, NEJM 2011) randomized 53,454 participants and found a 20% relative reduction in lung cancer mortality with LDCT versus chest X-ray over approximately 6.5 years of follow-up.[2] The NELSON trial (NEJM 2020), a European volume-doubling-time-based protocol study with 15,789 participants, confirmed a 24% mortality reduction in men and a larger reduction in women. These mortality benefits depend on sustained annual screening — a follow-through rate that most health systems have consistently failed to achieve.[4]

Real-world adherence to repeat LDCT has been poor. National annual completion rates among patients due for repeat screening have remained between 22% and 50%, well below the trial protocols that produced the mortality benefit. The barriers are structural: patients forget or deprioritize the annual scan, primary care physicians lack systems to proactively identify and prompt rescreening, and the scheduling infrastructure to act on a screening due date often doesn't exist. Prior quality improvement work has shown that mailed reminders and patient outreach can improve referral rates, but high-quality RCT evidence with hard imaging completion as the primary endpoint has been limited — until this trial.[3]

Why It Matters Clinically

The practical implication is clear. A screening program that relies on patients self-scheduling their annual follow-up — or on the annual visit as the only trigger for a rescreening order — will leave roughly half its patients unscreened each year. The trial demonstrates that the infrastructure fix is operational, not educational: the intervention that moved the needle was an automated EHR action directed at the physician's workflow, paired with a direct scheduling call to the patient. Telling patients why screening is important, without making it easy to schedule, doesn't work.[1, 3]

Limitations

The trial was conducted at a single integrated health system (Kaiser Permanente Washington) with strong EHR infrastructure and a high baseline capacity for systematic outreach — results may be harder to replicate in fragmented care settings. The study population consisted of patients who had already completed at least one screening scan with normal or benign results; adherence dynamics may differ in patients due for follow-up of indeterminate nodules, or in newly eligible patients who have never been screened. Health communication alone having a modest negative effect on adherence was unexpected and warrants further investigation. Long-term cancer detection and mortality benefit from improved adherence was not measured in this trial.