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Curr Oncol. 2019 Jun;26(3):205-216. doi: 10.3747/co.26.4829. Epub 2019 Jun 1.

Testing e-mail content to encourage physicians to access an audit and feedback tool: a factorial randomized experiment.

Author information

Quebec: Office of Education and Professional Development, Faculty of Medicine, Laval University (Vaisson, Witteman, Chipenda-Dansokho), Research Centre of the CHU de Québec, Laval University (Vaisson, Witteman), Department of Family and Emergency Medicine, Laval University (Witteman), and Laval University Primary Care Research Centre, Laval University, Quebec City (Witteman).
Ontario: Family Practice Health Centre, Women's College Hospital, Toronto (Saragosa, Desveaux, Ivers); Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto (Saragosa, Bouck, Desveaux, Ivers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bouck); Prevention and Cancer Control, Cancer Care Ontario, Toronto (Bravo, Llovet, Umar, Tinmouth); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Llovet); Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa (Presseau, Taljaard, Grimshaw); School of Epidemiology and Public Health, University of Ottawa, Ottawa (Presseau, Taljaard); School of Psychology, University of Ottawa, Ottawa (Presseau); Department of Medicine, University of Ottawa, Ottawa (Grimshaw); Institute for Clinical Evaluative Sciences, Toronto (Tinmouth); Department of Medicine, University of Toronto, Toronto (Tinmouth); and Department of Family and Community Medicine, University of Toronto, Toronto (Ivers).



In Ontario, an online audit and feedback tool that provides primary care physicians with detailed information about patients who are overdue for cancer screening is underused. In the present study, we aimed to examine the effect of messages operationalizing 3 behaviour change techniques on access to the audit and feedback tool and on cancer screening rates.


During May-September 2017, a pragmatic 2×2×2 factorial experiment tested 3 behaviour change techniques: anticipated regret, material incentive, and problem-solving. Outcomes were assessed using routinely collected administrative data. A qualitative process evaluation explored how and why the e-mail messages did or did not support Screening Activity Report access.


Of 5449 primary care physicians randomly allocated to 1 of 8 e-mail messages, fewer than half opened the messages and fewer than 1 in 10 clicked through the messages. Messages with problem-solving content were associated with a 12.9% relative reduction in access to the tool (risk ratio: 0.871; 95% confidence interval: 0.791 to 0.958; p = 0.005), but a 0.3% increase in cervical cancer screening (rate ratio: 1.003; 95% confidence interval: 1.001 to 1.006; p = 0.003). If true, that association would represent 7568 more patients being screened. No other significant effects were observed.


For audit and feedback to work, recipients must engage with the data; for e-mail messages to prompt activity, recipients must open and review the message content. This large factorial experiment demonstrated that small changes in the content of such e-mail messages might influence clinical behaviour. Future research should focus on strategies to make cancer screening more user-centred.


Cancer screening; audit and feedback; behaviour change techniques; e-mail; factorial experiments; persuasive communication; primary health care; process evaluations

Conflict of interest statement

CONFLICT OF INTEREST DISCLOSURES We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare the following interests: During the course of the project, authors CAB, DL, SU, and JT were employed at Cancer Care Ontario. The remaining authors have no conflicts to disclose.

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