Health Communication and Stepped Reminders Interventions for Lung Cancer Screening: A Randomized Clinical Trial.

Importance: For more than 10 years, the US Preventive Services Task Force has recommended annual lung cancer screening (LCS), but adherence to annual screening remains low. Objective: To test 2 multilevel, patient-centered interventions to increase adherence to guideline-concordant annual LCS. Design, Setting, and Participants: A pragmatic 2 × 2 factorial randomized clinical trial was conducted at Kaiser Permanente Washington among patients who completed LCS with normal findings from November 21, 2022, to April 5, 2024. The date of last follow-up was July 4, 2025. Data were analyzed from July to December 2025. Interventions: The 4 arms included usual care, health communication, Stepped Reminders, or both interventions. The health communication intervention addressed patient screening knowledge barriers with print and video messaging. The Stepped Reminders intervention pended LCS scan orders for primary care physicians (PCPs) and sent outreach to patients to remind them to schedule scans. Both interventions were facilitated by a system-level LCS coordinator with electronic health record registry to deliver interventions. Main Outcomes and Measures: The primary outcome was completion of screening low-dose computed tomography (LDCT) or chest CT 9 to 15 months after index LDCT. All participants eligible for annual screening were included in the modified intent-to-treat analysis. Participants were censored due to lung cancer diagnosis, death, early LDCT or chest CT, or disenrollment from the health plan. Results: Among 1837 trial participants, the mean (SD) age was 66.3 (6.5) years; 897 (48.8%) were female and 940 (51.2%) were male; 17 (1.0%) were American Indian or Alaska Native, 47 (2.7%) were Asian, 55 (3.1%) were Black, 10 (0.6%) were Native Hawaiian or Other Pacific Islander, 1560 (88.7%) were White, 37 (2.1%) were multiracial, and 32 (1.8%) were another race; and 875 (47.6%) were currently using tobacco. A total of 459 were randomized to the usual care group, 460 to the health communication group, 460 to the Stepped Reminders group, and 458 to the both interventions group. Adherence to annual screening was 4.7 percentage points lower in those who received the health communication intervention relative to those who did not (59.2% [476 of 804] vs 63.3% [516 of 815]; relative risk, 0.93; 95% CI, 0.86-1.00; P = .04) and 27.7 percentage points higher in those who received the Stepped Reminders intervention relative to those who did not (75.5% [604 of 800] vs 47.4% [388 of 819]; relative risk, 1.59; 95% CI, 1.47-1.72; P < .001). The Stepped Reminders intervention improved screening rates significantly more among participants currently using tobacco (received Stepped Reminders, 281 [73.0%]; did not receive Stepped Reminders, 160 [41.2%]; risk difference, 32.3 percentage points; 95% CI, 25.9-38.8) compared with former users (received Stepped Reminders, 323 [77.8%]; did not receive Stepped Reminders, 228 [52.9%]; risk difference, 24.1 percentage points; 95% CI, 18.1-30.0) (P for interaction = .03). Conclusions and Relevance: In this randomized clinical trial, appropriately timed multilevel reminders directed to PCPs to order and patients to schedule LDCT scans were effective at improving annual LCS adherence in programs led by PCPs. Trial Registration: ClinicalTrials.gov Identifier: NCT05747443.