Use of patient reminder letters to promote cancer screening services in women: A population-based study in Wisconsin.

BACKGROUND: Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking. METHODS: Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year. RESULTS: Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively. CONCLUSIONS: Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.     

Delivery of preventive health services for breast cancer control: a longitudinal view of a randomized controlled trial

OBJECTIVE: To develop a longitudinal model to characterize the delivery of mammography services using repeated observations of mammography referral rates during a randomized controlled trial (RCT) of physician mammography reminders. DATA SOURCES/STUDY SETTING: Administrative records of a health department and observational data on mammography appointment scheduling. STUDY DESIGN: The design was a longitudinal study of month-specific referral rates during a 1-year RCT. A retrospective case-control study was used to investigate differences between women with timely and delayed (or absent) mammography referral assessed at the end of the intervention year. DATA COLLECTION/EXTRACTION METHODS: Month-specific indicators for referrals and missed clinical opportunities, that is, months when clinic visitors were due for a mammogram and not referred, were constructed using administrative and observational data. FINDINGS: In the unadjusted analysis, the effectiveness of the reminder declined over time. However, in a multivariate analysis that controlled for the number of missed opportunities, the effectiveness was constant over time. On a monthly basis, physician reminders were significantly associated with higher referral rates among clinic visitors newly due for mammography (adjusted OR = 2.8, 95 percent CI = 1.3, 5.8) or who had one previously missed clinical opportunity (adjusted OR = 3.0, 95 percent CI = 1.6, 5.3) but were not for those with two or more missed clinical opportunities (adjusted OR = 1.2, 95 percent CI = 0.7, 2.3). Factors independently associated with delayed referral were age over 65, presence of more than one chronic illness, and the absence of a physician mammography reminder. CONCLUSIONS: Longitudinal models that examine rates of referral over time and include information about outcomes on previous visits can enhance our understanding of how intervention strategies work in practice.     

Predictors of early rescreening in the National Cervical Screening Program, Australia

OBJECTIVE: To identify variables that predict early rescreening after a negative Pap smear report. METHODS: Cohort study using the records of a statewide Cervical Cytology Registry in Victoria, Australia. The cohort comprised 31,082 women who had a negative Pap smear report during the first half of 1996 and who were rescreened within the subsequent 36 months. Early rescreening was defined as a further Pap smear within 21 months. RESULTS: The strongest predictor of early rescreening was a recommendation at the time of issuing the negative Pap smear report by the laboratory for retesting before two years (adjusted odds ratio = 3.81, 95% confidence interval (CI) 3.58-4.05). Mention of reactive or inflammatory change as part of the negative Pap smear report was also a powerful predictor (adjusted odds ratio = 1.67, 95% CI 1.50-1.85). Significant predictors associated with the women were young age, high socio-economic status and residence in the capital city. Significant predictors associated with the practitioner were if either the index or subsequent smear was collected by an obstetrician/ gynaecologist or a hospital-based clinic, or if the practitioner collecting the index smear was a female. The population-attributable risk per cent associated with the laboratory recommendation was 27%. CONCLUSIONS: This data suggests that a multifaceted strategy targeting pathology laboratories, practitioners and women may be needed to reduce early rescreening. IMPLICATIONS: Early rescreening is wasteful of health resources. New screening programs should be designed to avoid this problem.     

Relationship between Pap smear performance and physician ordering a mammogram.

BACKGROUND. Although Pap smear screening for cervical cancer in general has been successfully implemented, mammography screening for breast cancer remains relatively underused. Patients having one screening test are more likely to have other screening tests performed. The objective of this study was to determine whether visits by women for Pap smears serve as opportunities for physicians to order a screening mammogram. METHODS. A matched case-control design was used for this retrospective study. Eligible women included those over 50 years of age who had no history of breast cancer or mastectomy and who had made at least one visit to a family practice residency program during the 2-year study period. Cases were randomly selected from women who had mammograms performed. For each case, one control subject who did not have a mammogram was matched by age and number of visits. A chart audit was performed to collect data on the characteristics of these women and whether they completed their screening tests. RESULTS. The adjusted odds ratio (controlling for the patient's age and number of physician visits) for mammogram completion among women who had a Pap smear compared with those who did not was 6.67. This effect persisted after controlling for other confounding factors using logistic regression. CONCLUSIONS. Performing a Pap smear appears to serve as a prompt for the physician to order a screening mammogram. That physicians appear to provide screening tests, particularly Pap smears and mammograms, as a package of services should be considered when future efforts to improve implementation are made.     

Do follow-up recommendations for abnormal Papanicolaou smears influence patient adherence?

OBJECTIVE: To compare adherence to follow-up recommendations for colposcopy or repeated Papanicolaou (Pap) smears for women with previously abnormal Pap smear results. DESIGN: Retrospective cohort study. SETTING: Three northern California family planning clinics. PATIENTS: All women with abnormal Pap smear results referred for initial colposcopy and a random sample of those referred for repeated Pap smear. Medical records were located and reviewed for 90 of 107 women referred for colposcopy and 153 of 225 women referred for repeated Pap smears. INTERVENTION: Routine clinic protocols for follow-up--telephone call, letter, or certified letter--were applied without regard to the type of abnormality seen on a Pap smear or recommended examination. MAIN OUTCOME MEASURES: Documented adherence to follow-up within 8 months of an abnormal result. Attempts to contact the patients for follow-up, adherence to follow-up recommendations, and patient characteristics were abstracted from medical records. The probability of adherence to follow-up vs the number of follow-up attempts was modeled with survival analysis. Cox proportional hazards models were used to examine multivariate relationships related to adherence. RESULTS: The rate of overall adherence to follow-up recommendations was 56.0% (136/243). Adherence to a second colposcopy was not significantly different from that to a repeated Pap smear (odds ratio, 1.40; 95% confidence interval, 0.80-2.46). The use of as many as 3 patient reminders substantially improved adherence to follow-up. Women without insurance and women attending 1 of the 3 clinics were less likely to adhere to any follow-up recommendation (hazard ratio for no insurance, 0.43 [95% confidence interval, 0.20-0.93], and for clinic, 0.35 [95% confidence interval, 0.15-0.73]). CONCLUSIONS: Adherence to follow-up was low in this family planning clinic population, no matter what type of follow-up was advised. Adherence was improved by the use of up to 3 reminders. Allocating resources to effective methods for improving adherence to follow-up of abnormal results may be more important than which follow-up procedure is recommended.     

Delivering Preventive Health Services for Breast Cancer Control: A Longitudinal View of a Randomized Controlled Trial

Objective. To develop a longitudinal model to characterize the delivery of mammography services using repeated observations of mammography referral rates during a randomized controlled trial (RCT) of physician mammography reminders. Data Sources/Study Setting . Administrative records of a health department and observational data on mammography appointment scheduling. Study Design. The design was a longitudinal study of month‐specific referral rates during a 1‐year RCT. A retrospective case‐control study was used to investigate differences between women with timely and delayed (or absent) mammography referral assessed at the end of the intervention year. Data Collection/Extraction Methods. Month‐specific indicators for referrals and missed clinical opportunities, that is, months when clinic visitors were due for a mammogram and not referred, were constructed using administrative and observational data. Findings. In the unadjusted analysis, the effectiveness of the reminder declined over time. However, in a multivariate analysis that controlled for the number of missed opportunities, the effectiveness was constant over time. On a monthly basis, physician reminders were significantly associated with higher referral rates among clinic visitors newly due for mammography (adjusted OR=2.8, 95 percent CI=1.3, 5.8) or who had one previously missed clinical opportunity (adjusted OR=3.0, 95 percent CI=1.6, 5.3) but were not for those with two or more missed clinical opportunities (adjusted OR=1.2, 95 percent CI=0.7, 2.3). Factors independently associated with delayed referral were age over 65, presence of more than one chronic illness, and the absence of a physician mammography reminder. Conclusions. Longitudinal models that examine rates of referral over time and include information about outcomes on previous visits can enhance our understanding of how intervention strategies work in practice.     

Mammography-facility-based patient reminders and repeat mammograms for Medicare in New York State

BACKGROUND: Women who receive mammograms may fail to regularly return for repeat mammography. Many mammography facilities send annual patient reminders, but there are no large studies of their impact on overall mammography return rates, or by patient population subgroups. METHODS: Medicare claims data were used to identify New York women with claims for mammograms during a baseline and an 18-month follow-up period (1999-2000). Receipt of a second mammogram was examined in relation to whether the facility sends annual reminders, while controlling for other patient factors. RESULTS: Of 97,506 women studied, 76% attended facilities that send annual reminders. Of these women, 74% received a second mammogram within 18 months compared to 67% for other women. The impact of reminders was significant in all subgroups, but was less for women who were younger, minority, in Medicaid, in New York City or who received a diagnostic mammogram. In multivariate analysis, the adjusted odds ratio for return within 18 months if the facility uses reminders was 1.42 (95% CI 1.37-1.47). CONCLUSIONS: Annual patient reminders from mammography facilities are effective in increasing regular repeat mammography in Medicare women, although their impact is smaller in some groups. Facilities that do not currently send reminders should be encouraged to do so.     

Effect of provider status on preventive screening among Korean-American women in Alameda County,California

BACKGROUND: Previous research suggests that having a doctor of the same ethnicity may be associated with lower rates of breast and cervical cancer screening in some Asian-American women. This study analyzes the effect of having a Korean, non-Korean, or no regular doctor upon several measures of screening among Korean-American women. METHODS: A random sample of 339 Korean-American women in Alameda County, California, were surveyed by telephone. Contingency tables and multivariable logistic regression were used to evaluate the association between provider status and six measures of recent screening, controlling for insurance and demographics. RESULTS: Having a non-Korean doctor was associated with an increased likelihood of having a Pap smear (odds ratio = 2.19, 95% confidence interval = 1.00, 4.80), mammogram (odds ratio = 7.63, 95% confidence interval = 2.35, 24.84), and clinical breast examination (odds ratio = 3.76, 95% confidence interval = 1.54, 9.20) in the past 2 years, compared to having a Korean doctor. This relationship is less apparent for nonfemale specific screening tests like cholesterol exams and routine checkups. CONCLUSIONS: Women who have a Korean doctor have less than optimal rates of breast and cervical cancer screening compared to women who have a non-Korean doctor. Having a Korean doctor may indicate less access to preventive health services, and programs to increase screening should target both Korean physicians and their female patients.     

Cancer screening in women: body mass index and adherence to physician recommendations

BACKGROUND: The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear. METHODS: Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear. RESULTS: After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001). CONCLUSIONS: Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.     

Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study

OBJECTIVES: This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening. METHODS: Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors. RESULTS: Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant. CONCLUSIONS: Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend.     

Body mass index and use of mammography screening in the United States

BACKGROUND: Obese and underweight women may be less likely to seek cancer screening because of health status, self-perception, and body image related to non-desirable weight. This study examined the relationship between body mass index (BMI) and mammography screening, using the data from the year 2000 United States National Health Interview Survey. METHODS: This study included 7692 white and 1496 black female participants aged 40-80, who were randomly selected. Body mass index (kg/m2), based on self-reported weight and height, was compared between women with and without a mammogram in the past 2 years using logistic regression. RESULTS: Compared to women with normal body mass index, underweight and extremely obese women were more likely to have no screening mammograms in the past 2 years (odds ratio (OR) = 1.8, 95% confidence interval (CI), 1.2-2.6 for underweight women; odds ratio = 1.3, 95% confidence interval, 1.0-1.8 for extremely obese women). When data were analyzed by race, the odds ratio estimates were 1.8 for underweight white women (95% confidence interval, 1.3-2.7) and 1.4 for extremely obese white women (95% confidence interval, 1.0-1.9). The corresponding odds ratio estimates were close to 1.0 for black women. CONCLUSIONS: Underweight and extreme obesity may increase the risk of underusing screening mammography. The association between body mass index especially underweight and underuse of mammography might exist primarily in white women.     

Cost-effectiveness of a tailored intervention designed to increase breast cancer screening among a non-adherent population: a randomized controlled trial

ABSTRACT: BACKGROUND: Although the percentage of women who initiate breast cancer screening is rising, the rate of continued adherence is poor. The purpose of this study was to examine the effectiveness and cost-effectiveness of a tailored print intervention compared with a non-tailored print intervention for increasing the breast cancer screening rate among a non-adherent population. METHODS: In total, 1859 participants aged 51--59 years (except those aged 55 years) were recruited from a Japanese urban community setting. Participants were randomly assigned to receive either a tailored print reminder (tailored intervention group) or non-tailored print reminder (non-tailored intervention group). The primary outcome was improvement in the breast cancer screening rate. The screening rates and cost-effectiveness were examined for each treatment group (tailored vs. non-tailored) and each intervention subgroup during a follow-up period of five months. All analyses followed the intention-to-treat principle. RESULTS: The number of women who underwent a screening mammogram following the reminder was 277 (19.9%) in the tailored reminder group and 27 (5.8%) in the non-tailored reminder group. A logistic regression model revealed that the odds of a woman who received a tailored print reminder undergoing mammography was 4.02 times those of a women who had received a non-tailored print reminder (95% confidence interval, 2.67--6.06). The cost of one mammography screening increase was 2,544 JPY or 30 USD in the tailored intervention group and 4,366 JPY or 52 USD in the non-tailored intervention group. CONCLUSIONS: Providing a tailored print reminder was an effective and cost-effective strategy for improving breast cancer screening rates among non-adherent women.     

Use of mammography and Pap smear in Estonia,a country without organized cancer screening

Summary Objectives: To analyze mammography and Pap smear status in Estonia where no organized population-based cancer screening is available. Methods: 5000 individuals (aged 16–64) were randomly chosen from the national population register; among them, 1755 women filled out postal questionnaires. Results: 50% of respondents aged 45–64 reported having taken a mammogram, 51% of women aged 25–64 had the Pap smear at least once in their lifetime. Corresponding figures for the past two years were 37% and 30%. Irrespective of age, women taking fewer tests over the past two years were rural workers, unemployed, and health behavior recommendations ignorers. In most cases, initiative for mammogram came from women, and from the physician in the case of Pap smear. Moderate increase in mammography use occurred after a project for early detection of breast cancer was launched. Conclusion: Women must continuously be informed that early detection of breast and cervical cancer is possible. Young women should be encouraged to ask for Pap testing. Knowledge of family physicians should be improved. Submitted: 13 February 2006; Revised: 4 October 2006; Accepted: 8 November 2006     

Social networks and cancer screening in four U.S. Hispanic groups

BACKGROUND: Evidence shows that social relationships play an important role in health and health behavior. We examined the relationship between social networks and cancer screening among four U.S. Hispanic groups. METHODS: We used telephone surveys to collect data in eight U.S. regions that have concentrations of diverse Hispanic-origin populations. We interviewed 8903 Hispanic adults, for a response rate of 83%; analysis was restricted to the 2383 women aged > or =40. As a measure of social integration, we formed a social network index from items on the number of close relatives and friends, frequency of contact, and church membership. We used logistic regression to estimate the effects of social integration on screening, adjusting for sociodemographic factors. RESULTS: Among Mexican, Cuban, and Central-American women, the effect of social integration on mammography screening was slight. The odds ratios (OR) per unit change in social integration category ranged from 1.16 to 1.22 with confidence intervals (CI) that overlapped with the null. For Pap smear screening, the effect was strongest among Mexican-American women (OR=1.44, 95% CI=1.21 to 1.72), but also evident among Central-American women (OR=1.22, 95% CI=0.72 to 2.06) and Cuban women (OR = 1.25, 95% CI = 0.81 to 1.93). Among Puerto Rican women, social integration had no effect on either mammography (OR=1.03) or Pap smear screening (OR=1.08). CONCLUSIONS: Independent of socioeconomic factors, social integration appears to influence cancer screening participation of Hispanic women. The modest effect is not universal across Hispanic groups and was stronger for Pap smear than for mammography screening behavior. Researchers should recognize Hispanic group differences in social network characteristics and the potential of social networks to change screening behavior.     

Women's Behaviors Toward Mammogram and Pap Test: Opportunities to Increase Cervical Cancer Screening Participation Rates among Older Women

Objectives

Screening rates for cervical cancer remain moderate among women over 50 years of age. Because cervical and breast screening interventions can be linked, evaluating screening factors relating to both is important. This study evaluates factors associated with breast and cervical screening participation in women aged 52 to 69.

Loss-framed minimal intervention increases mammography use

INTRODUCTION: Although mammography is the most effective early detection breast cancer screening technology available, it is underutilized. This study was conducted to test the effectiveness of a loss-framed minimal intervention to increase mammography use. Loss-frame refers to a communication strategy in which messages are framed from the perspective of what a person has to lose by not taking a particular behavioral action. METHODS: Participants were medically un- and underinsured women 50-64 years old who called one of two urban clinics randomly selected based on demographic statistical equivalency. The women who participated telephoned to inquire about a mammogram during the 6-month study period. The group randomly designated as the experimental group received a loss-framed message conveyed by trained staff telephonically. Members of the comparison group received the "usual" communication, also conveyed telephonically. In the experimental group, 31 of 112 (27%) women who inquired received mammograms, whereas 157 of the 992 (16%) comparison group women who inquired received mammograms. RESULTS: The odds of a mammogram, adjusted for race and breast cancer symptoms, significantly increased for the experimental (odds ratio [OR] = 1.914, chi2 = 7.48, p = .0063, 95% confidence interval [CI] 1.20-3.05) versus comparison group. CONCLUSIONS: A loss-framed, in-reach, minimal intervention approach holds promise as a mammography promotion strategy.     

Comparative effectiveness of mailed reminder letters on mammography screening compliance

Objective

Reminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt.

Methods

The study included 48,583 women 52-74 years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest-posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing.

Results

Among women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1-2 recommendations: OR = 0.73; 95% CI:0.68-0.79; 3 recommendations: OR = 0.74; 95% CI:0.69-0.78; 4-8 recommendations: OR = 0.62 95% CI:0.55-0.68) after. Among overdue women, birthday letters with 4-8 recommendations were negatively associated with mammography receipt.

Conclusions

Transitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt.     

Cervical screening in general practice

Abstract: This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.     

Accuracy of Self-Report of Mammography and Pap Smear in a Low-Income Urban Population

Background:Cancer screening history can often be obtained only by self-report, particularly for disadvantaged populations. We examined the accuracy of self-report of mammography and Pap smear for an urban, low-income population.Methods:Women attending non-primary care clinics (mostly surgery and orthopedics) at a large public teaching hospital in Minneapolis between July 1992 and May 1993 were queried about their screening history (n = 477). The women were interviewed by a trained peer-recruiter and asked whether they had ever heard of a Pap smear or mammogram, whether they had ever had one, where it was done, and when the last one was. We verified self-report by checking medical records where the test was performed.Results:The positive and negative predictive value of recall of mammography in the previous year was 72.4% and 90.6%, respectively. The figures for Pap smear recall were somewhat lower, 65.5% and 85.9%, respectively. We found a record of a mammogram in 88% of women able to recall the year. Of these, slightly over two-thirds recalled their mammogram in the same year as their record indicated. Inaccurate recalls were more commonly of the “telescoping” type, i.e., tests were recalled as having occurred more recently than was the case. Recall was substantially better for recent tests. Results for Pap smear recalls were broadly similar.Conclusions:The accuracy of self-report of mammography and Pap smear is relatively poor for medical practice but is acceptable in population surveys with appropriate correction for overreporting.