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.     

Reminder letter, tailored stepped-care, and self-choice comparison for repeat mammography

BACKGROUND: The main benefits of mammography come from regular on-schedule screening. However, few studies have examined interventions to achieve repeat screening. SETTING AND PARTICIPANTS: Participants were women aged 50 to 74, recruited through one setting in Rhode Island and another in North Carolina. Participants had a mammogram already scheduled at recruitment, and had to keep that appointment in order to be eligible for the repeat mammography intervention. A total of 1614 women were in the intervention sample. DESIGN: A four-group randomized design was used: Group 1, a simple reminder letter; Group 2, a 2-month, tailored, stepped intervention delivered 2 months after the completed mammogram; Group 3, a 10-month, tailored, stepped intervention delivered 2 months before the repeat mammogram was due; and Group 4, self-choice of one of the above three strategies. INTERVENTION: The intervention took place between June 1996 and May 1997. The reminder letter and two levels of the stepped intervention were delivered by mail. The third level of the stepped strategy was a counselor telephone call. Groups 2 and 3 were identical, except for timing. OUTCOME MEASURE: Obtaining the next due mammogram within 15 months, based on clinic records. RESULTS: There were no statistically significant differences among the four groups, both in the total sample and at the two sites separately. CONCLUSIONS: On average, a simple reminder may be as effective as more complex strategies for women with a prior on-schedule exam. However, attention is still needed to identify women at risk of lapsing from screening. Some women may require more-intensive interventions.     

Promoting mammography use through progressive interventions: is it effective?

This study evaluated interventions implemented with women in a health maintenance organization who had not utilized their annual free mammogram referral 45 days (step 2) and 95 days (step 3) after its mailing. The step 2 evaluation compared mammography utilization for women randomly assigned to receive a brief reminder letter or no reminder: 42% of the reminder group vs 28% of the control group obtained mammograms. The step 3 evaluation compared utilization for women randomly assigned to receive a second reminder, a letter suggesting a preventive office visit, or telephone counseling: 29% of those who received telephone counseling, 14% of those who received a letter, and 12% of those who received a second reminder obtained mammograms.     

The effect of a combined influenza/pneumococcal immunization reminder letter

BACKGROUND: The effect of a combined influenza and pneumococcal immunization reminder letter on increasing influenza and pneumococcal immunization rates, and the timeliness of receiving immunizations after receipt of a reminder letter, have not been examined. This study addresses these issues using a sample of new Medicare beneficiaries residing in Hawaii. METHODS: Newly enrolled Medicare beneficiaries in Hawaii from 25 September 1995 through 31 August 1996 were randomly assigned to one of three groups: Group 1, no letter (n=2144); Group 2, influenza immunization reminder letter only (n=2213); or Group 3, pneumococcal and influenza immunization reminder letter (n=2171). Health Care Financing Administration claims data were compared among groups. RESULTS: In Group 3, the influenza immunization rate increased 3.8 percentage points (n=87; p=0.017) compared with Group 1. The Group 3 pneumococcal immunization rate increased 3.5 percentage points (n=78; p<0.001) compared to Group 1 and 4.0 percentage points (n=86; p<0.001) compared to Group 2. Sixty-six beneficiaries in Group 3 received simultaneous pneumococcal and influenza immunizations, a significant difference compared to Group 1 or Group 2. Increases in immunizations were observed immediately following the reminder letters and the effect persisted for 5 to 7 weeks. CONCLUSIONS: The combination letter increased both influenza and pneumococcal immunization rates and the simultaneous administration of immunizations without detrimental effect to influenza immunization rates. A combined reminder letter is inexpensive and recommended as part of a multicomponent campaign for adult immunization.     

Using physician correspondence and postcard reminders to promote mammography use.

OBJECTIVES. In a health maintenance organization that mails letters to women recommending that they schedule mammograms, we conducted a randomized trial to evaluate simple methods of increasing the use of screening mammography. METHODS. Using a 2 x 2 factorial design, we tested the effects of (1) mailing the recommendation letter from each woman's primary care physician rather than from the program director and (2) sending a subsequent reminder postcard. RESULTS. Sending a reminder postcard nearly doubled the odds that women would get mammograms within 1 year (participate). The letter from the woman's personal physician had no effect. Attending a clinic more than 45 minutes from the screening center, being a current smoker, or being in fair or poor health were negatively associated with subsequently obtaining a mammogram. The odds of participation doubled if women had had previous mammograms. CONCLUSIONS. When preceded by written recommendations to schedule mammograms, reminder postcards effectively increased participation. Future randomized trials to promote use of screening mammography should compare interventions with a reminder condition.     

Office Systems and Their Influence on Mammography Use in Rural and Urban Primary Care

CONTEXT: Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention. PURPOSE: Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization. METHODS: We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems. FINDINGS: Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets. CONCLUSIONS: Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.     

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.     

Improving access to mammograms through community-based influenza clinics. A quasi-experimental study

BACKGROUND: It is a national priority to increase breast-cancer screening among women aged > or = 50. Annual influenza clinics may represent an efficient setting in which to promote breast-cancer screening among older women. To our knowledge, this possibility has not previously been explored. OBJECTIVE: To examine whether offering women attending community-based influenza clinics the opportunity to receive a scheduling telephone call from a mammography facility will result in an increase in the number of mammograms performed over a 6-month period. METHODS: We used a quasi-experimental design with 6-month follow-up. A contemporaneous population-based survey provided a further control group for comparison. The sample group consisted of a total of 284 women attending nine community-based influenza clinics in a semirural county in Connecticut. All women were aged > or = 50 and reported no mammogram in the preceding 12 months. All women received informational literature on mammography. Experimental subjects were each asked if a radiology facility chosen by the subject could call her at home to schedule a mammogram. Mammograms performed were determined by hospital record for participants who received a scheduling call from a radiology facility, and by self-report for all other participants. RESULTS: Mammography use following access through influenza clinics was approximately twice that of women attending influenza clinics where access to mammography was not offered. Using three different assumptions regarding participants whose mammography status was unknown, the relative risks ranged between 1.6 and 2.1. For each assumption the results were statistically significant (chi(2)=8.51-12.2; p<0.001). CONCLUSIONS: Linking access to mammography at community-based influenza clinics can significantly increase the use of mammograms among women aged > or = 50. Further studies should seek to confirm these findings and determine the degree to which they can be replicated in a variety of communities. Enhancing preventive health practice through the bundling of services suggests a new strategy to exploit available interventions to improve health.     

The effect of a stage-matched and tailored intervention on repeat mammography(1).

BACKGROUND: Our objective was to determine whether a tailored, stage-matched educational intervention, guided by the transtheoretical model (TTM), would increase rates of repeat-screening mammography. DESIGN SETTING/PARTICIPANTS: A total of 1324 women (N=1026 after attrition) aged 50 to 74 years were recruited from a staff-model health maintenance organization. Some of the women were not due for mammograms at the time of recruitment.Intervention: Women were randomly assigned to one of three intervention conditions: Group 1, no educational materials (usual care); Group 2, standard materials; and Group 3, stage-matched/tailored materials. Women in Groups 2 and 3 received a mailed education packet after both a baseline and a follow-up telephone interview. All women in Group 2 received the same materials regardless of differences in baseline mammography-related attitudes and behaviors. Each woman in Group 3 received materials based on her stage of adoption for mammography and TTM constructs. MAIN OUTCOME: Using clinical records, repeat screening was defined as receipt of a second mammogram within 14 months after obtaining an initial postbaseline mammogram. RESULTS: Women in Group 3 were more likely to obtain repeat-screening mammograms than women in Group 1 (44.2% vs 35.8%; adjusted rate ratio = 1.29, 95% confidence interval [CI]=1.11-1.46; adjusted rate difference = 0.06, 95% CI=-0.01-0.13). The screening percentage in Group 2 was intermediate (39.3%), and did not differ from either Group 3 or Group 1. CONCLUSIONS: The effect of the stage-matched/tailored intervention was sustained for repeat screening, although no educational materials were delivered to coincide with the timing for a second mammogram. However, the stage-matched/tailored intervention was not sufficient to have a substantial impact on screening beyond the effect of standard educational materials. Future interventions may need to administer "booster" sessions to increase repeat screenings.     

Cost-effectiveness comparison of five interventions to increase mammography screening

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography. METHODS: There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness. RESULTS: Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened. CONCLUSIONS: A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.     

Patient views on reminder letters for influenza vaccinations in an older primary care patient population: a mixed methods study

OBJECTIVES: To explore the perspectives of older adults on the acceptability of reminder letters for influenza vaccinations. METHODS: We randomly selected 23 family physicians from each Family Health and Primary Care network participating in a demonstration project designed to increase the delivery of preventive services in Ontario. From the roster of each physician, we surveyed 35 randomly selected patients over 65 years of age who recently received a reminder letter regarding influenza vaccinations from their physician. The questionnaires sought patient perspectives on the acceptability and usefulness of the letter. We also conducted follow-up telephone interviews with a subgroup of respondents to explore some of the survey findings in greater depth. RESULTS: 85.3% (663/767) of patients completed the questionnaire. Sixty-five percent of respondents recalled receiving the reminder (n=431), and of those, 77.3% found it helpful. Of the respondents who recalled the letter and received a flu shot (n=348), 11.2% indicated they might not have done so without the letter. The majority of respondents reported that they would like to continue receiving reminder letters for influenza vaccinations (63.0%) and other preventive services (77.1%) from their family physician. The interview participants endorsed the use of reminder letters for improving vaccination coverage in older adults, but did not feel that the strategy was required for them personally. CONCLUSIONS: The general attitude of older adults towards reminder letters was favourable, and the reminders appear to have contributed to a modest increase in influenza vaccination rates.     

A two-step intervention of increase mammography among women aged 65 and older.

OBJECTIVES: This study evaluated a two-step intervention for mammography screening among older women. METHODS: Four hundred and sixty women, identified from physician practices, were randomized to a control or a two-step intervention (physician letter and peer counseling call) group. Women in the intervention group who obtained a mammogram received a grocery coupon. RESULTS: Over the 12 months of the study, more women in the intervention group than in the control group obtained mammograms (38% vs 16%). The most dramatic difference was in the higher odds that women in the intervention group would obtain a mammogram within 2 months (odds ratio = 10.5). CONCLUSIONS: The intervention significantly increased screening mammography. Future efforts must be multifaceted and incorporate the unique concerns of older women.     

Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms

OBJECTIVES: To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS: Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS: Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION: Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.     

Comparison of tailored interventions to increase mammography screening in nonadherent older women

BACKGROUND: Recent increases in mammography use have led to a decrease in mortality from breast cancer. METHODS: Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter. RESULTS: All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%. CONCLUSIONS: All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions.     

Evaluation of the New South Wales Cancer Council Pap Test Reminder Service

Abstract: This study aimed to assess the effect of reminder letters on Pap test rates for women enrolled on the New South Wales Cancer Council Pap Test Reminder Service and to identify predictors of response to the letter. Ten weeks after they had received their reminder letter a questionnaire was sent to 3086 women. It was completed by 1525 (49 percent) women, of whom 1393 (91 percent) said they had received their reminder letter. Of these 1393, 48 per cent (95 per cent confidence interval 46 per cent to 51 per cent) reported having had a Pap test within 10 weeks of the reminder letter arriving. The proportion of women having a Pap test in response to the reminder letter did not differ by age, region of residence or language spoken at home. Women were less likely to have had a Pap test if they did not know how they were enrolled, were of low socioeconomic status or had some tertiary education. Women on the reminder service have 15-month rescreening rates at least 9 per cent higher than other women in New South Wales; for women aged 50 to 69 in nonmetropolitan areas the increase is estimated at 19 per cent. Reminder services may be a cost-effective way to increase Pap test rescreening rates. Reminder services need accurate records and to follow up changes in address and date of next test.     

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.     

Improving preventive care at a medical clinic: how can the patient help?

We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services.     

Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback.

We evaluated a program for improving influenza immunization performance in a health maintenance organization (HMO). The HMO implemented several interventions successively from 1984-87: a postcard reminder to members at high risk for complications of influenza, a computer-generated reminder to the physician at the time of any primary care visit by high-risk patients, performance feedback to chiefs of service, and, finally, retrospective feedback to each physician comparing his/her performance with that of the other physicians. We examined immunization rates for a group of members older than age 65, a high-risk group under age 65, and a group of diabetic members who had not been subject to the reminders (vs a group who had been covered by the program). Vaccination rates were increased in those diabetic members who received reminders. Nevertheless, among members younger and older than age 65 whose experience was observed over three flu seasons, a significant increase in vaccination rates was not achieved until physician feedback was added to the program. We conclude that each element of the reminder and feedback program has contributed to the overall increase in vaccination rates at the HMO and that effective ongoing influenza immunization programs can be implemented in practice settings with appropriate systems support.     

Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services

Despite an emerging consensus on appropriate preventive services, a minority of patients receive them. A study was undertaken to assess the impact of computer-generated reminders to adult patients, their physicians, or both patients and physicians on adherence to five recommended preventive services: cholesterol measurements, fecal occult blood testing, mammography, Papanicolaou smears, and tetanus immunization. During the academic year 1988-1989, all 7397 adult patients and their 49 physicians in a university family medicine clinical practice were randomized by practice group into one of four study groups: control, physician reminders, patient reminders, and both physician and patient reminders. Adherence was defined in community-oriented terms: the percentage of patients within each group who had received the preventive service in the recommended interval. During the study period, adherence to four of the five preventive services increased significantly, with the largest increases in the physician and patient reminder group: cholesterol measurements increased from 19.5% to 38.1%, fecal occult blood testing 9.3% to 27.0%, mammography 11.4% to 27.1%, and tetanus immunization 23.4% to 35.4% (for each increase, P less than .0001, McNemar's chi-square test). In general, increases were greater in blacks and in patients with any form of insurance coverage. Computer-based physician and patient reminder systems have great promise of improving adherence to preventive services in primary care settings.