Implementation issues and costs associated with a proven strategy for increasing breast and cervical cancer screening among low-income women.

Results from a randomized controlled trial demonstrated that a physician reminder letter combined with telephone counseling from a health educator significantly increased women's use of both mammograms and Pap tests in a low-income population in a managed care setting. This article presents results from a process evaluation and cost analysis of the intervention. An average of 35 minutes was spent preparing each of 304 intervention letters for mailing, including the time needed to secure signatures from 110 physicians. The results of an economic analysis suggested that this intervention cost $11.44 per recipient and $28.93 per screening test received above expected. However, intervention costs can be reduced significantly if one physician signs all letters (rather than each woman's own primary care physician) and if the health educator labor costs are diminished (e.g., by using student interns). Overall, the women under study reported that they are comfortable with both mailed and telephone reminders when they are post due for a clinical preventive service.     

Mailed Fecal-Immunochemical Test for Colon Cancer Screening

Various interventions have been implemented to increase the rate of colon cancer screening. The purpose of this study was to determine if persons who are regular patients of a clinic, ages 50–64 years, and not up-to-date with colon cancer screening will complete the at-home fecal-immunochemical test (FIT) if it is mailed to them. This intervention was designed to have the subject avoid the signing of an informed consent and having to ask for the screening test; and, only one stool specimen was needed. Three hundred and fifty potential subjects were randomly selected from an electronic medical record database after meeting inclusion criteria. Eighty-seven fecal immunochemical tests were returned. Seven of the FIT kit results were positive for occult blood. Each respondent was sent a letter giving them their results. A minimal cue CRC screening intervention, a FIT kit sent in the mail without prerequisite of a signed informed consent, was offered to the study subjects. Twenty-six percent of the eligible persons were screened for colon cancer by this method. A mailed FIT kit or one handed to the patient at an office visit has minimal cost which can be recovered through insurance coverage. Commitment by health care providers is necessary for prevention. This method is one of several that could reach the hard to screen population.     

Diagnostic performance of flexible sigmoidoscopy combined with fecal immunochemical test in colorectal cancer screening: meta-analysis and modeling

Once-only flexible sigmoidoscopy (FS), which reliably detects neoplasms in the distal colon and rectum but not in the proximal colon, has been shown to reduce incidence and mortality of distal colorectal cancer (CRC). Fecal immunochemical tests (FITs) detect the majority of CRCs and some proportion of adenomas also in the proximal colon. We assessed the expected diagnostic performance of combined application of FS and FIT. We systematically reviewed screening studies conducted in an average risk population that reported specificities and site-specific sensitivities of FITs for detection of CRC or advanced adenoma (AA). Only studies that conducted colonoscopy in all subjects were included. PubMed and Web of Science were searched until May 13, 2016. Reference lists of eligible studies were also screened. Sensitivity of FS was derived from colonoscopy results, assuming the same sensitivity as colonoscopy for left-sided neoplasms and follow-up colonoscopy after detection of distal adenomas. Bivariate meta-analyses were used to derive summary estimates of overall sensitivity and specificity of individual and joint application of both tests. Ten eligible studies were identified. Summary estimates (95% confidence intervals) of overall sensitivity for detecting CRC and AA were 65% (56–74%) and 27% (23–31%) for FIT alone, 67% (58–75%) and 67% (59–75%) for FS alone, and 89% (83–92%) and 75% (68–80%), respectively, for the combination of both tests. The pooled specificity (95% CI) of FIT was 92% (90–95%). Adding a FIT to a once-only screening FS would substantially increase sensitivity of CRC screening at a modest loss in specificity.     

Physician participation in research surveys. A randomized study of inducements to return mailed research questionnaires

The authors randomly selected 400 physicians from a population of 1,545 practicing physicians providing follow-up care to patients who received bone marrow or blood stem cell transplants at the Fred Hutchinson Cancer Research Center to determine interest in receiving Internet-based transplant information. In a two-factor completely randomized factorial design, the 400 physicians were assigned to receive mailed surveys with either no compensation or a $5 check and either no follow-up call or a follow-up call 3 weeks after mailing. Overall, 51.5% of the physicians returned the mailed surveys. Comparison of logit models showed that inclusion of a $5 check in the mailer significantly (p = .016) increased the probability of returning the surveys (57.5% vs. 45.5%). In contrast, the telephone follow-up had no overall effect. The authors concluded a modest financial reward can significantly improve physician response rates to research surveys but a telephone follow-up may be inefficient and even ineffective.     

Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

PURPOSE

Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities.

METHODS

We conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008–2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims.

RESULTS

MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08–1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened.

CONCLUSIONS

The telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs.     

Telephone reminder calls increased response rates to mailed study consent forms

BACKGROUND: This study assessed the impact of follow-up reminder phone calls on response rates to a mailed consent form packet. METHODS: Patients with rheumatoid arthritis were invited to enroll in a study by signing and returning consent forms by mail. Patients not returning completed study consent forms were called and reminded to return the signed consent forms. RESULTS: Among 724 mailed consent form packets, 376 (52%) were returned without further follow-up. Follow-up reminder calls were made to 220 of the 348 patients who did not return signed consent forms. Among subjects contacted by phone, 67 (31% of those called) returned signed consent forms. CONCLUSION: Follow-up reminder phone calls raised the overall consent rate of 52 to 61%, suggesting that they can be an effective technique in increasing response rates.     

A telephone reminder intervention to improve breast screening information and access

ObjectivesIn the UK, women aged 50–70 are offered breast cancer screening every three years. Screening participation rates in London have been particularly low. Low rates have been associated with low socio-economic status, and some ethnic groups have been observed to be underserved by cancer screening. This paper reports on a telephone reminder intervention in London Newham, an area of high deprivation and ethnic diversity.Study DesignObservational study of planned intervention.MethodsWomen invited for breast screening were telephoned to confirm receipt of the invitation letter, remind invitees of their upcoming appointment, and to provide further information. Aggregate data at general practice level on invitation to and attendance at breast screening and on numbers reached by telephone were analysed by logistic regression.ResultsFor the 29 participating GP practices (10,928 invitees) overall uptake in 2010 was higher compared to the previous screening round in 2007 (67% vs. 51%; p < 0.001). On average 59% of invitees were reached by the reminder calls. A 10% increase in women reached resulted in an 8% increase in the odds of women attending their screening appointment (95% CI: 5%–11%), after adjusting for 2007 attendance rates. Practices with a higher proportion of South Asian women were associated with a larger uptake adjusted for 2007 uptake and population reached by the telephone intervention, (4% increase in odds of attendance per 10% increase in South Asian population, CI 1%–7%, p = 0.003) while practices with a higher proportion of black women were associated with a smaller uptake similarly adjusted. (11% decrease in odds of attendance per 10% increase in black population, CI 9%–16%, p < 0.001).ConclusionsA language- and culture-sensitive programme of reminder calls substantially improved breast cancer screening uptake.     

Prospective cohort study of compliance with faecal immunochemical tests for colorectal cancer screening in Hong Kong

Objective

This study aims to examine the rate and determinants of faecal immunochemical test (FIT) compliance over a four-year period among asymptomatic participants in a colorectal cancer (CRC) screening programme in Hong Kong.

Method

Self-referred screening participants aged between 50 and 70 years who chose FIT for annual screening were followed up for four years (2008–2012). All participants were reminded up to three times yearly for FIT retrieval within two months of the expected screening date. The proportions of screening participants who failed to adhere to annual FIT tests in 1, 2, 3 and 4-years, respectively, after the initial screening uptake were evaluated. The factors associated with non-compliance with FITs in any year were assessed by a binary logistic regression analysis.

Results

From 5700 consecutive screening participants, the compliance rates to FIT were 95.1%, 79.9%, 66.2% and 68.4% at years one to four, respectively. The proportions of people missing one, two and three tests were 6.2%, 19.6% and 2.1%, respectively. From multivariate regression analysis, male subjects, younger participants, smokers and those with positive family history of CRC were more likely to be non-compliant.

Conclusion

Participants identified as at higher risk for screening non-compliance should be especially considered for individual reminders to enhance screening effectiveness.     

Budget Impact Analysis of Against Colorectal Cancer In Our Neighborhoods (ACCION): A Successful Community-Based Colorectal Cancer Screening Program for a Medically Underserved Minority Population

Objectives

Given the uncertain cost of delivering community-based cancer screening programs, we developed a Markov simulation model to project the budget impact of implementing a comprehensive colorectal cancer (CRC) prevention program compared with the status quo.

Formative Research on Knowledge and Preferences for Stool-based Tests compared to Colonoscopy: What Patients and Providers Think

The rates of colorectal cancer (CRC) screening in the U.S. remain below national targets, so many people at risk are not being screened. The objective of this qualitative research project was to assess patient and provider knowledge and preferences about CRC screening modalities and specifically the use of the fecal immunochemical test (FIT) as a first line screening choice. Nine focus groups were conducted with a medically underserved patient population and qualitative interviews were administered to their medical providers. Thematic analysis was used to synthesize key findings. Both providers and patients thought that the FIT would be a good option for CRC screening both as an individual choice and for an overall program approach. The test is less expensive and therefore more readily available for patients compared to colonoscopy. Overall, there was consensus that the FIT offers a reasonably priced, simple approach to CRC screening which has broad appeal to both providers and patients. Concerns identified by patients and providers included the possibility of false positives with the FIT which could be caused by test contamination or failing to perform the test properly. Patients also described feelings of disgust toward performing the FIT and difficulties in following the instructions. Study findings indicate provider and patient support for using the FIT for CRC screening at both the individual and system-wide levels of implementation. While barriers to the use of the FIT were listed, benefits of using the FIT were perceived as positive motivators to engage previously unscreened and uninsured or under-insured individuals in CRC screening.     

Improving Physician Coverage of Pneumococcal Vaccine: A Randomized Trial of a Telephone Intervention

Improved pneumococcal vaccine (PPV) immunization for seniors is a national goal of the Medicare program. This study examined whether adding a simple telephone follow-up to an existing mailed physician performance feedback under the Medicare program would increase the impact on billed pneumococcal immunizations. Medicare fee-for-service claims data were used to select New York primary care physicians with high volume (n = 732) or African-American serving (n = 329) practices. All practices received mailed feedback on their 1999 Medicare practice specific PPV coverage rates, along with educational materials and offers of assistance. Practices were also randomized to receive telephone calls directing attention to the mailing and further promoting improvements in PPV coverage or no active follow-up. Physicians randomized to telephone follow-up showed significantly higher rates of practice specific PPV coverage in 2000 than those receiving the routine mailing only, and 27% vs. 17% (p = 0.01) of high volume physicians and 34% vs. 22% (p = .052) of African American serving physicians achieved at least a 5% increase in their cumulative PPV claims coverage. This study concludes that telephone follow-up is an effective and straightforward method to enhance the impact of practice specific feedback to promote improvements in Medicare PPV immunization. However, improved methods may be needed to induce a large percentage of physicians to change.     

Increasing response rates of gynaecologists to a survey: a randomised trial of telephone prompts

Abstract: This study used a randomised controlled trial to evaluate the effectiveness of telephone prompts to increase the response rate of gynaecologists to a survey. A nine-page questionnaire about management of women with abnormal Pap smears was mailed to Fellows of the Royal Australian College of Obstetricians and Gynaecologists. A random sample was contacted in advance by telephone, and nonrespondents received a telephone reminder 14 days after the initial mail-out. The control group was mailed questionnaires and a reminder letter conventionally. On Day 25, nonresponders in both groups were mailed a second questionnaire. Of the intervention group, 84 per cent responded to the survey compared to 69 per cent of the control group (P = 0.005). A telephone call in anticipation of a mailed questionnaire is highly recommended.     

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.     

Telephone reminders increase re-screening in a county breast screening program

INTRODUCTION: Mammography can reduce breast cancer mortality through routine screening. We tested an intervention to increase re-screening in a county program. METHODS: The program requires enrollment before screening. We randomized women who had previously been screened by the program to a telephone call reminder for re-enrollment or usual care (postcard reminder). We followed re-enrollment and re-screening rates for both groups. RESULTS: Compared with the control group (n=610), women in the intervention group (n=599) had higher rates of initial re-enrollment at one month (10% vs. 24%, p<.001) and re-screening at two months (11% vs. 19%, p<.001). These effects persisted over time (five-month re-enrollment: 24% vs. 35%, p<.001; six-month re-screening: 23% vs. 31%, p=.004). The intervention did not alter the odds of a woman's being re-screened once re-enrolled. CONCLUSION: The increase in our re-screening rate after this simple intervention was as great or greater than the rates reported in other studies. A telephone reminder for women previously enrolled in a county breast screening program can increase re-enrollment and subsequent re-screening rates.     

The effect of telephone reminders on attendance in respiratory outpatient clinics

INTRODUCTION: Patient non-attendance is an area of concern for all health care providers. A randomized controlled trial was undertaken to investigate whether reminder telephone calls improved attendance at respiratory outpatient clinics in the English National Health Service (NHS). METHODS: Patients were randomly allocated into one of two groups, either telephone reminder group or usual care. The telephone reminder group received a reminder telephone call between 9 am and 5 pm during the week prior to their appointment. Attendance and demographic information (age, sex, diagnosis and home postcode) were recorded. RESULTS: A total of 504 patients were recruited, 258 patients were allocated to the control group and 246 patients were allocated to the telephone reminder group. Fifty-eight percent of the patients allocated to the telephone reminder group were not contactable. Within the telephone reminder group, of the 104 patients who could be contacted, 86% attended. There was a significant 15% increase in attendance in the contacted group (n = 104) when compared both with the control group (71%, n = 258) and with the patients who could not be contacted (68%, n = 142) (P = 0.007; P = 0.004). It was estimated that the cost of telephoning 200 patients could be offset by preventing one non-attendance. CONCLUSION: Routine telephoning of outpatients should become standard practice if reducing non-attendance is thought to be desirable, but general practitioner (GP) referral letters and hospital records of current hospital outpatients need to include an up-to-date telephone number. Consideration should be given to 'out-of-hours' reminder calls to maximize the contact rate.     

Perceived Importance of the Benefits and Harms of Colorectal Cancer Screening: A Best-Worst Scaling Study

ObjectivesTo elicit the relative importance of the benefits and harms of colorectal cancer (CRC) screening among potential screening participants in the Dutch population.MethodsIn a consensus meeting with 11 experts, risk reduction of CRC and CRC deaths (benefits) and complications from colonoscopy, stress of receiving positive fecal immunological test (FIT) results, as well as false-positive and false-negative FIT results (harms) were selected as determinant end points to consider during decision making. We conducted an online best-worst scaling survey among adults aged 55 to 75 years from the Dutch Health Care Consumer Panel of The Netherlands Institute for Health Services Research to elicit preference values for these outcomes. The preference values were estimated using conditional logit regression.ResultsOf 265 participants, 234 (89%) had ever participated in CRC screening. Compared with the stress of receiving a positive FIT result, the outcome perceived most important was the risk of CRC death (odds ratio [OR] 4.5; 95% confidence interval [CI] 3.9-5.1), followed by risk of CRC (OR 4.1; 95% CI 3.6-4.7), a false-negative FIT result (OR 3.1; 95% CI 2.7-3.5), colonoscopy complications (OR 1.6; 95% CI 1.4-1.8), and a false-positive FIT result (OR 1.4; 95% CI 1.3-1.6). The magnitude of these differences in perceived importance varied according to age, educational level, ethnic background, and whether the individual had previously participated in CRC screening.ConclusionDutch men and women eligible for FIT-based CRC screening perceive the benefits of screening to be more important than the harms.     

Automated telephone reminder messages can assist electronic diabetes care

Telephone reminder systems have been used to assist in the treatment of many chronic diseases. However, it is unclear if these systems can increase medication and appointment adherence in patients with diabetes without direct patient-provider telephone contact. We tested the feasibility of using an automated telephone reminder system (ATRS) to deliver reminder messages to 253 adults with diabetes enrolled in a randomized controlled trial. Eighty-four percent of the patients were able to register using voice recognition and at least one reminder was delivered to 95% of registered patients over a period of 7.5 months. None of the demographic features studied predicted a patient's ability to enroll or to receive reminder calls. At the end of the study, 63% of patients indicated that they wished to continue to receive ATRS calls. The level of system use as determined by the number of received reminder calls was not associated with a change in the number of physician visits or diabetes-related laboratory tests during follow-up. The clinical benefits and sustainability of ATRS remain unproven, but our results indicate that an automated reminder system can be effective for providing messages to a large group of older patients with diabetes.     

Contribution of follow-up of nonresponders to prevalence and risk estimates: a Norwegian respiratory health survey

Achieving a high response rate is often expensive and time consuming. Does an extensive survey effort change prevalence estimates and exposure-disease relations? In 1998-1999, the authors conducted a population-based respiratory health survey in two Norwegian counties (Oslo, n = 20,000; Hordaland, n = 5,000) of a random sample of the adult population aged 15-70 years. A postal questionnaire was mailed, with as many as two reminder letters. A 25% random sample of postal nonresponders was contacted by ordinary or cellular telephone. Cumulative response rates after the first mailing, first reminder, second reminder, and telephone follow-up were 42.7%, 60.7%, 68.3%, and 79.9%, respectively. Compared with initial postal responders, responders at later stages were younger, and more were male. Late responders had a lower educational level, were more often smokers, and were occupationally exposed to dusts or gases more frequently. After the authors adjusted for these factors, late responders were found to have less asthma, attacks of breathlessness, and hay fever. Hardly any changes in prevalences and odds ratios were noted when initial responders were compared with all responders. The additional contribution of sending reminder letters and conducting a telephone follow-up to prevalence estimates and the exposure-disease relation was small. A single letter would have produced nearly the same prevalence estimates and risk factor associations.