A clinic-based mammography intervention targeting inner-city women

Shared decision-making for supporting women's decisions about breast cancer screening

BACKGROUND

In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain.

OBJECTIVES

To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health.

MAIN RESULTS

We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured.

AUTHORS' CONCLUSIONS

Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis

OBJECTIVE

Attendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.

DESIGN

CINAHL, Cochrane Library, Embase, Medline, OVID, PsycINFO and Web of Science were searched for studies of any design, published January 1987-June 2019, and reporting attendance in relation to at least one patient-level factor.

DATA SYNTHESIS

Independent reviewers performed screening, data extraction and quality appraisal. OR and 95% CIs were calculated for attendance for each factor and random-effects meta-analysis was undertaken where possible.

RESULTS

Of 19 776 studies, 335 were assessed at full text and 66 studies (n=22 150 922) were included. Risk of bias was generally low. In meta-analysis, increased attendance was associated with higher socioeconomic status (SES) (n=11 studies; OR 1.45, 95% CI: 1.20 to 1.75); higher income (n=5 studies; OR 1.96, 95% CI: 1.68 to 2.29); home ownership (n=3 studies; OR 2.16, 95% CI: 2.08 to 2.23); being non-immigrant (n=7 studies; OR 2.23, 95% CI: 2.00 to 2.48); being married/cohabiting (n=7 studies; OR 1.86, 95% CI: 1.58 to 2.19) and medium (vs low) level of education (n=6 studies; OR 1.24, 95% CI: 1.09 to 1.41). Women with previous false-positive results were less likely to reattend (n=6 studies; OR 0.77, 95% CI: 0.68 to 0.88). There were no differences by age group or by rural versus urban residence.

CONCLUSIONS

Attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Variations in service delivery, screening programmes and study populations may influence findings. Our findings are of univariable associations. Underlying causes of lower uptake such as practical, physical, psychological or financial barriers should be investigated.

TRIAL REGISTRATION NUMBER

CRD42016051597.

Barriers and facilitators to breast reconstruction in ethnic minority women-A systematic review

INTRODUCTION

Post-mastectomy breast reconstruction (PMBR) is an important component of the multidisciplinary care of breast cancer patients. Despite the improved quality of life, significant racial disparities exist in the receipt of PMBR. Given the increasing population of Black, Asian and minority ethnic (BAME) women in UK, it is important to address this disparity. Our review aims to identify the barriers and facilitators influencing the uptake of PMBR in BAME women and raise awareness for physicians on interventions that could improve uptake of PMBR in BAME women.

METHODS

The methodology outlined by the Cochrane guidelines was used to structure this systematic review. Systematic searches for qualitative studies on barriers and/or facilitators to PMBR in ethnic women published in English were conducted. The following databases were searched from their inception up to June 2019: MEDLINE, EMBASE, PubMed, Cochrane Library, Google Scholar and Scopus. Reference lists of all included articles and relevant systematic reviews were also hand-searched for possible additional publications. Publication year or status restrictions were not applied. Only full text articles published in English and by peer reviewed journals are included. Exclusion criteria were as follows: quantitative studies on barriers and/or facilitators to PMBR, abstracts, conference proceedings, non-English language and non-specific to BAME women. A thematic synthesis approach was used through the development of sub-themes and themes from the findings of the included qualitative studies.

RESULTS

Five studies satisfied the inclusion and exclusion criteria. Three overarching themes emerged from our review: physician-associated factors (physician recommendations), patient-associated factors (knowledge, language, community and cultural, emotions, logistics, patient characteristics) and system-associated factors (insurance coverage, income status).

CONCLUSION

Our systematic review suggests that there is a paucity of data in the literature on the barriers and facilitators to PMBR in BAME women. Considering the expanding population of BAME women and increasing breast cancer incidence, it is imperative that future research in this field is carried out. Physician and patient-associated factors were identified as the most important yet modifiable factors. Adopting a combination of culturally tailored interventions targeting these factors may help improve the access of PMBR in BAME women.

REGISTRATION

Prospero ID: CRD42019133233.

A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases

Transportation is an important social determinant of health. Transportation barriers disproportionately affect the most vulnerable groups of society who carry the highest burden of chronic diseases; therefore, it is critical to identify interventions that improve access to transportation. We synthesized evidence concerning the types and impact of interventions that address transportation to chronic care management. A systematic literature search of peer-reviewed studies that include an intervention with a transportation component was performed using three electronic databases-PubMed, EMBASE, and CINAHL-along with a hand-search. We screened 478 unique titles and abstracts. Two reviewers independently evaluated 41 full-text articles and 10 studies met eligibility criteria for inclusion. The transportation interventions included one or more of the following: providing bus passes (n = 5), taxi/transport vouchers or reimbursement (n = 3), arranging or connecting participants to transportation (n = 2), and a free shuttle service (n = 1). Transportation support was offered within multi-component interventions including counseling, care coordination, education, financial incentives, motivational interviewing, and navigation assistance. Community health/outreach workers (n = 3), nurses (n = 3), and research or clinic staff (n = 3) were the most common interventionists. Studies reported improvements in cancer screening rates, chronic disease management, hospital utilization, linkage and follow up to care, and maternal empathy. Overall, transportation is a well-documented barrier to engaging in chronic care among vulnerable populations. We found evidence suggesting transportation services offered in combination with other tailored services improves patient health outcomes; however, future research is warranted to examine the separate impact of transportation interventions that are tested within multi-component studies.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Monitoring and Developing a Volunteer Patient Navigation Intervention to Improve Mammography Compliance in a Safety Net Hospital

PURPOSE:

Although mammography screening is crucial for cancer detection, screening rates have been declining, particularly in patients of low socioeconomic status and minorities. We sought to evaluate and improve the compliance rates at our safety net hospital through a prospective randomized controlled trial of a volunteer-run patient navigation intervention.

METHODS:

Baseline 90-day institutional mammography compliance rates were evaluated for patients who received a physician order for screening mammograms over a 1-month period. This analysis aided in the creation of a prospective randomized controlled trial of a volunteer-run patient navigation intervention to improve compliance, with 49 total participants. The primary outcome was 14-day mammography compliance rates. Secondary analysis examined the efficacy of the intervention with respect to patient demographics, prior mammography compliance, family history of cancer, beliefs on mammography, and past medical history.

RESULTS:

Analysis of baseline institutional compliance revealed a 47.87% compliance rate, with the majority of compliance occurring within 14 days of order placement. The patient navigation intervention significantly improved compliance by 34% (42% in the control group, 76% in the intervention group). Additional findings included significantly improved compliance in patients who believed they had a low susceptibility to cancer, those who understood the benefits of mammography and early diagnosis, those who had a prior mammogram, those who were employed, and those with a family history of cancer.

CONCLUSION:

A system to monitor compliance and intervene using patient navigation significantly improved mammography compliance of patients in a safety net hospital. The relatively straightforward design of this volunteer-based intervention makes it affordable, easily replicable, and perhaps beneficial at other institutions.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Rapid review of evaluation of interventions to improve participation in cancer screening services

Objective

Screening participation is spread differently across populations, according to factors such as ethnicity or socioeconomic status. We here review the current evidence on effects of interventions to improve cancer screening participation, focussing in particular on effects in underserved populations.

Methods

We selected studies to review based on their characteristics: focussing on population screening programmes, showing a quantitative estimate of the effect of the intervention, and published since 1990. To determine eligibility for our purposes, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search and expanded this until the search yielded eligible papers on title review which were less than 1% of the total. We classified the eligible studies by intervention type and by the cancer for which they screened, while looking to identify effects in any inequality dimension.

Results

The 68 papers included in our review reported on 71 intervention studies. Of the interventions, 58 had significant positive effects on increasing participation, with increase rates of the order of 2%–20% (in absolute terms).

Conclusions

Across different countries and health systems, a number of interventions were found more consistently to improve participation in cancer screening, including in underserved populations: pre-screening reminders, general practitioner endorsement, more personalized reminders for non-participants, and more acceptable screening tests in bowel and cervical screening.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Engaging diverse underserved communities to bridge the mammography divide

Background

Breast cancer screening continues to be underutilized by the population in general, but is particularly underutilized by traditionally underserved minority populations. Two of the most at risk female minority groups are American Indians/Alaska Natives (AI/AN) and Latinas. American Indian women have the poorest recorded 5-year cancer survival rates of any ethnic group while breast cancer is the number one cause of cancer mortality among Latina women. Breast cancer screening rates for both minority groups are near or at the lowest among all racial/ethnic groups. As with other health screening behaviors, women may intend to get a mammogram but their intentions may not result in initiation or follow through of the examination process. An accumulating body of research, however, demonstrates the efficacy of developing 'implementation intentions' that define when, where, and how a specific behavior will be performed. The formulation of intended steps in addition to addressing potential barriers to test completion can increase a person's self-efficacy, operationalize and strengthen their intention to act, and close gaps between behavioral intention and completion. To date, an evaluation of the formulation of implementation intentions for breast cancer screening has not been conducted with minority populations.

Methods/Design

In the proposed program, community health workers will meet with rural-dwelling Latina and American Indian women one-on-one to educate them about breast cancer and screening and guide them through a computerized and culturally tailored "implementation intentions" program, called Healthy Living Kansas - Breast Health, to promote breast cancer screening utilization. We will target Latina and AI/AN women from two distinct rural Kansas communities. Women attending community events will be invited by CHWs to participate and be randomized to either a mammography "implementation intentions" (MI²) intervention or a comparison general breast cancer prevention informational intervention (C). CHWs will be armed with notebook computers loaded with our Healthy Living Kansas - Breast Health program and guide their peers through the program. Women in the MI² condition will receive assistance with operationalizing their screening intentions and identifying and addressing their stated screening barriers with the goal of guiding them toward accessing screening services near their community. Outcomes will be evaluated at 120-days post randomization via self-report and will include mammography utilization status, barriers, and movement along a behavioral stages of readiness to screen model.

Discussion

This highly innovative project will be guided and initiated by AI/AN and Latina community members and will test the practical application of emerging behavioral theory among minority persons living in rural communities.

Trial Registration

ClinicalTrials (NCT): NCT01267110

Cancer screening practices among physicians serving Chinese immigrants

Chinese immigrants in the United States are broadly affected by cancer health disparities. We examined the cancer screening attitudes and practices of physicians serving Chinese immigrants in the New York City (NYC) area by mailing a cancer screening survey, based on current guidelines, to a random sample of physicians serving this population. Fifty three physicians (44%) completed the survey. Seventy-two percent reported following the guidelines for breast cancer, 35% for cervical cancer screening, and 45% for all colorectal cancer screening tests. Sixty-eight percent of physicians were satisfied with their current rates of cancer screening with their Chinese immigrant patient population. Physicians serving the Chinese community in NYC follow cancer screening guidelines inadequately. Cancer screening rates in this population could likely be increased by interventions that target physicians and improve awareness of guidelines and recommended best practices.

Lower adherence to screening mammography guidelines among ethnic minority women in America: a meta-analytic review

OBJECTIVE

This study investigates the association between ethnic minority status and receiving a screening mammogram within the past 2 years among American women over 50.

METHOD

The findings from 33 studies identified from interdisciplinary research databases (1980 to 2006) were synthesized. Separate pooled analyses compared white non-Hispanics to African Americans (28 outcomes), Hispanics (18 outcomes), and Asian/Pacific Islanders (10 outcomes).

RESULTS

Using the random effects model, results showed that African Americans were screened less than white non-Hispanics at a marginal level (OR 0.87, 95% CI 0.75, 1.00). Larger and significant discrepancies were observed for Hispanics (OR 0.65, 95% CI 0.50, 0.85) and Asian/Pacific Islanders (OR 0.63, 95% CI 0.39, 0.99) compared to white non-Hispanics. However, among studies controlling for socioeconomic status, ethnic differences in mammography screening were no longer significant for African Americans (OR 1.05, 95% CI 0.71, 1.76), Hispanics (OR 1.08, 95% CI 0.64, 1.93), or Asian/Pacific Islanders (OR 1.08, 95% CI 0.64, 1.93). Subgroup analyses further showed that geographical region, sampling method, and data collection strategy significantly impacted results.

CONCLUSIONS

This study found evidence that ethnic minority-screening mammography differences exist but were impacted by socioeconomic status. Implications for interpreting existing knowledge and future research needs are discussed.

Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials

Preventive care measures remain underutilized despite recommendations to increase their use. The objective of this review was to examine the characteristics, types, and effects of paper- and computer-based interventions for preventive care measures. The study provides an update to a previous systematic review. We included randomized controlled trials that implemented a physician reminder and measured the effects on the frequency of providing preventive care. Of the 1,535 articles identified, 28 met inclusion criteria and were combined with the 33 studies from the previous review. The studies involved 264 preventive care interventions, 4,638 clinicians and 144,605 patients. Implementation strategies included combined paper-based with computer generated reminders in 34 studies (56%), paper-based reminders in 19 studies (31%), and fully computerized reminders in 8 studies (13%). The average increase for the three strategies in delivering preventive care measures ranged between 12% and 14%. Cardiac care and smoking cessation reminders were most effective. Computer-generated prompts were the most commonly implemented reminders. Clinician reminders are a successful approach for increasing the rates of delivering preventive care; however, their effectiveness remains modest. Despite increased implementation of electronic health records, randomized controlled trials evaluating computerized reminder systems are infrequent.

Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women

The authors conduct a systematic review of the literature to identify interventions designed to enhance breast cancer screening, diagnosis, and treatment among minority women. Most trials in this area have focused on breast cancer screening, while relatively few have addressed diagnostic testing or breast cancer treatment. Among patient-targeted screening interventions, those that are culturally tailored or addressed financial or logistical barriers are generally more effective than reminder-based interventions, especially among women with fewer financial resources and those without previous mammography. Chart-based reminders increase physician adherence to mammography guidelines but are less effective at increasing clinical breast examination. Several trials demonstrate that case management is an effective strategy for expediting diagnostic testing after screening abnormalities have been found. Additional support for these and other proven health care organization-based interventions appears justified and may be necessary to eliminate racial and ethnic breast cancer disparities.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Are Tri-Ethnic Low-Income Women with Breast Cancer Effective Teachers of the Importance of Breast Cancer Screening to Their First-Degree Relatives? Results from a Randomized Clinical Trial

The purpose of this study was to determine the efficacy of women with breast cancer as teachers of the importance of breast cancer screening to their first-degree female relatives. The sample was restricted to low-income working age women recruited from four hospitals. The study design was a randomized clinical trial. At each hospital, breast cancer patients (probands) were randomized into one of two study groups: (i) intensive, individual educational training on breast cancer screening or (ii) standard clinic education on breast cancer screening. The probands were instructed to teach at least one of their first-degree female relatives (21+ years of age) about breast cancer screening techniques. Three to six months after the enrollment of the probands, their relatives were contacted by telephone to determine breast cancer screening practices. A total of 79 probands and 96 relatives participated in the study. Relatives in the education group when compared with the control group were: 1.25 times more likely to have clinical breast examination (p = 0.005), 2.83 times more likely to have scheduled a clinical breast examination (p = 0.046), and, 1.36 times more likely to have been told about performing breast self-examination (p = 0.05). Additionally, relatives in the education group were more likely to have received a pamphlet on breast cancer screening (RR = 1.58, p = 0.009) and have discussed the importance of breast cancer screening (RR = 1.33, p = 0.020) from the proband. Special education training did not impact mammography utilization of the relatives. From these findings, a tri-ethnic group of low-income women with breast cancer can be effective teachers of breast cancer screening practices, at least for promoting clinical breast examination and transmitting messaging for performance of breast self-examination if given the adequate training.

A randomized controlled trial to increase cancer screening among attendees of community health centers

BACKGROUND

We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations.

METHODS

Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT).

RESULTS

In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096).

CONCLUSIONS

The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

Cost-effectiveness analysis of interventions to enhance mammography compliance using computer modeling (CAN*TROL)

OBJECTIVE

Tailored telephone counseling and physician-based and clinic-based interventions have been shown to be cost-effective in enhancing utilization of mammography among nonadherent women. The objective of this study was to evaluate the costs and benefits of a broad implementation of these interventions from a health payer perspective.

METHODS

CAN*TROL computer modeling was employed in the cost-effectiveness analysis of interventions in a 2000 Texas female population. The estimated effects of the various interventions and their related costs derived from the literature were applied to a hypothetical scenario of a broad implementation of these interventions.

RESULTS

Seven studies were identified from the literature, six of them employed tailored telephone counseling (TC), whereas two used comprehensive physician-based (PB) or clinic-based (CB) interventions. The estimated intervention cost per women was 43 dollars for TC, 71 dollars for PB, and 151 dollars for CB. CAN*TROL model showed that after 15 years of implementation, TC, PB, and CB could reduce cancer mortality by 6.5, 2.2, and 10.7%, respectively. The cumulative net costs of interventions, mammography screening, and medical care costs were lower for TC (TC vs. PB vs. CB, 1.05 million vs. 1.06 million vs. 1.60 million). Nevertheless, CB resulted in more life-years saved (TC vs. PB vs. CB, 11,413 vs. 8515 vs. 14,559). The incremental cost-effectiveness ratio was more favorable for tailored telephone counseling interventions. One-way sensitivity analysis indicated that compliance rates and intervention costs had the most significant impact on the incremental cost-effectiveness ratio.

CONCLUSION

Tailored telephone counseling interventions may be the preferred first-line intervention for getting nonadherent women aged 50 to 79 years on schedule for mammography screening.

Improving cancer screening among lesbians over 50: results of a pilot study

PURPOSE/OBJECTIVES

To explore the impact of two one-hour lesbian-specific educational interventions by a lesbian physician on the cancer screening behaviors of lesbians.

DESIGN

A pilot pre- and post-test intervention study.

SETTING

Two lesbian, gay, bisexual, and transgendered senior organizations in the San Francisco Bay Area (one urban, one suburban).

SAMPLE

36 participants aged 50-81 (meanX = 60.2, SD = 6.48). The majority were Caucasian (86%), single (61%), living in urban areas (67%), employed (56%), and educated beyond high school (meanX = 15.47 years, SD = 2.90, range 9-21). Eleven percent (n = 4) did not have any health insurance and were not on Medicaid or Medicare.

METHODS

A lesbian physician led a one-hour, didactic, lesbian- specific educational program on cancer screening, including a review of current research findings with regard to lesbians' risk for cancer and 45 minutes of information on recommended cancer screening, followed by a 15-minute question-and-answer period. Participants completed a pre- and postintervention survey.

FINDINGS

Follow-up data were available for 22 women. Of the six women (27%) who had not focused their attention on breast screening behaviors for two years or more, one-third had obtained mammograms and half began performing monthly breast self-examinations. Of the four women (18%) who had not undergone a pelvic examination for three years or more, one obtained a pelvic examination. The women reported no changes in colorectal cancer screening behaviors.

CONCLUSIONS

Some of these difficult-to-reach women changed their behavior in a very short period of time, supporting the need for a larger study to confirm these findings.

IMPLICATIONS FOR NURSING

A need exists to develop appropriate interventions for the underserved population of lesbians older than 50.

Provider characteristics and mammography recommendation among women in their 40s and 50s

OBJECTIVES

Healthcare provider recommendation for mammography is one of the strongest predictors of women's mammography use, but few studies have examined the association of provider characteristics with mammography recommendations. We examined the relationship of provider gender, age, medical specialty, and duration of relationship with the patient to report mammography recommendation.

METHODS

Participants were women ages 40-45 and 50-55 who were part of a larger intervention study of decision making about mammography. We examined the relationship of provider characteristics to patient-reported mammography recommendations at baseline and at 24-month follow-up.

RESULTS

At baseline, 74% of women in their 40s and 79% of women in their 50s reported provider mammography recommendations within the prior 2 years. Proportions were similar at the 24-month follow-up. In multivariate logistic regression models including both patient and provider characteristics, women in their 40s who had female providers were more likely to report mammography recommendations than those with male providers at baseline (OR=1.83, p=0.01) and follow-up (OR=1.74, p=0.03). Among women in their 50s, participants whose regular providers were primary care physicians were more likely to report recommendations at baseline than those whose regular providers were obstetrician/gynecologists (OR=1.68, p=0.03).

CONCLUSIONS

About one fourth of women in this study reported not having been advised by a healthcare provider to have a mammogram. All women in the study had health insurance. Among women in their 40s, for whom mammography guidelines were controversial at the time of data collection, provider gender was an important predictor of patient-reported mammography recommendation.

Costs and cost-effectiveness of a clinical intervention to increase mammography utilization in an inner city public health hospital

BACKGROUND

Studies have demonstrated the cost-effectiveness of screening women for breast cancer; however, the cost-effectiveness of strategies to motivate women to receive breast cancer screening has been less well studied.

METHODS

A total of 196 women, aged 50 to 74, who were enrolled in a public health hospital clinic, were noncompliant with mammography screening, and had at least one routine clinic appointment during the study period (15 months) were entered into a randomized, controlled trial of a motivational intervention to increase mammography rates. Costs were captured via a modified Delphi technique, accounting records, sampling of staff time logs, and an estimation of miscellaneous and overhead costs. Summary costs were calculated using Excel spread sheets.

RESULTS

Overall, 49% of women who received the intervention had a mammogram within 8 weeks of an index visit compared with 22% of control women. Calculation of the cost-effectiveness of the project showed an additional cost of $151 (1996 U.S.$) for each woman receiving the intervention and $559 for each additional woman motivated to receive a mammogram.

CONCLUSIONS

Cost tracking and cost-effectiveness analysis can be done when intervening in a clinical setting, thereby allowing clinics to make informed decisions about implementing programs to increase motivation of their patients to receive screening.

Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics?

Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women.

Feasibility of a tailored intervention to improve preventive care use in women

BACKGROUND

Women age 50 years and older are in need of multiple preventive health care services. Despite recent improvements in rates of delivery of preventive care services, especially within managed care organizations, substantial numbers of women are still being underscreened. Efforts to improve delivery of preventive care services have often focused on one outstanding service despite the fact that patients often are in need of many services.

METHODS

A total of 893 women age 50 to 55 years were mailed a self-administered survey to identify outstanding preventive health care service needs. Patients in need of three or more outstanding preventive health care services were identified from survey respondents to participate in a feasibility study evaluating a tailored, customized intervention called Tic Tac Health.

RESULTS

Five-hundred ninety-one women returned the survey (67%). Four-hundred forty-eight (76%) women were in need of one or more preventive health services; 92 (16%) were in need of three or more. Twenty-two patients (24%) completed the Tic Tac Health card. The women who completed the card were similar to those who did not.

CONCLUSIONS

Despite documented physician visits, presence of managed care health insurance, and a designated primary care provider, a significant number of women are still in need of multiple preventive health services. An intervention targeting multiple preventive health services was demonstrated to be both feasible and effective. Further evaluation via a randomized controlled trial should be conducted to determine if an intervention like Tic Tac Health would be an effective modality for improving rates of receipt of multiple preventive health care services.