The safety net: a cost-effective approach to improving breast and cervical cancer screening

Reasons for Non-Attendance in the German National Mammography Screening Program: Which Barriers Can Be Overcome Using Telephone Counseling?-A Randomized Controlled Trial

INTRODUCTION

Germany has established a national mammography screening program (MSP). Despite extensive awareness campaigns, the participation rate is only 54%, which is considerably below the European guidelines' recommendation of at least 70%. Several reasons why women do not participate are already known. Telephone consultations along with invitation letters have improved the participation rate. Here, we analyzed the reasons for non-participation and offered barrier-specific counseling to examine which impediments can be overcome to improve participation.

STUDY DESIGN

In a randomized controlled trial, women who had not attended their proposed screening appointment in the MSP after a written invitation were contacted by telephone and asked why they did not attend. Barrier-specific counseling via telephone was then offered. Participation in the MSP was rechecked 3 months after counseling.

SETTING

1772 women, aged 50-69 years, who had not scheduled a mammography screening after a written invitation were contacted by telephone and asked for their reasons for non-participation.

INTERVENTION

The reasons were recorded by the calling consultant and categorized either during the call or later based on their recorded statements. Afterward, the women received counseling specific to their statements and were given general information about the MSP.

MAIN OUTCOME MEASURES

We categorized the reasons given, calculated their frequency, and analyzed the probabilities to which they could be successfully addressed in individual counseling. Participation rates were determined post-consultation according to the reason(s) indicated.

RESULTS

The data were analyzed in 2022. After exclusions, 1494 records were analyzed. Allowing for multiple reasons to be stated by every individual 3280 reasons for not attending were abstracted. The most frequent reason was participation in "gray screening" (51.5%), which included various breast cancer prevention measures outside the national MSP. Time problems (26.6%) and health reasons (17.3%) were also important. Counseling was most effective when women had not participated for scheduling reasons.

CONCLUSION

Several reasons prevented women from participating in the MSP. Some reasons, such as time-related issues, could be overcome by telephone counseling, but others, like barriers resulting from fear of the examination procedure or its result, could not.

Combined incentive actions, focusing on primary care professionals, to improve cervical cancer screening in women living in socioeconomically disadvantaged geographical areas: a study protocol of a hybrid cluster randomised effectiveness and implementation trial- RESISTE

INTRODUCTION

Cervical cancer (CC) causes thousands of deaths each year. Nearly 100% of cases are caused by oncogenic strains of human papillomavirus (HPV). In most industrialised countries, CC screening (CCS) is based on the detection of HPV infections. For many reasons including lower adherence to CCS, underserved women are more likely to develop CC, and die from it. We aim to demonstrate that the use of incentives could improve screening rates among this population.

METHODS AND ANALYSIS

Our cluster randomised, controlled trial will include 10 000 women aged 30-65 years eligible for CCS, living in deprived areas in four French departments, two mainlands and two overseas, and who did not perform physician-based HPV testing within the framework of the nationally organised screening programme. HPV self-sampling kit (HPVss) will be mailed to them. Two interventions are combined in a factorial analysis design ending in four arms: the possibility to receive or not a financial incentive of €20 and to send back the self-sampling by mail or to give it to a health professional, family doctor, gynaecologist, midwife or pharmacist. The main outcome is the proportion of women returning the HPVss, or doing a physician-based HPV or pap-smear test the year after receiving the HPVss. 12-month follow-up data will be collected through the French National Health Insurance database. We expect to increase the return rate of HPV self-samples by at least 10% (from 20% to 30%) compared with the postal return without economic incentive.

ETHICS AND DISSEMINATION

Ethics approval was first obtained on 2 April 2020, then on July 29 2022. The ethics committee classified the study as interventional with low risk, thus no formal consent is required for inclusion. The use of health insurance data was approved by the Commission Nationale Informatique et Libertés on 14 September 2021 (ref No 920276). An independent data security and monitoring committee was established. The main trial results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04312178.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

Cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening

BACKGROUND

Cervical cancer screening is effective in reducing mortality, but adherence is generally low. We aimed to investigate the cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening in Portugal.

METHODS

We developed a decision tree model to compare the cost-effectiveness of four competing interventions to increase adherence to cervical cancer screening: (i) a written letter (standard-of-care); (ii) automated short message service text messages (SMS)/phone calls/reminders; (iii) automated SMS/phone calls/reminders + manual phone calls; (iv) automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. The main outcome measure was cost per quality-adjusted life year (QALY) measured over a 5-year time horizon. Costs were calculated from the societal and provider perspectives.

RESULTS

From the societal perspective, the optimal strategy was automated SMS/phone calls/reminders, below a threshold of €8171 per QALY; above this and below €180 878 per QALY, the most cost-effective strategy was automated SMS/phone calls/reminders + manual phone calls and above this value automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. From the provider perspective, the ranking of the three strategies in terms of cost-effectiveness was the same, for thresholds of €2756 and €175 463 per QALY, respectively.

CONCLUSIONS

Assuming a willingness-to-pay threshold of one time the national gross domestic product (€22 398/QALY), automated SMS/phone calls/reminders + manual phone calls is a cost-effective strategy to promote adherence to cervical cancer screening, both from the societal and provider perspectives.

Defining health-related quality of life in localized and advanced stages of breast cancer - the first step towards hereditary cancer genetic counseling

The important goal in breast cancer treatment is to improve patient quality of life. Due to the huge economic burden, it is necessary to estimate the health state utility values for different breast cancer stages accurately. A group of 114 women filled out the EuroQol-5D-3L questionnaire at two time points. The participants were divided into three groups, as follows: group 1 including healthy high-risk individuals; group 2 including patients with localized stage breast cancer; and group 3 including patients with advanced stage breast cancer. Results were expressed either as summary health state utility score or summary visual-analog score. The EuroQol utility index score and EuroQol visual-analog score were statistically significantly higher in the group of healthy high-risk individuals. The EuroQol visual-analog score was mostly correlated with the anxiety/depression and pain/discomfort quality of life dimensions. Health state utility values for different breast cancer stages are a necessary tool to perform economic analyses in breast cancer management decision making, due to its huge economic burden. Special attention should be paid to assessment of the psychosocial aspects of the disease, as well as pain management.

Impact of human papillomavirus (HPV) self-collection on subsequent cervical cancer screening completion among under-screened US women: MyBodyMyTest-3 protocol for a randomized controlled trial

Background

Screening substantially reduces cervical cancer incidence and mortality. More than half of invasive cervical cancers are attributable to infrequent screening or not screening at all. The current study, My Body My Test (MBMT), evaluates the impact of mailed kits for self-collection of samples for human papillomavirus (HPV) testing on completion of cervical cancer screening in low-income, North Carolina women overdue for cervical cancer screening.

Methods/design

The study will enroll at least 510 US women aged 25–64 years who report no Pap test in the last 4 years and no HPV test in the last 6 years. We will randomize participants to an intervention or control arm. The intervention arm will receive kits to self-collect a sample at home and mail it for HPV testing. In both the intervention and control arms, participants will receive assistance in scheduling an appointment for screening in clinic. Study staff will deliver HPV self-collection results by phone and assist in scheduling participants for screening in clinic. The primary outcome is completion of cervical cancer screening. Specifically, completion of screening will be defined as screening in clinic or receipt of negative HPV self-collection results. Women with HPV-negative self-collection results will be considered screening-complete. All other participants will be considered screening-complete if they obtain co-testing or Pap test screening at a study-affiliated institution or other clinic. We will assess whether the self-collection intervention influences participants’ perceived risk of cervical cancer and whether perceived risk mediates the relationship between HPV self-collection results and subsequent screening in clinic. We also will estimate the incremental cost per woman screened of offering at-home HPV self-collection kits with scheduling assistance as compared to offering scheduling assistance alone.

Discussion

If mailed self-collection of samples for HPV testing is an effective strategy for increasing cervical cancer screening among women overdue for screening, this method has the potential to reduce cervical cancer incidence and mortality in medically underserved women at higher risk of developing cervical cancer.

Trial registration

ClinicalTrials.gov NCT02651883, Registered on 11 January 2016.

A 3-step intervention to improve adherence to cervical cancer screening: The SCAN randomized controlled trial

The aim of this study was to test the effectiveness of a stepwise intervention with an increasing level of complexity and cost to increase adherence to organized cervical cancer screening. This was a randomized (1: 1) controlled trial, conducted among 13 Portuguese primary health care units. Participants (n = 1220) were women aged 25-49 years, eligible for cervical cancer screening, with a mobile phone number available. The tested intervention was a 3-step invitation to screening, based on automated text messages/phone calls (step 1), manual phone calls (step 2) and face-to-face interviews (step 3), applied sequentially to non-adherent women after each step. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women screened, which was assessed after step 1 (45 days after the initial invitation), steps 1 + 2 (90 days after the initial invitation) and steps 1 + 2 + 3 (150 days after the initial invitation). Adherence to cervical cancer screening was significantly higher among women assigned to the intervention than those in the control group for step 1 (39.9% vs. 25.7%, p < 0.001), steps 1 + 2 (48.6% vs. 30.7%, p < 0.001) and steps 1 + 2 + 3 (51.2% vs. 34.0%, p < 0.001). In conclusion, adherence to cervical cancer screening was higher by 17% among women invited through the 3-step intervention, compared to those receiving the standard invitation letter. The former strategy has the potential to be broadly implemented due to the low requirements of technology and training. Clinical Trial Registration: NCT03122275.

A 4-year randomized trial comparing three outreach interventions to promote screening mammograms

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.

Stepwise strategy to improve cervical cancer screening adherence (SCAN-Cervical Cancer) - Automated text messages, phone calls and reminders: Population based randomized controlled trial

The aim of this study was to test the effectiveness of invitation to cervical cancer screening through a very low-cost strategy based on automated and customized text messages, phone calls and reminders. A randomized (1:1) controlled trial was conducted among 13 Portuguese primary care units, recruiting women aged 25 to 49 years, eligible for cervical cancer screening, with an available mobile phone number. In the intervention group, participants were invited for cervical cancer screening through automated/customized text messages and phone calls, followed by text message reminders. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women adherent to screening up to 45 days after invitation and the secondary outcome was defined as the adherence proportion after invitation based only on text messages and reminders. A total of 1220 women were randomized, 605 to intervention and 615 to control group. The adherence to cervical cancer was significantly higher among women assigned to intervention (39.0% vs. 25.7%, p < 0.001); this corresponds to a difference of 13.3% (95% CI 8.1 to 18.5). The difference in adherence between an invitation strategy based only on text messages and reminders and the standard of care was -0.4%, 95% CI -5.3 to 4.5. In conclusion, an invitation to cervical cancer screening using automated text messages/phone calls and reminders increases the adherence to cervical cancer screening. Such a low-cost and operator-independent strategy of invitation may contribute to the sustainability of organized screening programs.

TRIAL REGISTRATION NUMBER

NCT03122275.

Stepwise strategy to improve Cervical Cancer Screening Adherence (SCAN-CC): automated text messages, phone calls and face-to-face interviews: protocol of a population-based randomised controlled trial

INTRODUCTION

Screening is highly effective for cervical cancer prevention and control. Population-based screening programmes are widely implemented in high-income countries, although adherence is often low. In Portugal, just over half of the women adhere to cervical cancer screening, contributing for greater mortality rates than in other European countries. The most effective adherence raising strategies are based on patient reminders, small/mass media and face-to-face educational programmes, but sequential interventions targeting the general population have seldom been evaluated. The aim of this study is to assess the effectiveness of a stepwise approach, with increasing complexity and cost, to improve adherence to organised cervical cancer screening: step 1a-customised text message invitation; step 1b-customised automated phone call invitation; step 2-secretary phone call; step 3-family health professional phone call and face-to-face appointment.

METHODS

A population-based randomised controlled trial will be implemented in Portuguese urban and rural areas. Women eligible for cervical cancer screening will be randomised (1:1) to intervention and control. In the intervention group, women will be invited for screening through text messages, automated phone calls, manual phone calls and health professional appointments, to be applied sequentially to participants remaining non-adherent after each step. Control will be the standard of care (written letter). The primary outcome is the proportion of women adherent to screening after step 1 or sequences of steps from 1 to 3. The secondary outcomes are: proportion of women screened after each step (1a, 2 and 3); proportion of text messages/phone calls delivered; proportion of women previously screened in a private health institution who change to organised screening. The intervention and control groups will be compared based on intention-to-treat and per-protocol analyses.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Northern Health Region Administration and National Data Protection Committee. Results will be disseminated through communications in scientific meetings and peer-reviewed journals.

TRIAL NUMBER

NCT03122275.

The relationship between four health-related quality-of-life indicators and use of mammography and Pap test screening in US women

PURPOSE

Limited evidence is available to explain the role of four components of health-related quality of life (HRQoL) on breast and cervical cancer screening. The objective of this study was to determine the relationship between four HRQoL aspects and use of mammography and Pap test screening in US women.

METHODS

Data were obtained from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). The outcome variables were receiving mammogram <2 versus ≥2 years in women aged 50-74 years, and receiving Pap test <3 versus ≥3 years in women aged 18-64 years. Eight logistic regression models were conducted to test the role of four HRQoL aspects (general health status, physical HRQoL, mental HRQoL, and activity limitation) on the two screening variables, after adjusting for covariates. Statistical analysis accounted for the complex sampling design of the BRFSS, and the a priori alpha error was set at p ≤ 0.05.

RESULTS

Among respondents, approximately 74 and 78 % of the women received mammography and Pap test, respectively. Three HRQoL aspects (general health status, physical HRQoL, and activity limitation) were significantly associated with mammography use (all p values < 0.05), whereas two HRQoL aspects (general health status and physical HRQoL) were significantly associated with Pap test (p values ≤ 0.05). All significant relationships demonstrated higher cancer screening rates among individuals with better HRQoL.

CONCLUSIONS

HRQoL is an important factor associated with use of mammography and Pap test. Future studies should explore the mechanisms associated with an individual's HRQoL and use HRQoL assessment as an avenue to influence adherence to use of mammography and Pap tests.

Implementation challenges and successes of a population-based colorectal cancer screening program: a qualitative study of stakeholder perspectives

Background

Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Our qualitative study explored viewpoints of multilevel stakeholders before, during, and after implementation of a centralized outreach program. Program implementation was part of a broader quality-improvement initiative.

Methods

During 2008–2010, we conducted semi-structured, open-ended individual interviews and focus groups at Kaiser Permanente Northwest (KPNW), a not-for-profit group model health maintenance organization using the practical robust implementation and sustainability model to explore external and internal barriers to CRC screening. We interviewed 55 stakeholders: 8 health plan leaders, 20 primary care providers, 4 program managers, and 23 endoscopy specialists (15 gastroenterologists, 8 general surgeons), and analyzed interview transcripts to identify common as well as divergent opinions expressed by stakeholders.

Results

The majority of stakeholders at various levels consistently reported that an automated telephone-reminder system to contact patients and coordinate mailing fecal tests alleviated organizational constraints on staff’s time and resources. Changing to a single-sample fecal immunochemical test (FIT) lessened patient and provider concerns about feasibility and accuracy of fecal testing. The centralized telephonic outreach program did, however, result in some screening duplication and overuse. Higher rates of FIT completion and a higher proportion of positive results with FIT required more colonoscopies.

Conclusions

Addressing barriers at multiple levels of a health system by changing the delivery system design to add a centralized outreach program, switching to a more accurate and easier-to-use fecal test, and providing educational and electronic support had both benefits and problematic consequences. Other health care organizations can use our results to understand the complexities of implementing centralized screening programs.

Is the phone call the most effective method for recall in cervical cancer screening?--results from a randomised control trial

OBJECTIVE

To compare the effectiveness of different methods of recall for repeat Pap smear among women who had normal smears in the previous screening.

DESIGN

Prospective randomized controlled study.

SETTING

All community clinics in Klang under the Ministry of Health Malaysia.

PARTICIPANTS

Women of Klang who attended cervical screening and had a normal Pap smear in the previous year, and were due for a repeat smear were recruited and randomly assigned to four different methods of recall for repeat smear.

INTERVENTION

The recall methods given to the women to remind them for a repeat smear were either by postal letter, registered letter, short message by phone (SMS) or phone call.

MAIN OUTCOME MEASURES

Number and percentage of women who responded to the recall within 8 weeks after they had received the recall, irrespective whether they had Pap test conducted. Also the numbers of women in each recall method that came for repeat Pap smear.

RESULTS

The rates of recall messages reaching the women when using letter, registered letter, SMS and phone calls were 79%, 87%, 66% and 68%, respectively. However, the positive responses to recall by letter, registered letter, phone messages and telephone call were 23.9%, 23.0%, 32.9% and 50.9%, respectively (p<0.05). Furthermore, more women who received recall by phone call had been screened (p<0.05) compared to those who received recall by postal letter (OR=2.38, CI=1.56-3.62).

CONCLUSION

Both the usual way of sending letters and registered letters had higher chances of reaching patients compared to using phone either for sending messages or calling. The response to the recall method and uptake of repeat smear, however, were highest via phone call, indicating the importance of direct communication.

Cervical cancer screening with AMIGAS: a cost-effectiveness analysis

BACKGROUND

Hispanic women have a higher incidence of cervical cancer than all other races and ethnicities. In Hispanic subgroups, Mexican American women were among the least likely to have received cervical cancer screening. In a recent RCT, Ayudando a las Mujeres con Información, Guia, y Amor para su Salud (AMIGAS) was shown to increase cervical cancer screening rates among women of Mexican descent at 6 months in all intervention arms compared to the control arm. Limited information exists about the economics of interventions to increase cervical cancer screening rates among women of Mexican descent.

PURPOSE

This study aims to estimate the cost-effectiveness of the alternative AMIGAS intervention methods for increasing cervical cancer screening among low-income women of Mexican descent in three U.S. communities.

METHODS

Cost data were collected from 2008 to 2011 alongside the AMIGAS study of 613 women. Receipt of Pap test within 6 months of intervention was the primary outcome measure in the cost-effectiveness analysis, conducted during 2012-2013.

RESULTS

The cost per additional woman screened comparing the video-only intervention to usual care was $980. The cost increased to $1,309 with participant time cost included. With an additional cost per participant of $3.90 compared to flipchart only, the full AMIGAS program (video plus flipchart) yielded 6.8% additional women screened.

CONCLUSIONS

Results on the average and incremental cost-effectiveness of the AMIGAS program elements may assist health policymakers and program managers to select and appropriately budget for interventions shown to increase cervical cancer screening among low-income women of Mexican descent.

Cervical cancer screening: a prospective cohort study of the effects of historical patient compliance and a population-based informatics prompted reminder on screening rates

AIMS AND OBJECTIVES

The aim of this study was to assess the impact of historical screening compliance with the effectiveness of patient reminder letters on cervical cancer screening rates.

METHOD

Using population-based informatics systems, women with no cervical cancer screening in the prior 3 years were identified in two primary care clinics, Mayo Family Clinic Northeast (NE; n = 1613) and Northwest (NW; n = 1088). Patients were divided into two compliance groups: overdue/unknown screening status at study start or previously compliant. The NE Clinic sent reminder letters over a 6 months window to patients eligible for screening at the study start or during the study that were also identified as employees/dependents (E/D). There were 795 intervention (NE Clinic E/D patients) and 1906 control subjects. Using an intent-to-treat analysis, differences in screening rates were assessed.

RESULTS

A higher unadjusted screening rate was observed for the E/D group than the non-E/D group at both sites (32.7 versus 18.2% at NW, P < 0.001; 39.0 versus 14.7% at NE, P < 0.001). For the historically compliant group, unadjusted screening rates were higher for those who received letters (E/D subjects at NE) versus those who did not (E/D subjects at NW; 56.1 versus 44.5%, P = 0.01). No difference was observed between E/D subjects at NE (received letters) and NW (no letters) for the overdue/unknown group (27.4 versus 25.9%, P = 0.62). There was no difference in screening rates for non-E/D subjects at NE versus at NW (none of whom received letters) for both the compliant (24.2 versus 30.6%, P = 0.18) and the overdue/unknown groups (11.9 versus 13.0%, P = 0.59). Multivariate logistic regression models showed a significant overall effect of E/D status (P = 0.006), compliance group (P < 0.001), and the interaction between clinic site and E/D status (P = 0.04).

CONCLUSION

Among insured women, reminder letters appear to improve cervical cancer screening rates for those with a history of screening compliance. Reminder letters appear insufficient to motivate women if screening is overdue. Further investigation of the cohort of women overdue for screening is needed to develop interventions to successfully target this group.

Improving cervical cancer screening rates in an urban HIV clinic

Human immunodeficiency virus (HIV)-infected women are at increased risk of invasive cervical cancer; however, screening rates remain low. The objectives of this study were to analyze a quality improvement intervention to increase cervical cancer screening rates in an urban academic HIV clinic and to identify factors associated with inadequate screening. Barriers to screening were identified by a multidisciplinary quality improvement committee at the Washington University Infectious Diseases clinic. Several strategies were developed to address these barriers. The years pre- and post-implementation were analyzed to examine the clinical impact of the intervention. A total of 422 women were seen in both the pre-implementation and post-implementation periods. In the pre-implementation period, 222 women (53%) underwent cervical cancer screening in the form of Papanicolaou (Pap) testing. In the post-implementation period, 318 women (75.3%) underwent cervical cancer screening (p < 0.01). Factors associated with lack of screening included fewer visits attended (pre: 4.2 ± 1.5; post: 3.4 ± 1.4; p < 0.01). A multidisciplinary quality improvement intervention was successful in overcoming barriers and increasing cervical cancer screening rates in an urban academic HIV clinic.

Effect size and cost-effectiveness estimates of breast and cervical cancer screening reminders by population size through complete enumeration of Japanese local municipalities

Background

Client reminders are known to increase cancer screening attendance rates. However, there are significant costs associated with them, and their effect by population size is unknown.

Methods

In 2007 and 2008, the Japanese Government surveyed breast and cervical cancer screening in every municipality in Japan. From the results, we selected all 1,464 municipalities that carried out both screening types. We examined whether changes in screening attendance rates between 2007 and 2008 were associated with client reminders, number of public health nurses per 100,000 population, financial strength index, and 2007 attendance rates for different population sizes. We then calculated cost-effectiveness estimates of client reminders by population size and screening type.

Results

Client reminders were associated with increased attendance rates in populations <100,000. For populations of 50,000–100,000, there was a 2.76% increase in breast cancer screening (95% CI: 0.41, 5.11), and a 2.25% increase in cervical cancer screening (95% CI: 0.89, 3.61). The incremental cost per additional attendance was higher in populations <50,000 than in populations of 50,000–100,000 (breast, $100 versus $54; cervical, $149 versus $67 respectively).

Conclusions

Client reminders for breast and cervical cancer screening increased attendance rates in smaller municipalities in Japan.

'Born in Michigan? You're in the biobank': engaging population biobank participants through Facebook advertisements

BACKGROUND/AIMS

Despite a broad call for biobanks to use social media, data is lacking regarding the capacity of social media tools, especially advertising, to engage large populations on this topic.

METHODS

We used Facebook advertising to engage Michigan residents about the BioTrust for Health. We conducted a low-budget (<USD 5,000), 26-day social media campaign targeting Michigan residents aged 18-28. We placed 25 Facebook advertisements and analyzed their performance in terms of reach and cost across 3 engagement types: passive, active and interactive. We compared engagement before, during and after the campaign.

RESULTS

The Facebook page was viewed 1,249 times during the month of the advertising campaign, versus once in the month prior. 779,004 Michigan residents saw ads an average of 25.8 times; 4,275 clicked ads; the average click-through-ratio was 0.021%. Interactions included 516 'likes' and 30 photo contest entries. Cost per outcome ranged from <USD 0.005 per exposure to USD 182 per photo entry. The average cost per click was USD 1.04.

CONCLUSION

A social media strategy to build public awareness about biobanking is not likely to be effective without a promotional 'push' to distribute content. Social media advertisements have the capacity to scale-up engagement on biobanking while keeping costs manageable. Facebook advertisements provide necessary access points for unaware participants, with implications for public trust.

Methods to increase participation in organised screening programs: a systematic review

BACKGROUND

The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs.

METHODS

We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000).

RESULTS

Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90).

CONCLUSION

Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

How to increase uptake in oncologic screening: a systematic review of studies comparing population-based screening programs and spontaneous access

BACKGROUND

Cervical, breast and colorectal cancer (CRC) screenings are universally recommended interventions. High coverage of the target population represents the most important factor in determining their success. This systematic review aimed at assessing the effectiveness of population-based screening programs in increasing coverage compared to spontaneous access.

METHODS

Electronic databases and national and regional websites were searched. We included all studies on interventions aimed at increasing screening participation published between 1999 and 2009; for those published before, we consulted the Jepson et al. review (2000). We compared spontaneous access (including no intervention) vs population-based screening programs actively inviting the target population. Among the latter, we compared GP-based vs invitation letter-based interventions.

RESULTS

The invitation letter vs no intervention showed significantly more participation (RR=1.60 95%CI 1.33-1.92; RR=1.52 95%CI 1.28-1.82; RR=1.15 95%CI 1.12-1.19, for breast, cervical and CRC screenings, respectively). GP-based interventions, although more heterogeneous, showed a significant effect when compared with no intervention for breast (RR=1.74 95%CI 1.25-2.43), but not for cervical and CRC. No significant differences were found between invitation letter-based and GP-based organization (RR=0.99 95%CI 0.94-1.05; RR=1.08 95%CI 0.99-1.17, for breast and cervical cancer, respectively).

CONCLUSION

Population-based programs are more effective than spontaneous screening in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective.

Effectiveness of interventions to increase the participation rate of gastric cancer screening in the Republic of Korea: a pilot study

This study assessed the effectiveness of three intervention strategies to improve the participation rate of gastric cancer screening among people who had never undergone such screening, and those who had been screened for the disease, but not recently. It was conducted in the Ilsandong-gu District of Goyang City, Korea. The population for the current study was restricted to male residents, aged 40-65 years, who received an invitation letter to undergo gastric cancer screening from the National Health Insurance (NHI) Corporation at the beginning of 2010. The subjects were divided into two categories according to their screening history: never-screened, and ever-screened. A total of 2,065 men were eligible: 803 never-screened and 1,262 ever-screened. In each screening category they were randomly assigned to one of three intervention groups: 1) tailored telephone counseling; 2) tailored postcard reminder after tailored telephone counseling;and 3) tailored telephone counseling after tailored postcard reminder. At 3 months post-intervention, never- screened men with any intervention were more likely to undergo gastric cancer screening (OR=2.75, 95% CI: 1.22-6.18) compared to those in the reference group (no intervention). However, there was no statistically significant intervention effect in ever-screened men (OR=1.21, 95% CI: 0.65-2.27). Examination of the intervention effects by intervention group among never-screened men showed that those in the postcard reminder after telephone counseling group to be statistically significantly more likely to undergo gastric cancer screening (OR=4.49, 95% CI: 1.79-11.29) than the reference group (no intervention). Our results highlight that use of tailored postcard reminders after tailored telephone counseling is an effective method to increase participation in gastric cancer screening among men who had never been screened.

Cervical cancer screening in the United States and the Netherlands: a tale of two countries

CONTEXT

This article compares cervical cancer screening intensity and cervical cancer mortality trends in the United States and the Netherlands to illustrate the potential of cross-national comparative studies. We discuss the lessons that can be learned from the comparison as well as the challenges in each country to effective and efficient screening.

METHODS

We used nationally representative data sources in the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. The following questions are addressed: How do differences in intensity of Pap smear use between the countries translate into differences in mortality trends? Can population coverage rates (the proportion of eligible women who had a Pap smear within a specified period) explain the mortality trends better than the total intensity of Pap smear use?

FINDINGS

Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries' mortality trends were quite similar. The five-year coverage rates for women aged thirty to sixty-four were quite comparable at 80 to 90 percent. Because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. These differences had consequences for age-specific mortality trends. The relatively good coverage rate in the Netherlands can be traced back to a nationwide invitation system based on municipal population registries. While both countries followed a "policy cycle" involving evidence review, surveillance of screening practices and outcomes, clinical guidelines, and reimbursement policies, the components of this cycle were more systematically linked and implemented nationwide in the Netherlands than in the United States. To a large extent, this was facilitated by a public health model of screening in the Netherlands, rather than a medical services model.

CONCLUSIONS

Cross-country studies like ours are natural experiments that can produce insights not easily obtained from other types of study. The cervical cancer screening system in the Netherlands seems to have been as effective as the U.S. system but used much less screening. Adequate coverage of the female population at risk seems to be of central importance.

Telephone counseling and attendance in a national mammography-screening program a randomized controlled trial

BACKGROUND

In Germany, a mammography-screening program (MSP) was implemented on a national level. It complies with all criteria of the European guidelines for quality assurance in screening mammography; however, the attendance rate is 54%, falling short of the target attendance rate of 70%. The aim of this study was to investigate whether additional telephone counseling improves attendance among nonresponders and the level of satisfaction with telephone counseling.

DESIGN

In a prospective RCT, women identified as nonresponders in the MSP were randomized to a control group that received written reminders or to an intervention group that additionally received telephone counseling. In a follow-up, a subset of the intervention group was contacted by telephone regarding their satisfaction with telephone counseling.

SETTING/PARTICIPANTS

In 2008, a total of 5477 women aged 50-69 years who were eligible for the German MSP but had not participated up to 6 weeks after the first invitation were included in the study.

INTERVENTIONS

Individual telephone counseling consisted of scripted calls from a trained counselor who provided information on MSP and answered the woman's questions.

MAIN OUTCOME MEASURES

Report of mammography use provided by the screening unit 3 months after the reminder was sent.

RESULTS

Analysis was conducted in 2009. Comparison of screening attendance revealed a significantly higher attendance rate in the intervention group compared with controls (29.7% vs 26.1%, p=0.0035). When only women for whom telephone numbers were available were analyzed, attendance was even better (35.5% vs 29.7%, p=0.0004). In the follow-up, 278 of 404 women were actually surveyed. Of those, 33% stated that telephone counseling had influenced their decision, 56% stated that they had undergone screening mammography, and 77% agreed that personal telephone counseling should be used routinely to encourage nonresponders to go for screening.

CONCLUSIONS

Individual telephone counseling for nonresponders to a national program for breast cancer screening was well accepted by participants and effective.

TRIAL REGISTRATION

This study is registered at the Australian New Zealand Clinical Trials Registry ACTRN12611000645954.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Organizational factors and the cancer screening process

Cancer screening is a process of care consisting of several steps and interfaces. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes. We reviewed 79 studies assessing the relationship between organizational factors and cancer screening. Screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care. Optimal screening rates can be achieved when health-care organizations tailor strategies to the steps and interfaces in the cancer screening process that are most critical for their organizations, the providers who work within them, and the patients they serve.

Effect of a multimodal reminder program on repeat mammogram screening

BACKGROUND

Patient mammogram reminders are effective but have not been fully implemented in practice to improve routine screening. The effectiveness of implementation and maintenance phases of a multimodal reminder program that incorporated automated calls capable of efficiently reaching large numbers of women was evaluated to improve repeat mammography screening.

DESIGN

A quasi-experimental study was conducted in 2008 using electronic medical record data during three time periods: pre-reminder phase (2004), post-reminder implementation phase (2006), and post-reminder maintenance phase (January 1-July 1, 2007).

SETTING/PARTICIPANTS

Participants were female Kaiser Permanente Northwest HMO members aged 42 years or more who were 20 months past their last mammogram (index date) (N=35,104). The intervention program targeted women aged 50-69 years. Women aged 42-49 years (for whom clinical guidelines also recommend mammography) not targeted by the program constituted the primary comparison group (CG1).

INTERVENTION

A "mammogram due soon" postcard was mailed to participants 20 months after their last mammogram, followed by up to two automated phone calls and one live call for nonresponders.

MAIN OUTCOME MEASURES

The outcome measure was the time until participants received a mammogram in the 10 months following the index date.

RESULTS

Pre-reminder, 63.4% of targeted women completed a mammogram; this number increased to 75.4% in the post-reminder implementation phase; 80.6% completed a mammogram in the maintenance phases. After controlling for demographics and clinic visits, intervention women were 1.51 times more likely to complete a mammogram (CI=1.40, 1.62) post-reminder implementation, compared to CG1. The effect was maintained in 2007 (hazard ratio 1.81, CI=1.65, 1.99).

CONCLUSIONS

The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system. If widely implemented, this intervention could substantially improve community mammography screening.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Testing three different cancer genetics registry recruitment methods with Hispanic cancer patients and their family members previously registered in local cancer registries in Texas

OBJECTIVE

To increase accrual among Hispanics to the Cancer Genetics Network national cancer genetics registry.

METHODS

Drawing from South Texas cancer registries, 444 Hispanic men and women were randomly assigned to one of three experimental conditions: standard direct-mailed procedures (X1), X1 plus culturally tailored materials (X2), and X2 plus interpersonal phone contact (X3). Participants were also surveyed about the effectiveness of the education materials and the phone contact. A refusal survey was provided for those who declined to join the study.

RESULTS

A total of 154 individuals joined the Cancer Genetics Network. The X3 condition yielded the greatest accrual (43.2%) compared to X1 (30.9%) and X2 (29.9%; p < 0.05). Tailored materials appeared to have no effect but were highly regarded. The main reasons for not participating were a lack of interest and time requirements.

CONCLUSION

Interpersonal communication can have a powerful effect on recruitment. However, more research is needed to determine the cost-efficacy of more labor-intensive approaches to registry accrual.

Colonoscopy completion in a large safety net health care system

BACKGROUND & AIMS

Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations.

METHODS

We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type.

RESULTS

The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non-safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups.

CONCLUSIONS

A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations.

Lessons from cost-effectiveness research for United States public health policy

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule.

Electronic medical records and prevention quality: the prevention index

BACKGROUND

The Prevention Index is a methodology for using electronic medical records to identify and evaluate practice variations in the delivery of preventive care.

METHODS

The Prevention Index was used to evaluate the provision of 10 recommended adult preventive services using electronic medical record data for the years 1999 through 2002 among the 450,000 members of a large Northwest integrated care system. The analyses were conducted in 2005. The Prevention Index determines the proportion of person-time that is covered using consensus guidelines as a standard of care. It is analyzed at the population level and produces quality measures at the individual, practice, clinic, and system levels. The Prevention Index also removes diagnostic services in evaluating preventive care.

RESULTS

Overall, about 47% of recommended person-time was actually covered by the services in 2002. For nine services with care guidelines, the percent of covered person-time ranged from 19% for chlamydia screening to 80% for blood pressure screening. The percent of recommended person-time covered by these preventive services varied widely across clinical practices. From 17% to 53% of preventive screening tests were delivered for non-screening purposes.

CONCLUSIONS

There are wide variations across clinical practices in the adherence to standard prevention guidelines, and also wide variations across different recommended clinical services. The Prevention Index methodology may allow the identification of the source of these variations, allowing system corrections and other remedial actions to be applied precisely and efficiently.

Mammography screening rates decline: a person-time approach to evaluation

OBJECTIVES

Early detection through mammography can reduce breast cancer mortality. This cohort study evaluated trends in mammography screening, demonstrating a person-time approach.

METHODS

Included were women HMO members aged 50-69 from 1999 to 2002 who had not had breast cancer, dysplasia, fibrocystic disease, or implant. The amount of person-time covered by mammography as a percent of the time eligible for mammography screening (the prevention index (PI)) was calculated using electronic data. The denominator was the time during which the guidelines recommended that each participant should have been covered by a mammogram (every 24 months), excluding times when breast mass, abnormal mammogram, galactorrhea, or other breast disorders were under evaluation. The numerator was the time during which she was covered by a mammogram.

RESULTS

The number of women who contributed person-time increased from 43,283 to 49,512 and the number of screening mammograms declined from 23,586 to 22,719. The overall PI for screening mammography declined from 67.0 (67% of eligible person-time was appropriately covered by a mammogram) to 62.5, and the proportion of women with no coverage during a given year increased 16%.

CONCLUSIONS

This study shows a declining pattern of mammography screening using a person-time approach, a decline greater than that shown by methods that include diagnostic mammograms. The study highlights opportunities for use of the PI and quality improvement initiatives to improve breast cancer outcomes.

Use of cervical cancer screening among insured women: the extent of missed opportunities

The objective of the study is to identify opportunities to improve cervical cancer screening among privately insured women. From MedStat's Marketscan database, we identified 735,181 women aged 21-64 years who remained in the same insurance plan during the entire period of 2000-2002. We obtained the percentages of women who had a Papanicolaou (Pap)-test reimbursement claim and any health-related claim during the 3-year period. For women without a Pap-test claim, we obtained information about the frequency of insurance claims, type of health-care provider, and type of insurance plan in which the women were enrolled. The multivariate logistic regression model was used to identify factors independently associated with not having a Pap test. Of the total sample, in the 3-year period, 96% had at least one health insurance reimbursement claim and 69% had at least one claim for a Pap test. Approximately, 87% of the women who had no Pap-test claim had a health claim; 44% of such claims were from primary care providers. In the multiple logistic regression model, factors that were independently associated with having no Pap test were old age, being dependents of employees, and enrollment in comprehensive insurance plans. Efforts to increase the use of cervical cancer screening service should consider additional risk factors besides lack of insurance coverage. Concerted efforts by insurance and health-care providers are needed to improve adherence to the recommended cervical cancer screening guidelines, both by consumers and service providers.

Increasing mammography screening through inpatient education

BACKGROUND

The reasons why women do not undergo regular screening mammograms have not been clearly defined. In this study, we addressed an educational intervention based on Health Belief Model constructs for 3 of the most common reasons why women do not participate in mammography screening: cost, fear, and lack of knowledge. The purpose of the project was to study whether an educational intervention addressing these factors could increase mammography screening among age-appropriate women who had not had a recommended mammogram within the previous 12 months.

METHODS

The educational intervention consisted of providing a tailored brochure addressing either the barrier of (1) cost, (2) fear, or (3) lack of information. Participants were hospital inpatients admitted for noncancer diagnoses. They were followed up approximately 3 months after hospital discharge to ascertain subsequent mammography utilization either before or after leaving the hospital.

RESULTS

Of the 272 women originally interviewed, 147 (54%) were reached for follow-up. Although there were no differences related to which mammography barrier was addressed, 42 (28.6%) reported that they had obtained a mammogram after the intervention.

CONCLUSIONS

These data suggest that a fairly simple, low-cost patient education intervention of brochure distribution can produce substantially increased patient awareness and consequent mammography utilization.

The Prevention Index: using technology to improve quality assessment

OBJECTIVE

To improve quality of care assessment for preventive medical services and reduce assessment costs through development of a comprehensive prevention quality assessment methodology based on electronic medical records (EMRs).

DATA SOURCES

Random sample of 775 adult and 201 child members of a large nonprofit managed care system.

STUDY DESIGN

Problems with current, labor-intensive quality measures were identified and remedied using EMR capabilities. The Prevention Index (PI) was modeled by assessing five-year patterns of delivery of 24 prevention services to adult and child health maintenance organization (HMO) members and comparing those services to consensus recommendations and to selected Health Plan Employer Data and Information Set (HEDIS) scores for the HMO.

DATA COLLECTION

Comprehensive chart reviews of 976 randomly selected members of a large managed care system were used to model the Prevention Index.

PRINCIPAL FINDINGS

Current approaches to prevention quality assessment have serious limitations. The PI eliminates these limitations and can summarize care in a single comprehensive index that can be readily updated. The PI prioritizes services based on benefit, using a person-time approach, and separates preventive from diagnostic and therapeutic services.

CONCLUSIONS

Current methods for assessing quality are expensive, cannot be applied at all system levels, and have several methodological limitations. The PI, derived from EMRs, allows comprehensive assessment of prevention quality at every level of the system and at lower cost. Standardization of quality assessment capacities of EMRs will permit accurate cross-institutional comparisons.