Prospective randomised controlled trial of methods of call and recall for cervical cytology screening

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.

Cervical screening during the COVID-19 pandemic: optimising recovery strategies

Disruptions to cancer screening services have been experienced in most settings as a consequence of the COVID-19 pandemic. Ideally, programmes would resolve backlogs by temporarily expanding capacity; however, in practice, this is often not possible. We aim to inform the deliberations of decision makers in high-income settings regarding their cervical cancer screening policy response. We caution against performance measures that rely solely on restoring testing volumes to pre-pandemic levels because they will be less effective at mitigating excess cancer diagnoses than will targeted measures. These measures might exacerbate pre-existing inequalities in accessing cervical screening by disregarding the risk profile of the individuals attending. Modelling of cervical screening outcomes before and during the pandemic supports risk-based strategies as the most effective way for screening services to recover. The degree to which screening is organised will determine the feasibility of deploying some risk-based strategies, but implementation of age-based risk stratification should be universally feasible.

Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

Aims and background

Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.

Methods

Women eligible for invitation - 8385 for cervical and 8069 for breast cancer screening - listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A - letter signed by the GP, with a prefixed appointment; Group B - open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C - letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D - extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).

Results

Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).

Conclusions

Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored.

Continuing medical education at a university—evaluation of an MSc programme in general practice

In 1986 London University launched a new MSc programme for GPs. This paper describes the problems met with, and the progress made by course members and tutors during the first part-time, 2-year course. We also describe some early measures of the outcome of this form of CME.

Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in Pap smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

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.

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.

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.

Missed opportunities for diabetes prevention: post-pregnancy follow-up of women with gestational diabetes mellitus in England

BACKGROUND

Women with gestational diabetes mellitus (GDM) should be followed-up to exclude ongoing diabetes and for prevention of type 2 diabetes. The National Institute for Health and Clinical Excellence (NICE) diabetes in pregnancy guideline recommends checking fasting plasma glucose (FPG) at 6 weeks postpartum (short term), and annually thereafter (long term).

AIM

To examine the reported practice regarding GDM follow-up.

DESIGN AND SETTING

Nationwide postal survey in England 2008-2009.

METHOD

Questionnaires were distributed to a consultant diabetologist and obstetrician in all maternity units, and to a random sample of general practices (approximately 1 in 5).

RESULTS

Response rates were: 60% (915/1532) GPs, 93% (342/368) specialists; 80% of GPs and 98% of specialists reported women with GDM had short-term follow-up. More GPs (55%) than specialists (13%) used a FPG test to exclude ongoing diabetes; 26% of GPs versus 89% of specialists thought the hospital was responsible for ordering the test. Twenty per cent of GPs had difficulty in discovering women had been diagnosed with GDM in secondary care. Seventy-three per cent of specialists recommended long-term follow-up; only 39% of GPs recalled women with GDM for this. A minority of GPs and specialists had joint follow-up protocols.

CONCLUSION

Follow-up of GDM in England diverged from national guidance. Despite consensus that short-term follow-up occurred, primary and secondary care doctors disagreed about the tests and responsibility for follow-up. There was lack of long-term follow-up. Agreement about the NICE guideline, its promotion and effective implementation by primary and secondary care, and the systematic recall of women with GDM for long-term follow-up is required.

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.

Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders

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 regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

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.

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.

Promoting use of colorectal cancer screening tests. Can we change physician behavior?

BACKGROUND

Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality.

OBJECTIVE

To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening.

DESIGN

A randomized clinical trial of community physicians and their patients.

PARTICIPANTS

Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards.

MEASUREMENTS

After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonoscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups.

RESULTS

9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01).

CONCLUSION

With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.

Characteristics of respondents to a cervical cancer screening program in a developing country

BACKGROUND

Characteristics associated with the response to a personalized, mailed invitation for the Papanicolaou (Pap) test vary among women. This study assesses the relationship between selected characteristics (e.g., demographic, obstetric, Pap history) and the response to a letter of invitation to undergo a Pap test among Mexican women affiliated with the Mexican Social Security Institute (IMSS).

METHODS

Study subjects were 328 women affiliated with the IMSS who received and responded to a mailed letter of invitation, and 247 age- and clinically matched controls who received but did not respond to the letter of invitation. Statistical analysis consisted of multivariate conditional regression model.

RESULTS

Having better housing conditions was one of the factors associated with letter response (medium level vs. low level, odds ratio [OR] = 3.17, 95% confidence interval [95% CI] = 2.46-4.09; high level vs. low level, OR = 2.65, 95% CI = 2.06-3.41). Other factors positively associated with letter response were greater number of pregnancies, previous Pap testing, being pleased at receipt of the letter of invitation, and knowing another woman who had received the invitation. Factors associated negatively to letter response were 7 or more years of formal education (> or =7 years vs. 0-6 years, OR = 0.50, 95% CI = 0.40-0.63), having a current job, availability of other medical services in addition to the IMSS, and willingness to receive Pap results by mail.

CONCLUSIONS

Low educational level is not a limitation for cervical cancer screening call and recall among women affiliated with the IMSS.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

Cervical cancer is the third most common cancer world-wide. 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 increasing uptake, and informed uptake of cervical cancer screening.

SEARCH STRATEGY

Twenty-three electronic databases (to March 2000) were searched with no language restrictions.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Data on study characteristics and quality were extracted independently by two reviewers. Where data were available, relative risks and 95% CI were calculated and a chi-squared test for heterogeneity was performed.

MAIN RESULTS

Thirty-five studies were included (27 RCTs and eight quasi-RCTs). Heterogeneity between studies 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. The number and quality of included studies limited evidence regarding effectiveness of other interventions. Informed uptake of cervical screening was not considered by any studies.

REVIEWER'S CONCLUSIONS

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

Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis

OBJECTIVE

To perform a meta-analysis on existing randomized controlled trials to investigate the efficacy of patient letter reminders on increasing cervical cancer screening using Pap smears.

METHODS

A search was conducted for all relevant published and unpublished studies between the years 1966 and 2000. Eligibility criteria included randomized controlled studies that examined populations due for Pap smear screening. The intervention studied was in the form of a reminder letter. The Mantel-Haenszel method was used to measure the summary effect of the intervention. A test for homogeneity using the Mantel-Haenszel method was performed.

RESULTS

Ten articles fulfilled the inclusion criteria, including one unpublished study. The test for homogeneity showed evidence of heterogeneity (chi2 = 31, 9 df, P <.001). An analysis for causes of heterogeneity was pursued. Division into subpopulations based on socioeconomic status resolved the heterogeneity (chi2 = 5.2, 8 df, P =.75). The studies evaluating those in lower socioeconomic groups had a smaller response (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.99 to 1.35) than those studies using mixed populations (OR, 2.02; 95% CI, 1.79 to 2.28). The pooled odds ratio showed that patients who received the intervention were significantly more likely to return for screening than those who did not (OR, 1.64; 95% CI, 1.49 to 1.80).

CONCLUSIONS

Patient reminders in the form of mailed letters increase the rate of cervical cancer screening. Patient letter reminders have less efficacy in lower socioeconomic groups.

Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care

OBJECTIVE

To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care.

DESIGN

Pragmatic, unblinded, cluster randomised controlled trial.

SETTING

Warwickshire.

SUBJECTS

21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease.

INTERVENTIONS

Audit of notes with summary feedback to primary health care team (audit group); assistance with setting up a disease register and systematic recall of patients to general practitioner (GP recall group); assistance with setting up a disease register and systematic recall of patients to a nurse led clinic (nurse recall group).

MAIN OUTCOME MEASURES

At 18 months' follow up: adequate assessment (defined) of 3 risk factors (blood pressure, cholesterol, and smoking status); prescribing of hypotensive agents, lipid lowering drugs, and antiplatelet drugs; blood pressure, serum cholesterol level, and plasma cotinine levels.

RESULTS

Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups (85%, 76%) than the audit group (52%). The advantage in the nurse recall compared with the audit group was 33% (95% confidence interval 19% to 46%); in the GP recall group compared with the audit group 23% (10% to 36%), and in the nurse recall group compared with the GP recall group 9% (-3% to 22%). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mm Hg), total cholesterol (5.4, 5.5, 5.5 mmol/l), and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the nurse recall, GP recall, and audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the nurse recall group (85%) than the GP recall or audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the nurse recall group compared with the audit group was 10% (3% to 17%), in the nurse recall group compared with the GP recall group 8% (1% to 15%) and in the GP recall group compared with the audit group 2% (-6% to 10%).

CONCLUSIONS

Setting up a register and recall system improved patient assessment at 18 months' follow up but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease.

Call and recall for cervical cancer screening in a developing country: a randomised field trial

A randomised field trial was used to assess Mexican women's response to a mailed invitation for a Papanicolaou test. A sample of 4,802 women, 20 to 64 years old, chosen at random from the Mexican Social Security Institute Register were randomly assigned to an intervention and to a control group. A letter of invitation and a reminder were sent to the intervention group. A letter was also sent to the control group at the end of the follow-up period (8.5 weeks) in order to compare the response among women who received a letter in both groups. Cumulative incidence and incidence rates were used to determine the response and the speed of response, respectively. The response among women who had received the letter was 33.5% (efficacy) in the intervention group, while 5.9% (p<0.001) in the control group attended a Papanicolaou test. For the total of women invited, the response was 20.1% (effectiveness) and 3.3% (p<0.001), respectively. The response was greater in rural areas (rural vs. urban/suburban; p = 0.002) and eldest women (50-64 vs. 20-49; p = 0. 02). The response rate was 7 times grater in the intervention than in the control group (RR = 7.1; 95% CI 5.4-9.4; p < 0.001). A mailed invitation to have a Papanicolaou test substantially increases attendance by women who receive it. A mailed reminder improves results. This strategy could be implemented in addition to the ones already in use, mainly among rural and elderly women.

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

BACKGROUND

Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking.

METHODS

Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year.

RESULTS

Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively.

CONCLUSIONS

Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.

General practitioners' continuing education: a review of policies, strategies and effectiveness, and their implications for the future

BACKGROUND

The accreditation and provision of continuing education for general practitioners (GPs) is set to change with new proposals from the General Medical Council, the Government, and the Chief Medical Officer.

AIM

To review the theories, policies, strategies, and effectiveness in GP continuing education in the past 10 years.

METHOD

A systematic review of the literature by computerized and manual searches of relevant journals and books.

RESULTS

Educational theory suggests that continuing education (CE) should be work-based and use the learner's experiences. Audit can play an important role in determining performance and needs assessment, but at present is largely a separate activity. Educational and professional support, such as through mentors or co-tutors, has been successfully piloted but awaits larger scale evaluation. Most accredited educational events are still the postgraduate centre lecture, and GP Tutors have a variable role in CE management and provision. Controlled trials of CE strategies suggest effectiveness is enhanced by personal feedback and work prompts. Qualitative studies have demonstrated that education plays only a small part in influencing doctors' behavior.

CONCLUSION

Maintaining good clinical practice is on many stakeholders' agendas. A variety of methods may be effective in CE, and larger scale trials or evaluations are needed.

Recruitment of women by GPs for pap tests: a meta-analysis

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.

Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes

OBJECTIVE

To answer the question, "does CME work?" by reviewing the effectiveness of continuing medical education (CME) and other related educational methods on objectively-determined physician performance and/or health care outcomes. These interventions include educational materials, formal, planned CME activities or programs, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit and feedback, reminders, or a combination of these strategies.

METHODS

MEDLINE, ERIC, NTIS, the Research and Development Resource Base in CME and other relevant data sources including review articles were searched for relevant terms, from 1975 to 1994. Of those articles retrieved, randomized controlled trials of educational strategies or interventions which objectively assessed physician performance and/or health care outcomes were selected for review. Data were extracted from each article about the specialty of the physician targeted, the clinical subject of the intervention, the setting and the nature of the educational method, and the presence or degree of needs assessment or barriers to change.

RESULTS

More than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be most effective activities. Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without enabling or practice-reinforcing strategies, had relatively little impact.

CONCLUSION

Strategies which enable and/or reinforce appear to "work" in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change.

Clinic-based interventions to promote breast and cervical cancer screening

BACKGROUND

Breast and cervical cancer continue to claim the lives of women. Early detection modalities for these cancers are available; however, utilization rates are far from optimal. Studies have documented the motivating effect that physician recommendations have on compliance with preventive health behaviors. The goal of this study was to develop and implement strategies to improve the use of cervical and breast cancer screening among African-American women age 40 and older who resided in low-income housing communities.

METHODS

Baseline surveys among clinic providers and a random sample of women in the target population indicated areas to be included in intervention material. Community health center-based strategies included educational interventions for providers and patients, follow-up interventions for abnormal screening tests, and the implementation of a computer tracking system. Pap smear and mammogram utilization rates at the health center were tracked throughout the project period to assess the effect of the clinic-based interventions.

RESULTS

Both Pap smear and mammography rates increased over time. Fifteen cases of breast cancer and 1 case of invasive cervical cancer have been detected. Compliance rates for follow-up for cervical dysplasia have increased from 50 to 90%.

CONCLUSIONS

These results suggest that clinic-based interventions can improve the use of breast and cervical cancer screening and follow-up among low-income women.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Casting the screening net: separating big fish from little fish

Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non-selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit.

Encouraging underscreened women to have cervical cancer screening: the effectiveness of a computer strategy

BACKGROUND

Computers that collect data from patients and provide both patients and practitioners with printed feedback on a range of health risks are a tool for assisting general practitioners with preventive care. This study assessed the impact of computer-generated printed feedback on cervical screening among women who were underscreened for cervical cancer.

METHOD

Female attenders at two Australian general practices were randomly allocated to Experimental or Control groups. Women in both groups completed a health risk survey on a touch screen computer prior to their consultation. Those in the Experimental group received printed pages summarizing their results, including their eligibility for cervical screening and last Pap test, for themselves and their doctor. The number and proportion of underscreened women who had a Pap test in the 6 months after completing the computer survey, as determined by pathology records, were examined.

RESULTS

Of the 679 participants, 139 were classified as underscreened on the basis of self-report (74 Experimental, 65 Control) and 272 on the basis of their pathology records (148 Experimental, 124 Control). Overall about one-third of women had a test in the 6-month period, and the differences between the groups were not significant for women overall (18-70 years) or for women 18-49 years. Among women 50-70 who were underscreened based on self-report, those receiving the printout were more likely to have a Pap test in the next 6 months (P < 0.05). This pattern was also evident, but did not reach statistical significance, for older women who were underscreened based on pathology records.

CONCLUSIONS

We are unable to draw conclusions regarding the effectiveness of the computer system due to the modest proportions of women screened, the small numbers, and the fact that the computer survey may have created an intervention effect in the Control group. As the study suggests the computer system is acceptable to women and may be effective for encouraging screening among older women, further exploration of the system is desirable.

The costs and effects of cervical and breast cancer screening in a public hospital emergency room. The Cancer Control Center of Harlem

OBJECTIVES

This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room.

METHODS

Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts.

RESULTS

The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403,203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21,324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen.

CONCLUSIONS

Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs.

PSA-based screening for prostate cancer in asymptomatic younger males: pilot study in blood donors

BACKGROUND

The efficacy and success of a screening program for prostate cancer in young and healthy asymptomatic volunteers are described.

METHODS

In the present study, prostate specific antigen (PSA) samples obtained from 2,272 males (aged 40-65 years) who donated blood at the local Red Cross Blood Bank were evaluated. Two groups of donors were distinguished, which were investigated in different ways. Group 1 comprised individuals aged 40-49 years (n = 568), while group 2 consisted of males aged 50-65 years (n = 1,704). Volunteers in group 2 who had PSA levels greater than 4 ng/ml (n = 302) were referred for ultrasound guided biopsy irrespective of findings on digital rectal examination (DRE). In group 2, individuals with PSA levels exceeding 4 ng/ml and positive DRE findings biopsy specimen was ordered (n = 2). In patients with unremarkable findings on DRE, serum PSA was determined 1 year later and in case of more than 20% increase in the PSA level biopsy was obtained under ultrasound guidance.

RESULTS

The biopsy specimen yielded prostatic carcinoma in 58 patients in group 1. As a screening test, serum PSA determination was superior to digital rectal examination. On digital palpation only 2 presented with abnormal prostates. These 58 patients underwent radical prostatectomy and histological examination revealed organ-confined disease in all but 8. In group 2, in 4 of 12 males the biopsy specimen yielded prostatic carcinoma.

CONCLUSIONS

This study shows that PSA measurement in blood donors is a useful method for recruiting screening volunteers, and therefore represents an additional possibility for early detection of prostate cancer in asymptomatic younger males. Furthermore, it represents an effective tool for following relatively young patients known to have a significant risk of prostate cancer.

Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem

STUDY OBJECTIVE

To assess the feasibility and yields of screening for breast and cervical cancer in an urban public hospital emergency department.

METHODS

Women who presented to the ED of a large, urban public hospital during the study period with nonurgent conditions were eligible for a Papanicolaou test (Pap smear) and a clinical breast examination (CBE) if they were 18 years of age or older and for a mammogram if they were 40 years of age or older, provided they had not had the screening examination within the past year. The Pap smear and CBE were performed by a nurse, and mammography was scheduled for a later date. Women with gynecologic complaints were excluded.

RESULTS

On the basis of screening history, medical status, and age, 1,850 (32%) of the 5,830 women seen in the ER during the 23-month study period were eligible for both mammography and CBE, and 2,361 (41%) were eligible for Pap smears. Of these women, 116 (6%) completed mammography and CBE, and 644 (27%) received Pap smears. Among screened women, 10 (9%) and 20 (3%), respectively, had results that were suspicious or positive for breast or cervical cancer. Follow-up rates were low: 20% for breast screening and 50% for Pap smears. Among those receiving follow-up, 1 woman was found to have breast cancer and 8 were found to have cervical neoplasia.

CONCLUSION

ED cancer screening was feasible and yielded a high rate of cancer detection. Program efficiency was hampered by low volume and high numbers of patients lost to follow-up after abnormal screening results. Greater integration into the acute care setting and more intensive recruitment and follow-up strategies are needed to maximize the potential yield and cost effectiveness of such programs.

Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem

OBJECTIVE

To describe factors related to compliance diagnostic follow-up among minority women of low socioeconomic status with abnormal screening mammograms.

METHODS

A retrospective cross-sectional survey using a structured telephone interview. Three cancer screening clinics at an urban inner-city public hospital. All women with abnormal screening mammograms between September 1990 and January 1992 were eligible; women were interviewed in August 1992. Abnormal mammograms were those requiring specific, non-routine clinical follow-up; non-compliance was defined as delayed follow-up (four to six months after the date of the mammogram), or no follow-up at the time of interview (more than 6 months after abnormal).

RESULTS

Sixty-two of 442 screened women had abnormal results; the overall rate of non-compliance with follow-up was 50%. Among the 42 (68%) women who agreed to be interviewed, non-compliers were less likely to state that they had been told to receive follow-up than compliers (65% versus 100%; p = 0.008). Non-compliant women were less likely to have suspicious mammography interpretations (p = 0.05), and more likely to report barriers to follow-up, such as cost of lost wages and medical care, system barriers, or fears, than compliant women (61.9% versus 9%, p = 0.01). There were no differences between the two groups for age, education, insurance, source of care, family history, knowledge or attitudes.

CONCLUSIONS

These preliminary results suggest that follow-up of low income, minority women with abnormal screening mammograms could be enhanced by improved communication of results. Future studies should extend these findings with larger samples and in other settings and populations.

Mass mailing campaigns to promote screening for cervical cancer: do they work, and do they continue to work?

Campaigns involving sending personally addressed letters to encourage women to have Pap smears increase Pap smear rates. The aim of this study was to assess whether this effect is maintained when campaigns are repeated regularly. In October 1992, a letter reminding women of the importance of screening was mailed to all women in three New South Wales postcode regions where a similar letter had been sent three years previously. The response was compared to the response in three regions receiving no earlier letter. The number of women attending for cervical screening during the three months after distribution of the letters was assessed from Health Insurance Commission claims for cervical cytology. These attendances were compared with expected attendances based on the attendance patterns over 28 pre-intervention quarters. Significant postintervention increases in attendance were observed in all three regions receiving an initial letter. However, in one region, the increase in attendances, around 1 per cent of eligible women, was not significantly greater than the increase in the control region (z = 0.15, P = 0.88). The second letter campaign had no measurable effect on attendances. No significant increase in screenings was observed in two of the towns. A significant increase was observed in one region, but this was not significantly greater than the increase in the control region (z = -0.05, P = 0.96). These results suggest that repeated direct-mail campaigns to promote screening for cervical cancer may be of no benefit. A one-off campaign may result in an increase in screenings in the short term.

Cost-effectiveness of interventions to promote cervical screening in general practice

A cost-effectiveness study of three different interventions to promote the uptake of screening for cervical cancer in general practice was carried out in Perth in 1991. Women eligible for a Pap smear were randomly allocated to one of four groups: one receiving letters with specific appointments to attend a screening clinic staffed by female doctors, one receiving letters informing them of the availability of the clinic and suggesting they make an appointment, one whose files were tagged to remind a doctor to offer a smear during a consultation, and a comparison control group that received opportunistic screening only. Variable and fixed costs for each group were itemised and summarised to give an average cost per smear taken. The cost and effectiveness of each intervention were then compared with those of the control group. Sensitivity analysis was performed on the major component of the costs, the doctor's time. Opportunistic screening cost $14.60 per smear and attained 16 per cent recruitment. Tagging files was the cheapest intervention ($14.75 per smear) although it was the least effective in recruiting women (20 per cent). This result held true for different scenarios of doctor's time allocated. Intervention by invitation letter with no appointment cost $45.35 per smear and attained 26 per cent recruitment, and intervention with a specific appointment cost $48.21 per smear and attained 30 per cent recruitment. Compared with the control group, the incremental cost-effectiveness for the tagged group was $15.40, for the letter-without-appointment group $97.75 and for the letter-with-appointment group $86.50.

Uptake of cervical screening in general practice: effect of practice organisation, structure, and deprivation

OBJECTIVES - To investigate associations between uptake for cervical screening in general practice and the organisation of screening, features of practice structure, and deprivation. SETTING - Greater Glasgow Health Board area in the west of Scotland, which covers a socioeconomically varied population. METHODS - General practice questionnaire survey and interview based study. The main outcome measure was the uptake rate for each participating practice over the five and a half years ending 31 December 1993. This was used to determine whether practices achieved 80% uptake to trigger maximum payment for cervical screening services. RESULTS - Forty seven percent (n = 92) of all practices in the Greater Glasgow Health Board area agreed to take part in the research, with complete data collected for 87 practices. Participation varied according to number of partners in the practice and the average deprivation score of the practice. Uptake rates ranged from 48-2% to 92-9% (median 77.5%, interquartile range 69.8% to 83.4%). Thirty seven practices (43%) achieved the 80% target. None of the recommended features of good organisation of cervical screening showed any statistically significant association with uptake rates. In stepwise multiple regression four variables were shown to have independent associations with uptake. These were the number of partners in the practice, the average deprivation of the practice, the presence of a female general practitioner, and using a practice's own lists for sending out letters of invitation. In stepwise logistic regression just two of these variables contributed to the prediction of achieving 80% uptake namely, average deprivation and number of partners. There were no significant interactions between deprivation and the organisation of screening in relation to uptake. CONCLUSIONS - Organising cervical screening in general practice according to accepted standards is less important in predicting uptake than more intractable features of the practice such as the size of the partnership, its average deprivation level, the presence of a female general practitioner, and using their own (presumed more accurate) register of addresses to call women. A flexible incentive scheme may more fairly reward the efforts of those general practitioners who achieve high uptake rates but who do not trigger remuneration at the 80% level.

The quality of cervical cancer screening: a primary care perspective

The bulk of cervical cancer screening is performed by primary care providers; mostly nurses and physicians. The literature regarding the quality of this screening is largely described from three perspectives; clinical, laboratory, and public health. This article describes the primary care perspective regarding issues of quality in cervical cancer screening and suggests areas for improvement. The authors discuss how effectiveness of the test, sampling methods, interpretation by the laboratory, and reporting results impact on the quality of cervical cancer screening. Other factors which influence the quality of screening such as access to care, recall intervals, communication with the patient, costs of testing, and organizational issues are also reviewed.

Breast screening: a randomised controlled trial in UK general practice of three interventions designed to increase uptake

STUDY OBJECTIVES

To determine the relative effectiveness of three interventions designed to increase the uptake of breast screening.

DESIGN

Randomised controlled trial of a nurse visit with health education (group A), nurse visit without health education (group B), and GP letter (group C).

SETTING

The area of south east London served by the Butterfly Walk Breast Screening Unit in Camberwell.

PARTICIPANTS

Women aged between 50 and 64 years who were registered with 27 GPs in the Lambeth, Southwark and Lewisham family health services authority and who had not attended for first round screening.

MAIN RESULTS

Altogether 799 women were randomly allocated to the three groups. In general, delivering the nurse based interventions proved difficult. In group A, 11.4% (95% CI 7.9, 14.9%) of women subsequently attended for screening compared with 7.8% (95% CI 5.1, 11.4%) in group B and 13.1% (95% CI 7.9, 18.4%) in group C. The differences between the groups (95% CIs) were not statistically significant: A versus C, -1.7% (-8.0, +4.6%); B versus C, -5.3% (-11.3, +0.7%); A versus B, +3.6% (-1.0, +8.2%).

CONCLUSIONS

A personal letter from the GP seems to be at least as effective at increasing the uptake of breast screening in non-attenders as a nurse making a home visit to discuss the issue of breast screening, and is not noticeably less effective than a visit at which a health education intervention is delivered. It is possible that the GP letter is considerably more effective than either of the two interview-based interventions. With regard to implementing strategies which will increase breast screening uptake and are cost effective, further trials of similar minimal interventions in primary care are required.

Barriers to cancer screening

Many barriers to cancer screening have been summarized and discussed. Barriers have been documented in all patient populations, but some groups such as ethnic minorities and the elderly face unique barriers. The barriers to cancer screening, are multifactorial, but much of the responsibility for change must lie with health care providers and the health care delivery industry. This is not to free the patient of all responsibility, but some significant barriers are beyond their direct control. Take, for example, socioeconomic status, disease knowledge, and culturally related perceptions and myths about cancer detection and treatment. The health care industry must do a better job identifying and overcoming these barriers. The significant effects of provider counseling and advice must not be underestimated. Patients must first be advised, and then further actions must be taken if they reject the screening advice. Did they refuse adherence to recommendations because they do not view themselves as susceptible, because of overwhelming personal barriers, or because of a fatalistic attitude toward cancer detection and treatment? If that is the case, physicians and health care institutions must attempt to change perceptions, educate, and personalize the message so that patients accept their disease susceptibility [table: see text]. Multiple patient and provider risk factors have been identified that can be used to target patients particularly at high risk for inadequate cancer screening and providers at high risk for performing inadequate screening. Research has clearly demonstrated the effectiveness of interventions to improve tracking of patient and physician compliance with screening recommendations. Further research is needed to show the impact of managed-care penetration and payer status on screening efforts, and incentive schemes need to be tested that reward institutions and third-party payers who develop uniform standards and procedures for cancer screening. The greatest responsibility lies with medical and health care institutions and those who determine the priorities of these institutions. Patient and physician barriers to mass cancer screening can be addressed by institutional support. If the quality of care delivered by providers, group practices, managed-care organizations, and HMOs is assessed with priority given to the regularity and consistency with which basic screening procedures are performed, cancer screening will undoubtedly receive greater attention in the clinic. Medical institutions must collaborate to develop standards for cancer screening with attention to the cost-effectiveness of various screening techniques to determine how limited resources can best be spent in cancer control. Such efforts should keep in mind "that a very small change implemented over a broad population may have a greater effect in absolute numbers than a large level of change applied in a small segment of the population."

A randomised controlled trial of strategies to prompt attendance for a Pap smear

OBJECTIVE

To assess the comparative efficacy, by randomised controlled trial, of three interventions designed to encourage "at risk" women to have a Pap smear: an educational pamphlet; letters inviting attendance at a women's health clinic; and letters from physicians.

METHODS

Subjects at risk for cervical cancer who had not been adequately screened were identified by a random community survey and randomly allocated to one of the intervention groups or a control group. Six months after intervention implementation, a follow up survey assessed subsequent screening attendance. Self report was validated by comparison with a national screening data base.

RESULTS

A significantly greater proportion of women (36.9%) within the group receiving a physician letter reported screening at follow up than in any other group (P = 0.012). The variables most strongly predicting screening attendance were: age, perceived frequency of screening required, use of oral contraceptives, and allocation to receive the physician letter intervention.

CONCLUSIONS

The relative efficacy of the GP letter in prompting screening attendance shows that this strategy is worthy of further investigation. There remains a need to examine the barriers to screening for older women, and to develop tailored strategies for this population.

General practitioner attitudes to recall systems for cervical screening

OBJECTIVES

To document the factors associated with general practitioner (GP) use of Pap smear reminder/recall systems and to canvass options for coordinating these GP-based systems with similar centrally based schemes.

METHODS

A questionnaire survey of a random sample of South Australian GPs.

RESULTS

259 (78%) of 334 GPs returned questionnaires. 117 (45.2%) GPs had practice-based reminder/recall systems, with a higher prevalence among metropolitan GPs with a computer and who had been in practice for less than 20 years. 91.9% of GPs reported that the central register would be of some help in ensuring regular cervical screening. 38.2% of the GPs preferred reminder letters from the register to be sent to their practice; 27.8% preferred them to be sent directly to women and 22.8% opted for letters to be sent from the register via the laboratories to their practice. 61.4% of respondents had a method of recording women with abnormal smears and 95.6% of these actively recalled such women.

CONCLUSION

Substantial variation exists in the use of practice-based reminder/recall systems among GPs. A central register would assist most GPs by providing a back-up reminder service to follow-up women for cervical screening.

Attendance and compliance at an oral cancer screening programme in a general medical practice

The purpose of this study was to measure the attendance and compliance rates in a demonstration invitational screening programme for oral cancer. 4348 subjects aged 40 years or over registered at an inner city medical practice in north London were invited for screening by post. The socioeconomic profile of the group was determined by analysis of residential areas. Screening was conducted by one of several dentists and a referral pathway was established for patients requiring follow-up. Attendance rates for screening and referral for follow-up were measured. The response rate was 985/3826 (25.7%) after removing 522 subjects whose invitations could not be delivered or who refused appointments. No reply was obtained for 2841 patients. Attendance for referral of lesions considered to have malignant potential was 67% (8/12), compared to 92% (11/12) for patients requiring referral for incidental benign lesions. The low compliance suggests that oral cancer screening may not be able to achieve the desired benefits of reducing morbidity and mortality, and establishment of such a programme may not, therefore, be cost-effective. Further research is required into how to identify people in high risk groups and motivate them to present themselves for screening.

Cervical screening in general practice

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

Intercultural consultations: investigation of factors that deter non-English speaking women from attending their general practitioners for cervical screening

OBJECTIVES

To determine the factors that deter ethnic minority women living in east London from attending their general practitioner for cervical cytology screening.

DESIGN

Qualitative study by means of focus group discussions between October 1993 and March 1994.

SETTING

East London.

SUBJECTS

Non-health specific established community groups and specially convened groups of Bengali, Kurdish, Turkish, Urdu and Punjabi, and Chinese speaking women.

MAIN OUTCOME MEASURES

The spontaneous views of non-English speaking women resident in east London on cervical screening, focusing on attitudes to screening, their experiences of the cervical cytology screening services as currently provided, and their knowledge and beliefs about cervical screening.

RESULTS

Some reported attitudinal barriers to cervical cytology screening such as fear of cancer were not deterrents. Administrative and language barriers were more important, as were inadequate surgery premises and concerns about sterility.

CONCLUSION

Contrary to popular belief among general practitioners in east London, women from ethnic minorities are enthusiastic about cervical cytology screening once they understand the purpose of the test and the call and recall procedures. It is possible to consult with community groups in their own language through focus group discussions, working with bilingual health advocates who have had a short practical training in facilitating small group discussions. This form of user consultation could be carried out focusing on other aspects of health promotion.

Screening for ovarian, prostatic, and testicular cancers

Screening for cancer should not be offered routinely to a symptomatic people on a population basis unless it has been shown to be effective in reducing mortality in randomised controlled trials. A suitable screening test should have high sensitivity and specificity and a high positive predictive value. There is an ethical imperative to ensure that the benefit to each person from screening is likely to outweight the possible harm. Preliminary studies have identified suitable screening tests for ovarian cancer, and a randomised controlled trail is about to start. There is considerable controversy about whether to screen for prostatic cancer. Likewise, there is uncertainty about the best means of treating localised prostatic cancer. Screening for prostatic cancer raises important ethical considerations which should not be ignored. Testicular self examination is of unproved benefit. Although there is a need for education about the early signs and symptoms of testicular cancer to reduce delay at presentation, a case cannot be made for screening.