Systematic Review of Interventions to Increase Stool Blood Colorectal Cancer Screening in African Americans

African Americans experience colorectal cancer (CRC) related disparities compared to other racial groups in the United States. African Americans are frequently diagnosed with CRC at a later stage, screening is underutilized, and mortality rates are highest in this group. This systematic review focused on intervention studies using stool blood CRC screening among African Americans in primary care and community settings. Given wide accessibility, low cost, and ease of dissemination of stool-based CRC screening tests, this review aims to determine effective interventions to improve participation rates. This systematic review included intervention studies published between January 1, 2000 and March 16, 2019. After reviewing an initial search of 650 studies, 11 studies were eventually included in this review. The included studies were studies conducted in community and clinical settings, using both inreach and outreach strategies to increase CRC screening. For each study, an unadjusted odds ratio (OR) for the CRC screening intervention compared to the control arm was calculated based on the data in each study to report effectiveness. The eleven studies together recruited a total of 3334 participants. The five studies using two-arm experimental designs ranged in effectiveness with ORs ranging from 1.1 to 13.0 using interventions such as mailed reminders, patient navigation, and tailored educational materials. Effective strategies to increase stool blood testing included mailed stool blood tests augmented by patient navigation, tailored educational materials, and follow-up calls or mailings to increase trust in the patient-provider relationship. More studies are needed on stool blood testing interventions to determine effectiveness in this population.

Comparison of a web-push survey research protocol with a mailed paper and pencil protocol in the Monitoring the Future panel survey

AIMS

The experiment tested the effects of a web-push survey research protocol, compared with the standard mailed paper-and-pencil protocol, among young adults aged 19-30 years in the 'Monitoring the Future' (MTF) longitudinal study.

DESIGN, SETTING AND PARTICIPANTS

The US-based MTF study has measured substance use trends among young adults in panel samples followed biennially, using consistent mailed survey procedures from 1977 to 2017. In 2018, young adult participants in the MTF longitudinal component scheduled to be surveyed at ages 19-30 in 2018 (from high school senior cohorts of 2006-17, n = 14 709) were randomly assigned to receive the standard mail/paper survey procedures or new web-push procedures.

MEASUREMENTS

Primary outcomes were responding to the survey and prevalence estimates for past 30-day use of alcohol, cigarettes, marijuana and illicit drugs.

FINDINGS

The web-push response rate was 39.07% [95% confidence interval (CI) = 37.889, 40.258]; this was significantly better than the standard MTF response rate of 35.12% (95% CI = 33.964, 36.285). After adjusting for covariates, the web-push condition was associated with a 19% increase in the odds of responding compared with standard MTF (adjusted odds ratio = 1.188; 95% CI = 1.096, 1.287). Substance use prevalence estimates were very similar and differences became negligible when using attrition weights and controlling for socio-demographic characteristics.

CONCLUSIONS

The web-push protocol produced a higher response rate than the mailed pencil and paper protocol in the Monitoring the Future panel study, without substantially affecting estimates of substance use once attrition weights and socio-demographic variables were factored in.

Are patients more adherent to newer drugs?

The annual preventable cost from non-adherence in the US health care system amounts to $100 billion. While the relationship between adherence and the health system, the condition, patient characteristics and socioeconomic factors are established, the role of the heterogeneous productivity of drug treatment remains ambiguous. In this study, we perform cross-sectional retrospective analyses to study whether patients who use newer drugs are more adherent to pharmacotherapy than patients using older drugs within the same therapeutic class, accounting for unobserved heterogeneity at the individual level (e.g. healthy adherer bias). We use US Marketscan commercial claims and encounters data for 2008-2013 on patients initiating therapy for five chronic conditions. Productivity is captured by a drug's earliest Food and Drug Administration (FDA) approval year ("drug vintage") and by FDA" therapeutic potential" designation. We control for situational factors as promotional activity, copayments and distribution channel. A 10-year increase in mean drug vintage is associated with a 2.5 percentage-point increase in adherence. FDA priority status, promotional activity and the share of mail-order prescription fills positively influenced adherence, while co-payments had a negative effect. Newer drugs not only may be more effective in terms of clinical benefits, on average. They provide means to ease drug therapy to increase adherence levels as one component of drug quality, a notion physicians and pharmacy benefit managers should be aware of.

Dynamics of COVID-19 transmission including indirect transmission mechanisms: a mathematical analysis

The outbreak of the novel coronavirus severe acute respiratory syndrome-coronavirus-2 has raised major health policy questions and dilemmas. Whilst respiratory droplets are believed to be the dominant transmission mechanisms, indirect transmission may also occur through shared contact of contaminated common objects that is not directly curtailed by a lockdown. The conditions under which contaminated common objects may lead to significant spread of coronavirus disease 2019 during lockdown and its easing is examined using the susceptible-exposed-infectious-removed model with a fomite term added. Modelling the weekly death rate in the UK, a maximum-likelihood analysis finds a statistically significant fomite contribution, with 0.009 ± 0.001 (95% CI) infection-inducing fomites introduced into the environment per day per infectious person. Post-lockdown, comparison with the prediction of a corresponding counterfactual model with no fomite transmission suggests fomites, through enhancing the overall transmission rate, may have contributed to as much as 25% of the deaths following lockdown. It is suggested that adding a fomite term to more complex simulations may assist in the understanding of the spread of the illness and in making policy decisions to control it.

Proactively Offered Text Messages and Mailed Nicotine Replacement Therapy for Smokers in Primary Care Practices: A Pilot Randomized Trial

INTRODUCTION

Proactive, population health cessation programs can guide efforts to reach smokers outside of the clinic to encourage quit attempts and treatment use.

AIMS AND METHODS

This study aimed to measure trial feasibility and preliminary effects of a proactive intervention offering text messages (TM) and/or mailed nicotine replacement therapy (NRT) to smokers in primary care clinics. From 2017 to 2019 we performed a pilot randomized trial comparing brief telephone advice (control: BA), TM, 2 weeks of mailed NRT, or both interventions (TM + NRT). Patients were identified using electronic health records and contacted proactively by telephone to assess interest in the study. We compared quit attempts, treatment use, and cessation in the intervention arms with BA.

RESULTS

Of 986 patients contacted, 153 (16%) enrolled (mean age 53 years, 57% female, 76% white, 11% black, 8% Hispanic, 52% insured by Medicaid) and 144 (94%) completed the 12-week assessment. On average, patients in the TM arms received 159 messages (99.4% sent, 0.6% failed), sent 19 messages, and stayed in the program for 61 days. In all groups, a majority of patients reported quit attempts (BA 67% vs. TM 86% [p = .07], NRT 81% [p = .18], TM + NRT 79% [p = .21]) and NRT use (BA 51% vs. NRT 83% [p = .007], TM 65% [p = .25], TM + NRT 76% [p = .03]). Effect estimates for reported 7-day abstinence were BA 10% versus TM 26% (p = .09), NRT 28% (p = .06), and TM + NRT 23% (p = .14).

CONCLUSIONS

Proactively offering TM or mailed nicotine medications was feasible among primary care smokers and a promising approach to promote quit attempts and short-term abstinence.

IMPLICATIONS

Proactive intervention programs to promote quit attempts outside of office visits among smokers enrolled in primary care practices are needed. TM have potential to engage smokers not planning to quit or to support smokers to make a planned quit attempt. This pilot study demonstrates the feasibility of testing a proactive treatment model including TM and/or mailed NRT to promote quit attempts, treatment use, and cessation among nontreatment-seeking smokers in primary care.

CLINICALTRIALS.GOV IDENTIFIER

NCT03174158.

Effect of Mailed Human Papillomavirus Test Kits vs Usual Care Reminders on Cervical Cancer Screening Uptake, Precancer Detection, and Treatment: A Randomized Clinical Trial

IMPORTANCE

In the United States, more than 50% of cervical cancers are diagnosed in underscreened women. Cervical cancer screening guidelines now include primary human papillomavirus (HPV) testing as a recommended strategy. Home-based HPV self-sampling is a viable option for increasing screening compliance and effectiveness; however, US data are needed to inform health care system implementation.

OBJECTIVE

To evaluate effectiveness of mailed HPV self-sampling kits vs usual care reminders for in-clinic screening to increase detection and treatment of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and uptake of cervical cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Women aged 30 to 64 years with health plan enrollment for 3 years and 5 months or more, a primary care clinician, no Papanicolaou test within 3 years and 5 months, and no hysterectomy were identified through electronic medical records and enrolled from February 25, 2014, to August 29, 2016, with follow-up through February 26, 2018.

INTERVENTIONS

The control group received usual care (annual patient reminders and ad hoc outreach from primary care clinics). The intervention group received usual care plus a mailed HPV self-sampling kit.

MAIN OUTCOMES AND MEASURES

Two primary outcomes were (1) CIN2+ detection within 6 months of screening and (2) treatment within 6 months of CIN2+ detection. Screening uptake within 6 months of randomization was a secondary outcome.

RESULTS

A total of 19 851 women (mean [SD] age, 50.1 [9.5] years) were included, with 9960 randomized to the intervention group and 9891 randomized to the control group. All women randomized were included in analysis. In the intervention group, 12 participants with CIN2+ were detected compared with 8 in the control group (relative risk, 1.49; 95% CI, 0.61-3.64) and 12 cases were treated vs 7 in the control group (relative risk, 1.70; 95% CI, 0.67-4.32). Screening uptake was higher in the intervention group (2618 participants [26.3%] vs 1719 participants [17.4%]; relative risk, 1.51; 95% CI, 1.43-1.60).

CONCLUSIONS AND RELEVANCE

Mailing HPV kits to underscreened women increased screening uptake compared with usual care alone, with no significant differences in precancer detection or treatment. Results support the feasibility of mailing HPV kits to women who are overdue for screening as an outreach strategy to increase screening uptake in US health care systems. Efforts to increase kit uptake and follow-up of positive results are warranted to maximize detection and treatment of CIN2+.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02005510.

The Condom Fairy program: A novel mail-order service for condoms and sexual health supplies

Objective: In recent years college health professionals have used a variety of innovative strategies to increase availability and accessibility of condoms and safer sex products. The purpose of this study is to evaluate the efficacy and efficiency of a mail-order delivery program titled the Condom Fairy. Participants: Seven hundred thirty-three students (63.4% women, 86.1% heterosexual, and 59.2% Caucasian) completed a questionnaire assessing their overall experience with the program. Methods: Participants completed a 60 item questionnaire 30 days after receiving condoms and safer sex products. Results: Overall, 46,980 condoms were distributed over a six semester period. Almost all of the participants (97.4%) reported they ordered male condoms while 58.0% ordered sexual lubricant, 11.1% female condoms, and 10.2% latex dams. Nearly than three-quarters (73.9%) of participants reported they used the condoms provided. Conclusions: Findings support the implementation of innovative mail-in condom and safer sex product programs on college campuses.

Exercise and cardiovascular load in workers with high occupational physical activity

This study investigated the association between exercise and cardiovascular load in Korean mail carriers with high occupational physical activity (OPA). A total of 36 subjects completed a questionnaire, and their heart rates were measured for 3 consecutive days. Treadmill tests were used determine maximal oxygen uptake (VO_2max). The subjects' relative heart rate (RHR) was 25.6%±4.5%, which was higher than the recommended RHR (24.5%). Daily working hours were 11.1 ± 0.9 hours, which was longer than the maximum acceptable work time (7.8 ± 1.7 hours). Multiple regression analysis showed that daily working hours were positively associated with RHR, but exercise did not show any significant association. According to the results of this study, exercise may not be of benefit to workers with high OPA, suggesting that exercise should be cautiously considered for workers with high OPA.

Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial

Importance

Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups.

Objective

To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates.

Design, Setting, and Participants

This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled.

Interventions

Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion).

Main Outcomes and Measures

The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures.

Results

A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03).

Conclusions and Relevance

Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups.

Trial Registration

ClinicalTrials.gov identifier: NCT00697047.

The impact of survey mode on the response rate in a survey of the factors that influence Minnesota physicians' disclosure practices

BACKGROUND

There is evidence that the physician response rate is declining. In response to this, methods for increasing the physician response rate are currently being explored. This paper examines the response rate and extent of non-response bias in a mixed-mode study of Minnesota physicians.

METHODS

This mode experiment was embedded in a survey study on the factors that influence physicians' willingness to disclose medical errors and adverse events to patients and their families. Physicians were randomly selected from a list of licensed physicians obtained from the Minnesota Board of Medical Practice. Afterwards, they were randomly assigned to either a single-mode (mail-only or web-only) or mixed-mode (web-mail or mail-web) design. Differences in response rate and nonresponse bias were assessed using Fischer's Exact Test.

RESULTS

The overall response rate was 18.60%. There were no statistically significant differences in the response rate across modes (p - value = 0.410). The non-response analysis indicates that responders and non-responders did not differ with respect to speciality or practice location.

CONCLUSIONS

The mode of administration did not affect the physician response rate.

A Retrospective Database Study Comparing Diabetes-Related Medication Adherence and Health Outcomes for Mail-Order Versus Community Pharmacy

BACKGROUND

Adherence to oral antihyperglycemic agents (AHAs) is important for managing blood glucose levels and avoiding hospitalizations or diabetes complications. Previous studies have found that use of mail-order pharmacy dispensing channels results in greater adherence than use of community pharmacies, but the link between use of mail-order pharmacies and improved clinical outcomes has not been established.

OBJECTIVE

To compare the effect of mail-order and community pharmacy use on adherence to oral AHAs, hemoglobin A1c (A1c) level, and glycemic control, as well as emergency department (ED) and inpatient hospital use.

METHODS

This retrospective cohort study of administrative claims data from January 1, 2008, to December 31, 2016, included patients with Medicare Advantage Prescription Drug plan coverage with ≥ 2 claims for the same oral AHA and a diagnosis of type 2 diabetes mellitus (T2DM). Patients were indexed to the start of the most advanced oral AHA identified to begin study observations at the start of a new treatment and assigned to mail-order or community pharmacy cohorts based on which channel dispensed ≥ 80% of their oral AHA claims; all others were excluded. Mail-order and community pharmacy patients were 1:1 propensity score matched. Matched cohorts were compared on proportion of days covered (PDC), adherence (PDC ≥ 0.8), A1c level, glycemic control, and ED and inpatient use for measurement periods of 12, 24, 36, and 48 months post-index.

RESULTS

19,307 mail-order and 19,307 community pharmacy users were matched. PDC was higher for mail-order pharmacy users at 12 months (0.93 vs. 0.82, P < 0.001) and sustainable through 48 months (0.87 vs. 0.77, P < 0.001). Adherence was also greater for mail-order pharmacy patients through 12 months (86% vs. 68%, P < 0.001) and sustainable through 48 months (78% vs. 62%, P < 0.001). Glycemic control as A1c < 7% was not significantly different, but control as A1c < 8% was greater for mail-order pharmacy users at 12 months (91% vs. 89%, P = 0.006) and was greater through 36 months (93% vs. 89%, P = 0.043). Effects on A1c level were not evident. Mail-order pharmacy users were less likely to have an ED visit within 12 months (26% vs. 28%, P < 0.0001), and the difference was observed through 36 months (50% vs. 54%, P < 0.0001). Similarly, fewer mail-order pharmacy users had an inpatient hospitalization within 12 months (17% vs. 19%, P < 0.0001), and the difference was observed through 48 months (43% vs. 47%, P = 0.009).

CONCLUSIONS

The results of the study demonstrate a benefit to patients who use mail-order pharmacies for chronic medications to treat T2DM. The study identified greater glycemic control, lower ED use, and lower hospitalization among individuals using mail-order pharmacies. These positive outcomes were evident in the near term and sustained over time.

DISCLOSURES

This study received no outside funding but was sponsored by Humana through regular employment activities by Schwab, Racsa, and Worley, who are employed by Humana Healthcare Research (formerly Comprehensive Health Insights). This study found benefits related to using mail-order versus community pharmacies for dispensing antihyperglycemic agents in the treatment of type 2 diabetes. Humana owns mail-order pharmacies under the Humana Pharmacy subsidiary. Mourer and Meah are paid employees of Humana Pharmacy Solutions. Rascati is employed by the University of Texas College of Pharmacy at Austin.

Informing future research for carriage of multiresistant Gram-negative bacteria: problems with recruiting to an English stool sample community prevalence study

OBJECTIVES

This study aims to highlight problems with recruiting to an English stool sample community prevalence study. It was part of a larger cross-sectional research to determine the risk factors for the presence of extended-spectrum beta-lactamase and carbapenemase-producing coliforms in stool samples of the asymptomatic general English population.

SETTING

Four National Health Service primary care trusts (PCTs) of England representing a different section of the population of England: Newham PCT; Heart of Birmingham Teaching PCT; Shropshire County PCT; and Southampton City PCT.

PARTICIPANTS

Sixteen general practices across the four PCTs were purposefully selected. After stratification of GP lists by age, ethnicity and antibiotic use, 58 337 randomly selected patients were sent a postal invitation.Patients who had died, moved to a different surgery, were deemed too ill by their General Practitioner or hospitalised at the time of mailing were excluded.

RESULTS

Stool and questionnaire returns varied by area, age, gender and ethnicity; the highest return rate of 27.3% was in Shropshire in the age group of over 60 years; the lowest, 0.6%, was in Birmingham in the age group of 18-39 years. Whereas only 3.9%(2296) returned a completed questionnaire and stool sample, 94.9% of participants gave permission for their sample and data to be used in future research.

CONCLUSION

Researchers should consider the low stool specimen return rate and wide variation by ethnicity and age when planning future studies involving stool specimen collection. This is particularly pertinent if the study has no health benefit to participants. Further research is needed to explore how to improve recruitment in multicultural communities and in younger people.

Using Facebook ads with traditional paper mailings to recruit adolescent girls for a clinical trial

INTRODUCTION

Clinical trials require sufficient samples recruited within limited time and budget constraints. Trials with minors are additionally burdened by the requirement for youth assent and parental permission. This paper details the use of Facebook ads and traditional paper mailings to enroll 797 adolescent girls for a longitudinal, web-based, drug abuse prevention trial. Data on sample representativeness and retention are also provided.

METHODS

Facebook ads appeared on the pages of females aged 13 or 14years who reside in the U.S. Ads linked girls to a recruitment website. Girls who wanted more information submitted contact information and were mailed information packets to their homes containing, among other things, youth assent and parent permission forms. Returned forms were verified for accuracy and validity.

RESULTS

The Facebook ad campaign reached 2,267,848 girls and had a unique click-through rate of 3.0%. The campaign cost $41,202.37 with an average cost of $51.70 per enrolled girl. Information packets were mailed to 1,873 girls. Approximately one-half of girls returned the forms, and 797 girls were enrolled. The Facebook campaign's success varied by ad type, month, and day of the week. Baseline data revealed comparability to national data on demographic and substance use variables.

CONCLUSIONS

Results suggest that Facebook ads provide a useful initial point of access to unparalleled numbers of adolescents. Clinical trials may benefit from a two-fold recruitment strategy that uses online ads to attract interested adolescents followed by traditional recruitment methods to communicate detailed information to adolescents and parents.

Cancer Screening Reminders: Addressing the Spectrum of Patient Preferences

CONTEXT

Health care systems continue to seek evidence about how to optimize the efficiency and effectiveness of cancer screening reminders. Annual reminders to receive preventive services can be an efficient strategy.

OBJECTIVE

To understand patient motivators and barriers to cancer screening and preferences about reminder strategies.

DESIGN

We conducted 11 focus groups among adults recommended for cancer screening within Kaiser Permanente Washington. We held separate focus groups with women aged 21 to 49 years, women 50 to 75 years, and men 50 to 75 years. We used an inductive, validated coding scheme for analysis.

MAIN OUTCOME MEASURES

Motivators and barriers to obtaining recommended cancer screening and general cancer screening reminder content and modality preferences.

RESULTS

Half of our participants were women aged 50 to 75 years, and 25% were men aged 50 to 75 years. Differences by age, sex, insurance status, financial status, and health beliefs all drove the participants' preferences for whether they seek these recommended services and how and when they wish to be reminded about recommended cancer screening. Most participants preferred personalized reminders, and many favored receiving reminders less than 3 months before the recommended procedure date rather than a consolidated annual reminder. Younger participants more commonly requested electronic reminders, such as texts and e-mails.

CONCLUSION

Optimizing cancer screening reminders within a health care system involves a multifaceted approach that enables members to request which form of reminder they prefer (eg, electronic, paper, telephone) and the timing with which they want to be reminded, while staying affordable and manageable to the health care system.

Community pharmacy and mail order cost and utilization for 90-day maintenance medication prescriptions

BACKGROUND

Pharmacy benefit management (PBM) companies promote mail order programs that typically dispense 90-day quantities of maintenance medications, marketing this feature as a key cost containment strategy to address plan sponsors' rising prescription drug expenditures. In recent years, community pharmacies have introduced 90-day programs that provide similar cost advantages, while allowing these prescriptions to be dispensed at the same pharmacies that patients frequent for 30-day quantities.

OBJECTIVE

To compare utilization rates and corresponding costs associated with obtaining 90-day prescriptions at community and mail order pharmacies for payers that offer equivalent benefits in different 90-day dispensing channels.

METHODS

We performed a retrospective, cross-sectional investigation using pharmacy claims and eligibility data from employer group clients of a large PBM between January 2008 and September 2010. We excluded the following client types: government, third-party administrators, schools, hospitals, 340B (federal drug pricing), employers in Puerto Rico, and miscellaneous clients for which the PBM provided billing services (e.g., the pharmacy's loyalty card program members). All employer groups in the sample offered 90-day community pharmacy and mail order dispensing and received benefits management services, such as formulary management and mail order pharmacy, from the PBM. We further limited the sample to employer groups that offered equivalent benefits for community pharmacy and mail order, defined as groups in which the mean and median copayments per claim for community and mail order pharmacy, by tier, differed by no more than 5%. Enrollees in the sample were required to have a minimum of 6 months of eligibility in each calendar year but were not required to have filled a prescription in any year. We evaluated pharmacy costs and utilization for a market basket of 14 frequently dispensed therapeutic classes of maintenance medications. The proportional share of claims for each therapeutic class in the mail order channel was used to weight the results for the community pharmacy channel. Using ordinary least squares regression models, we controlled for differences between channel users with respect to the following confounding factors: age, gender, presence or absence of each of the top 11 drug-inferred conditions (e.g., asthma/chronic obstructive pulmonary disease, cardiovascular disease), drug mix, and calendar year. We calculated estimated predicted means holding all covariates at their mean values. For both 90-day dispensing channels, we calculated number of 90-day claims per member per year (PMPY) and cost per pharmacy claim, with all claims counts adjusted to 30-day equivalents (i.e., number of 90-day claims × 3). Differences were compared using t-tests for statistical significance.

RESULTS

Of 355 PBM clients prior to exclusions, 72 unique employers covering 644,071 unique members (range of approximately 100 to more than 100,000 members per employer) were included in the analysis. On an unadjusted basis, community pharmacies represented 80.8% of 90-day market basket claims (in 30-day equivalents: 3.97 claims PMPY vs. 0.95 in mail order) and 77.2% of total allowed charges. After adjustments for therapeutic group mix and patient characteristics, predicted mean pharmacy claim counts PMPY were 4.09 for community pharmacy compared with 0.85 for mail order (P  less than  0.001). Predicted mean allowed charges per claim for community and mail order pharmacies did not significantly differ ($49.03 vs. $50.04, respectively, P = 0.202).

CONCLUSIONS

When offered maintenance medications through community and mail order pharmacies on a benefit-equivalent basis, commercially insured employees and their dependents utilized the community pharmacy channel more frequently by a margin of more than 4 to 1 in terms of claims PMPY. Overall allowed charges per claim for community and mail order pharmacy did not significantly differ.

Adherence to medication under mandatory and voluntary mail benefit designs

OBJECTIVE

To compare adherence rates under voluntary and mandatory mail benefit designs.

STUDY DESIGN

Matched retrospective cohort.

METHODS

Adherence rates in the first year of therapy were compared between voluntary and mandatory mail cohorts composed of individuals who initiated statin, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), platelet aggregation inhibitor, metformin, glitazone, or sulfonylurea therapy at a retail pharmacy between January 1 and March 31, 2009. Initiators in mandatory mail plans were matched on therapeutic class, age, sex, prospective risk, and cost of initial prescription with those in voluntary mail plans. Logistic regression models of optimal adherence were constructed to adjust for measured confounders.

RESULTS

Persistence rates were similar through the first 60 days of therapy. The mandatory mail cohort had a notable drop in persistence by day 90 (63.3% vs 56.3%, P <.001), with a more pronounced drop among those without previous mail-service pharmacy use (50.5%). Median medication possession ratio (49.2% vs 57.4%) and optimal adherence (33.6% vs 36.1) were also lower. In the multivariable models, mandatory mail participants were less likely to achieve optimal adherence overall (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.67-0.74) and in the metformin (OR 0.55), sulfonylurea (OR 0.72), ACE inhibitor (OR 0.74), ARB (OR 0.69), and statin (OR 0.69) classes. Participants with no prior use of mail-service pharmacy had significantly lower odds of achieving optimal adherence in all therapeutic classes.

CONCLUSIONS

Mandatory mail appears to cause some members to discontinue therapy prematurely, particularly those without previous mail service pharmacy experience.

Descriptive analysis of mail interventions with physicians and patients to improve adherence with antihypertensive and antidiabetic medications in a mixed-model managed care organization of commercial and Medicare members

BACKGROUND

Medication nonadherence is a major concern for many health care stakeholders. Improving medication adherence in health plan members who have both hypertension and diabetes is essential for the successful management of these chronic diseases, with anticipated outcomes in decreased health care utilization, all-cause mortality and cost.

OBJECTIVE

To (a) identify patients who are potentially nonadherent to antidiabetic or antihypertensive agents within 1 managed care organization and (b) determine the relationship of rates of medication nonadherence with 2 mail intervention programs that involved quarterly medication-specific profiles of patients with potential nonadherence sent to primary care physicians (PCPs) and general medication adherence letters sent to patients with potential nonadherence.

METHODS

The study sample consisted of commercial members, Medicare Advantage-Prescription Drug Plan (MA-PD) members and Medicare Prescription Drug Plan (PDP) members who filled prescriptions for antihypertensive and antidiabetic medications and utilized their managed care pharmacy benefit during each measurement quarter (3 months) in the 2-year study period. Nonadherence was defined as a medication possession ratio (MPR) less than 77.0% for 1 or more antihypertensives and/or antidiabetic medications for each standalone calendar quarter. The first intervention, letters to PCPs with patient-specific medication profiles for 2008 Q2, began 6-8 weeks after 2008 Q2 and continued for each standalone calendar quarter through the end of the study period in 2010 Q1 (January 1, 2010, through March 31, 2010). We assumed that patient care was managed by PCPs for hypertension and diabetes treatment. The medication profile also included antihyperlipidemic medication claims information, but there was no adherence analysis performed for antihyperlipidemic medications. The second intervention, letters sent to potentially nonadherent patients, began 6-8 weeks after 2009 Q1 for patients with MPR less than 77% for 1 or more antidiabetic or antihypertensive medications in 2009 Q1 and continued for each standalone calendar quarter through the end of the study period in 2010 Q1.

RESULTS

Because there were 2 different interventions, 2 baseline adherence rates were calculated, for 2008 Q2 for the PCP mailing and for 2009 Q1 for the patient mailing. Compared with the baseline nonadherence rate in 2008 Q2 (35.6%), a small increase in nonadherence was observed in 2008 Q3 (36.4%), following by 6 calendar quarters of lower rates of nonadherence with a 27.7% nonadherence rate in the last measurement period in 2010 Q1. Compared with the nonadherence rate of 30.8% in baseline 2 (2009 Q1), the patient mailings were associated with small increases in nonadherence to 31.4% in 2009 Q2 and 31.1% in 2009 Q3, respectively, followed by lower nonadherence rates in 2009 Q4 (29.2%) and 2010 Q1 (27.7%).

CONCLUSIONS

A 2-part intervention that involved mailings to PCPs for patients with both diabetic and antihypertensive medications who were potentially nonadherent to at least 1 medication, followed 9 months later by a general mailing sent to these potentially nonadherent patients regarding medication adherence, was associated with apparent improvement. However, the effect of the 2-part intervention on medication nonadherence could not be isolated because of coincident disease management interventions in diabetes and hypertension during the 2-year study period.

Contemporary options for longitudinal follow-up: lessons learned from a cohort of urban adolescents

This study reports efforts to locate and survey participants in Project Northland Chicago (PNC), a longitudinal, group-randomized trial of an alcohol preventive intervention for racial/ethnic minority, urban, early-adolescents, 3-4 years following the end of the intervention. Data were collected annually among students from 6th-8th grade and then at age 17-18. Tracking procedures were used to maintain contact with participants and data collection consisted of three phases: (1) Internet- and mail-based surveys; (2) in-school survey administration; and (3) courier service delivery. Contact was lost with 11% of this urban cohort from the end of the PNC intervention activities through these longterm follow-up efforts, as indicated by returned locating postcards. Fifty-three percent of the cohort responded to the survey, the majority completing in Phase 1 of our data collection. Additional school-based and courier-delivery efforts increased our response rate by 11.5%. Costs per completed survey were $118 in Phase 1, $166 in Phase 2, and $440 in Phase 3. This study illustrates that it is possible to track and follow-up a high-risk cohort as they progress through adolescence, even with minimal efforts in intervening years. Lessons learned from this study may inform future efforts to track and collect longitudinal data among high-risk populations.

The effects of tracking responses and the day of mailing on physician survey response rate: three randomized trials

BACKGROUND

The response rates to physician postal surveys remain modest. The primary objective of this study was to assess the effect of tracking responses on physician survey response rate (i.e., determining whether each potential participant has responded or not). A secondary objective was to assess the effects of day of mailing (Monday vs. Friday) on physician survey response rate.

METHODS

We conducted 3 randomized controlled trials. The first 2 trials had a 2 x 2 factorial design and tested the effect of day of mailing (Monday vs. Friday) and of tracking vs. no tracking responses. The third trial tested the effect of day of mailing (Monday vs. Friday). We meta-analyzed these 3 trials using a random effects model.

RESULTS

The total number of participants in the 3 trials was 1339. The response rate with tracked mailing was not statistically different from that with non-tracked mailing by the time of the first reminder (RR = 1.01 95% CI 0.84, 1.22; I²  =  0%). There was a trend towards lower response rate with tracked mailing by the time of the second reminder (RR = 0.91; 95% CI 0.78, 1.06; I²  =  0%). The response rate with mailing on Mondays was not statistically different from that with Friday mailing by the time of first reminder (RR = 1.01; 95% CI 0.87, 1.17; I²  =  0%), and by the time of the 2(nd) reminder (RR = 1.08; 95% CI 0.84, 1.39; I²  =  77%).

CONCLUSIONS

Tracking response may negatively affect physicians' response rate. The day of mailing does not appear to affect physicians' response rate.

Mail-order pharmacy use and adherence to diabetes-related medications

OBJECTIVE

To investigate whether patients who use mail-order pharmacies were more likely to have good medication adherence than patients who use local pharmacies.

STUDY DESIGN

Cross-sectional investigation.

METHODS

We conducted cross-sectional analyses of patients from the Kaiser Permanente Northern California (KPNC) diabetes registry who received a new antiglycemic, antihypertensive, or lipid-lowering index medication between January 1, 2006, and May 31, 2006. We defined good adherence as medication availability at least 80% of the time (ie, a continuous measure of medication gaps value of < or = 20%) and compared adherence between mail-order users (> or = 66% of refills by mail) and KPNC local pharmacy users (all refills in person). Adherence was calculated from the initial dispensing through 15 months of follow-up, medication discontinuation, or May 31, 2007, whichever came first. We analyzed the data using multivariate logistic regression models, after determining that unmeasured patient-level factors and self-selection did not significantly bias our analyses.

RESULTS

A total of 13,922 eligible patients refilled an index medication. Compared with those who used only local KPNC pharmacies, patients who received medications by mail were more likely to have good adherence (84.7% vs 76.9%, P <.001). After adjusting for potential confounders, including days' supply and out-of-pocket costs, mailorder users had better adherence to antiglycemic, antihypertensive, and lipid-lowering medications (P <.001 for all).

CONCLUSIONS

Compared with patients who obtained medication refills at local pharmacies, patients who received them by mail were more likely to have good adherence. The association between mail-order use and medication adherence should be evaluated in a randomized clinical trial.

A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy

OBJECTIVE

To compare long-term diabetes medication adherence and healthcare costs in patients using mail order pharmacy versus retail pharmacy.

METHODS

The MarketScan database was used to identify patients who filled prescriptions for oral anti-diabetes medications in a retail pharmacy for at least 6 months before switching to mail order pharmacy for at least 12 months. These patients were matched to others who used retail pharmacy continuously for at least 18 months. A propensity score was used to create matched groups of patients comparable on probability of switching to mail order, weighted Poisson regression was used to analyze differences in medication adherence, and Tobit regression was used to compare costs.

RESULTS

A total of 14,600 patients who switched to mail order were matched to 43,800 patients who used retail pharmacy continuously. The average adjusted adherence in retail pharmacy was 63.4% compared to 84.8% after switching to mail order. Per-member-per-month total healthcare and total medical costs were on average $34.32 and $37.54 lower in the mail order group, respectively. Diabetes-related medical costs were on average $19.14 lower in the mail order group, while pharmacy costs were $14.13 higher.

LIMITATIONS

Limitations include a patient population under the age of 65, no information on pharmacy benefit design, and limited follow-up time relative to that necessary to identify long-term diabetes complications.

CONCLUSIONS

After adjusting for measured confounders of medication adherence and disease severity, individuals who switched to mail order pharmacy had higher medication possession ratios and trended toward lower total and diabetes-related medical costs over time.

Evaluating geographic imputation approaches for zip code level data: an application to a study of pediatric diabetes

BACKGROUND

There is increasing interest in the study of place effects on health, facilitated in part by geographic information systems. Incomplete or missing address information reduces geocoding success. Several geographic imputation methods have been suggested to overcome this limitation. Accuracy evaluation of these methods can be focused at the level of individuals and at higher group-levels (e.g., spatial distribution).

METHODS

We evaluated the accuracy of eight geo-imputation methods for address allocation from ZIP codes to census tracts at the individual and group level. The spatial apportioning approaches underlying the imputation methods included four fixed (deterministic) and four random (stochastic) allocation methods using land area, total population, population under age 20, and race/ethnicity as weighting factors. Data included more than 2,000 geocoded cases of diabetes mellitus among youth aged 0-19 in four U.S. regions. The imputed distribution of cases across tracts was compared to the true distribution using a chi-squared statistic.

RESULTS

At the individual level, population-weighted (total or under age 20) fixed allocation showed the greatest level of accuracy, with correct census tract assignments averaging 30.01% across all regions, followed by the race/ethnicity-weighted random method (23.83%). The true distribution of cases across census tracts was that 58.2% of tracts exhibited no cases, 26.2% had one case, 9.5% had two cases, and less than 3% had three or more. This distribution was best captured by random allocation methods, with no significant differences (p-value > 0.90). However, significant differences in distributions based on fixed allocation methods were found (p-value < 0.0003).

CONCLUSION

Fixed imputation methods seemed to yield greatest accuracy at the individual level, suggesting use for studies on area-level environmental exposures. Fixed methods result in artificial clusters in single census tracts. For studies focusing on spatial distribution of disease, random methods seemed superior, as they most closely replicated the true spatial distribution. When selecting an imputation approach, researchers should consider carefully the study aims.

[Occupational stress and the risk of sickness absence in customer service workers]

BACKGROUND

The aim of this study was to indicate psychosocial stressors at work that significantly affect sickness absence a workers.

MATERIALS AND METHODS

Study subjects included a group of 233 randomly selected women employed as post-office clerks. Sickness absence data covered the period of 2004-2006. The psychosocial factors were assessed by means of the Subjective Work Characteristics Questionnaire. The hazard ratio (HR) of sickness absence was analysed using the Cox regression model, separately for short- (1-9 days) medium- (10-29 days) and long-term (30 days and above) sickness absence.

RESULTS

The shortterm sickness absence risk was significantly related with the post-office size--in the offices employing 8-12 workers, the risk was by 50% lower compared to those employing a smaller number of workers (HR = 0.49; 95% CI: 0.27-0.90) and unpleasant working conditions (dirt), which contributed to the increased risk (HR = 1.30; 95% CI: 1.12-1.50). In the case of a 10-29-day absence, the risk was slightly elevated by the demand of long-term vigilance, financial responsibility, and strictly determined breaks at work In the model of long-term sickness absence, a significantly higher risk was noted when the number of employees was 16-25 compared to a smaller number of employees (HR = 2.92; 95% CI: 1.09-7.82), non-occupational, self-assessed workload was high (HR = 2.97; 95% CI: 1.34-6.62) or moderate (HR = 2.22; 95% CI: 1.11-4.44) compared to self-assessed low workload, and the work space was limited (HR = 1.21; 95% CI: 1.00-1.47).

CONCLUSIONS

Our analysis showed a significant effect of stressogenic work conditions on the patterns of sickness absence. Our findings may help in developing programs intended to reduce sickness absence through limiting the prevalence of unfavourable conditions at workplaces.

Factors associated with choice of pharmacy setting among DoD health care beneficiaries aged 65 years or older

BACKGROUND

Department of Defense (DoD) health care planners want to stimulate a voluntary migration of prescription fills from military and community pharmacies to its mail-order pharmacy, a lower-cost dispensing option for the department. Beneficiary cost share for a 90-day supply of generic/ brand medication is $0/$0 at military (DoD) pharmacies, $3/$9 at the DoD mail-order pharmacy, and $9/$27 at network community pharmacies.

OBJECTIVE

To examine the pharmacy use patterns among the beneficiary population age 65 years or older, traditionally the heaviest users of the TRICARE DOD prescription drug benefit, to identify factors that are associated with beneficiary use of pharmacy setting(s).

METHODS

Outpatient prescription fill records were examined for TRICARE beneficiaries age 65 years or older (N = 300,084) residing in North Carolina, Texas, and California for dates of service from December 1, 2004 through February 28, 2005. Binary logistic regression models were run for each type (military, community, and mail order) and number of pharmacy settings used by beneficiary gender, age group, catchment area status (located either within or outside a 40-mile radius of each military pharmacy), state, and number of medications obtained (defined as count of unique combinations of strength, and route of administration). The mean number of medications per beneficiary and cost per medication were tabulated for each type and number of settings used.

RESULTS

In the 3-month period from December 1, 2004 through February 28, 2005, beneficiary use of military, community, and mail-order pharmacies was 45.4%, 67.6%, and 22.1%, respectively. About 67% of the study population used 1 setting exclusively and 2.4% used all 3 settings. Noncatchment residents were significantly less likely (adjusted odds ratio [AOR]= 0.080; 95% confidence interval [CI], 0.078-0.082) to use a military pharmacy exclusively and significantly more likely to use a community pharmacy (AOR = 4.64; 95% CI, 4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI, 3.80-4.05) exclusively than were catchment residents. Beneficiaries taking 10 or more medications were more likely (AOR = 8.43; 95% CI, 8.21-8.65) to use multiple settings than were those who obtained 3 or fewer medications. Single-setting users obtained a median of 4 (interquartile range [IQ]) 2-7) medications with a median copayment of $7.00 (IQ $0-$13.19) per medication. Those who used all 3 settings obtained a median of 9 (IQ 7-12) medications with a median copayment of $4.33 (IQ $3.00-$6.00) per medication. Among beneficiaries who obtained 6 or more unique medications during the 90-day study period, approximately 25% used the mail-order pharmacy to obtain 1 or more prescription fills.

CONCLUSION

A significant portion of the study population did not use the mail-order pharmacy despite the financial incentive to use mail-order rather than community pharmacies. Relatively small financial incentives alone may be inadequate for promoting a switch to the mail-order option among those beneficiaries not already using it in a pharmacy benefit plan with low copayments. Larger monetary and other incentives may be necessary to achieve the desired transfer of prescriptions fills to the mail-order pharmacy and the associated reduction in military pharmacy workload.

Willingness of gynaecologists, doctors in family planning, GPs, practice nurses and pharmacists to adopt novel interventions for treating sexual partners of women with chlamydia

OBJECTIVE

To determine willingness of health professionals to adopt new interventions for treating sexual partners of women with chlamydia.

DESIGN

Anonymous, self-administered questionnaires of doctors, practice nurses and community pharmacists regarding novel testing/treatment options for partners of women with chlamydia.

SETTING

Local (Scotland) and national (UK) clinical meetings in reproductive health, and community pharmacy (Lothian).

POPULATION

Doctors (general practice, gynaecology, family planning) and practice nurses who were delegates at selected meetings in reproductive health and community pharmacists attending pharmacy meetings.

METHODS

Doctors and nurses were invited to complete a questionnaire indicating their preferred strategy for testing/treating sexual partners of women with chlamydia if given choice of partner notification, postal testing kit (PTK), patient delivered partner medication (PDPM) with azithromycin or combined PDPM and PTK. Community pharmacists were invited to complete a questionnaire regarding their willingness to introduce chlamydia testing and treatment services.

MAIN OUTCOME MEASURES

Reported preferences of doctors and nurses for partner testing/treatment strategies and willingness of pharmacists to offer new services.

RESULTS

Questionnaires were completed by 211 doctors, 73 practice nurses and 50 pharmacists. The most popular choice of doctors (30%) and nurses (23%) was a combination of PDPM with PTK, with partner notification the least popular (8 and 3%, respectively). One in four doctors had previously used PDPM for treating partners. Most pharmacists were willing to supply free PTKs (98%), offer testing (75%) and treatment services (100%) and give women PDPM for partners (80%).

CONCLUSION

Relevant health professionals, who are increasingly involved in managing chlamydia, are largely in favour of introducing new strategies for treating sexual partners.

Ensayo clínico aleatorizado acerca de la efectividad del recordatorio postal para aumentar la cobertura vacunal contra tétanos-difteria en población adulta joven

OBJECTIVE

To evaluate the effectiveness of individual postal reminders compared with no action of any kind in increasing the tetanus-diphtheria immunization rate in the population aged between 24 and 30 years old in an area where a general population strategy was simultaneously being conducted through information posters on tetanus vaccination.

METHOD

We performed an open, randomized clinical trial with parallel groups among the population aged 24-30 years old in a basic health area with 13,523 inhabitants over a 3-month period in 2005. There were 311 patients in the control group and 311 in the experimental group, after exclusion of individuals correctly vaccinated according to the computerized medical records system. The intervention evaluated was a postal reminder on tetanus vaccination. The response variable was the immunization rate due to the intervention. Other variables studied were sex, age, reason for seeking vaccination, compliance with the vaccination timetable, whether vaccination was rejected, and whether prior vaccination was verified. The statistical analysis consisted of Student's t-test and the chi2 test, with a confidence level of 95% (p < 0.05).

RESULTS

Vaccination coverage among the general population at the end of 2005 was 75.6%. After the postal reminder, 22.2% of the control group and 40.5% of the experimental group were correctly vaccinated.

CONCLUSIONS

Individual postal reminders sent to the population aged between 24 and 30 years is effective in increasing the immunization rate in this age group. Periodic reminders could help to ensure continuity in vaccination of the adult population.

Mail versus internet surveys: determinants of method of response preferences among health professionals

The authors evaluated determinants of response to Internet-based surveys in a sample (n = 5600) of Texas healthcare professionals. Participants were given the option of responding by mail or over the Web (response, 66%). Internet respondents were younger (p < .001), had worked fewer years in healthcare (p < .001), and were more likely to be male (p < .001) and to work in a hospital (p = .007). Missing questionnaire items were significantly higher among Web responders with regard to age, sex, race, body mass index, and smoking (p < .001). In the final multivariate logistic regression, only male gender (odds ratio [OR] = 2.09, 95% CI = 1.56-2.80) and younger age remained significantly associated with response over the Internet. Age quartile and responding electronically were inversely associated. Taken together with a priori knowledge of the demographic and professional profile of a study population, these findings can be useful in planning and implementation of surveys among healthcare workers.

Following up nonrespondents to an online weight management intervention: randomized trial comparing mail versus telephone

Background

Attrition, or dropout, is a problem faced by many online health interventions, potentially threatening the inferential value of online randomized controlled trials.

Objective

In the context of a randomized controlled trial of an online weight management intervention, where 85% of the baseline participants were lost to follow-up at the 12-month measurement, the objective was to examine the effect of nonresponse on key outcomes and explore ways to reduce attrition in follow-up surveys.

Methods

A sample of 700 nonrespondents to the 12-month online follow-up survey was randomly assigned to a mail or telephone nonresponse follow-up survey. We examined response rates in the two groups, costs of follow-up, reasons for nonresponse, and mode effects. We ran several logistic regression models, predicting response or nonresponse to the 12-month online survey as well as predicting response or nonresponse to the follow-up survey.

Results

We analyzed 210 follow-up respondents in the mail and 170 in the telephone group. Response rates of 59% and 55% were obtained for the telephone and mail nonresponse follow-up surveys, respectively. A total of 197 respondents (51.8%) gave reasons related to technical issues or email as a means of communication, with older people more likely to give technical reasons for noncompletion; 144 (37.9%) gave reasons related to the intervention or the survey itself. Mail follow-up was substantially cheaper: We estimate that the telephone survey cost about US $34 per sampled case, compared to US $15 for the mail survey. The telephone responses were subject to possible social desirability effects, with the telephone respondents reporting significantly greater weight loss than the mail respondents. The respondents to the nonresponse follow-up did not differ significantly from the 12-month online respondents on key outcome variables.

Conclusions

Mail is an effective way to reduce attrition to online surveys, while telephone follow-up might lead to overestimating the weight loss for both the treatment and control groups. Nonresponse bias does not appear to be a significant factor in the conclusions drawn from the randomized controlled trial.

On the use of ZIP codes and ZIP code tabulation areas (ZCTAs) for the spatial analysis of epidemiological data

BACKGROUND

While the use of spatially referenced data for the analysis of epidemiological data is growing, issues associated with selecting the appropriate geographic unit of analysis are also emerging. A particularly problematic unit is the ZIP code. Lacking standardization and highly dynamic in structure, the use of ZIP codes and ZIP code tabulation areas (ZCTA) for the spatial analysis of disease present a unique challenge to researchers. Problems associated with these units for detecting spatial patterns of disease are explored.

RESULTS

A brief review of ZIP codes and their spatial representation is conducted. Though frequently represented as polygons to facilitate analysis, ZIP codes are actually defined at a narrower spatial resolution reflecting the street addresses they serve. This research shows that their generalization as continuous regions is an imposed structure that can have serious implications in the interpretation of research results. ZIP codes areas and Census defined ZCTAs, two commonly used polygonal representations of ZIP code address ranges, are examined in an effort to identify the spatial statistical sensitivities that emerge given differences in how these representations are defined. Here, comparative analysis focuses on the detection of patterns of prostate cancer in New York State. Of particular interest for studies utilizing local, spatial statistical tests, is that differences in the topological structures of ZIP code areas and ZCTAs give rise to different spatial patterns of disease. These differences are related to the different methodologies used in the generalization of ZIP code information. Given the difficulty associated with generating ZIP code boundaries, both ZIP code areas and ZCTAs contain numerous representational errors which can have a significant impact on spatial analysis. While the use of ZIP code polygons for spatial analysis is relatively straightforward, ZCTA representations contain additional topological features (e.g. lakes and rivers) and contain fragmented polygons that can hinder spatial analysis.

CONCLUSION

Caution must be exercised when using spatially referenced data, particularly that which is attributed to ZIP codes and ZCTAs, for epidemiological analysis. Researchers should be cognizant of representational errors associated with both geographies and their resulting spatial mismatch, especially when comparing the results obtained using different topological representations. While ZCTAs can be problematic, topological corrections are easily implemented in a geographic information system to remedy erroneous aggregation effects.

Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy

PURPOSE

The purpose of this study was to investigate the relationship between socioeconomic status (SES) and the use of intentionally reduced doses of chemotherapy in the adjuvant treatment of breast cancer.

PATIENTS AND METHODS

Patients with breast cancer treated with a standard chemotherapy regimen (n = 764) were enrolled in a prospective registry after signing informed consent. Detailed information was collected on patient, disease, and treatment, including chemotherapy doses. Zip code level data on median household income, proportion of people living below the poverty level, and educational attainment were obtained from the US Census. Doses for the first cycle of chemotherapy lower than 85% of standard were considered to be reduced. Univariate analyses and multivariate logistic regression were performed to identify factors associated with the use of reduced first cycle doses.

RESULTS

In univariate analysis, individual education attainment, zip code SES measures, body mass index, and geographic region were all significantly associated with receipt of intentionally reduced doses of chemotherapy. In multivariate analysis, controlling for geography, factors independently associated with reduced doses were obesity (odds ratio [OR], 2.47; 95% CI, 1.36 to 4.51), severe obesity (OR, 4.04; 95% CI, 1.46 to 11.19), and education less than high school (OR, 3.07; 95% CI, 1.57 to 5.99).

CONCLUSION

Social disparities in breast cancer outcomes may be in part the result of lower quality chemotherapy doses in the adjuvant treatment of breast cancer. Efforts to address such prescribing patterns may help reduce SES disparities in breast cancer survival.

Telephone outreach to increase colorectal cancer screening in an urban minority population

OBJECTIVES

We compared the effectiveness of a telephone outreach approach versus a direct mail approach in improving rates of colorectal cancer (CRC) screening in a predominantly Black population.

METHODS

A randomized trial was conducted between 2000 and 2003 that followed 456 participants in the New York metropolitan area who had not had recent CRC screening. The intervention group received tailored telephone outreach, and the control group received mailed printed materials. The primary outcome was medically documented CRC screening 6 months or less after randomization.

RESULTS

CRC screening was documented in 61 of 226 (27.0%) intervention participants and in 14 of 230 (6.1%) controls (prevalence rate difference=20.9%; 95% CI = 14.34, 27.46). Compared with the control group, the intervention group was 4.4 times more likely to receive CRC screening within 6 months of randomization.

CONCLUSIONS

Tailored telephone outreach can increase CRC screening in an urban minority population.

Match rate and positional accuracy of two geocoding methods for epidemiologic research

PURPOSE

This study compares the match rate and positional accuracy of two geocoding methods: the popular geocoding tool in ArcGIS 9.1 and the Centrus GeoCoder for ArcGIS.

METHODS

We first geocoded 11,016 Texas addresses in a case-control study using both methods and obtained the match rate of each method. We then randomly selected 200 addresses from those geocoded by using both methods and obtained geographic coordinates of the 200 addresses by using a global positioning system (GPS) device. Of the 200 addresses, 110 were case maternal residence addresses and 90 were control maternal residence addresses. These GPS-surveyed coordinates were used as the "true" coordinates to calculate positional errors of geocoded locations. We used Wilcoxon signed rank test to evaluate whether differences in positional errors from the two methods were statistically significantly different from zero. In addition, we calculated the sensitivity and specificity of the two methods for classifying maternal addresses within 1500 m of toxic release inventory facilities when distance is used as a proxy of exposure.

RESULTS

The match rate of the Centrus GeoCoder was more than 10% greater than that of the geocoding tool in ArcGIS 9.1. Positional errors with the Centrus GeoCoder were less than those of the geocoding tool in ArcGIS 9.1, and this difference was statistically significant. Sensitivity and specificity of the two methods are similar.

CONCLUSIONS

Centrus GeoCoder for ArcGIS for geocoding gives greater match rates than the geocoding tool in ArcGIS 9.1. Although the Centrus GeoCoder has better positional accuracy, both methods give similar results in classifying maternal addresses within 1500 m of toxic release inventory facilities when distance is used as a proxy of exposure.

A randomised controlled trial to assess the effectiveness of offering study results as an incentive to increase response rates to postal questionnaires [ISRCTN26118436]

Background

Postal questionnaires are widely used to collect outcome data on participants. However, a poor response to questionnaires will reduce the statistical power of the study and may introduce bias. A meta analysis of ten trials offering study results, largely in the fields of education and marketing, was shown to be ineffective, with the odds ratio for response with offering research findings is 0.92 (95% CI 0.75 to 1.11). However uncertainty still exists as it is uncertain whether results from such trials can be extrapolated to that of a health care setting. The aim of this study was to assess whether offering participants study results increases the response rates to postal questionnaires.

Methods

1038 women aged over 70 years were remotely randomised by computer in a 3:1 ratio. 250 participants did not receive the offer of knowing the results of the trial and 788 participants were offered the results of the trial in a postal questionnaire. The main outcome measure was response rate. Chi square test was used to evaluate the overall differences in response rate between the two groups. An adjusted analysis, adjusting for whether the participant was taking calcium and age was also undertaken.

Results

The response rates were not significantly different Odds Ratio 0.88 (95% confidence intervals 0.48 to 1.63) p = 0.69.

Conclusion

Offering study results to women living in the community aged over 70 does not increase response rates to postal questionnaires. Although researchers have an ethical obligation to offer participants study results, since 10% of women did not wish to receive the results, investigators should give participants the option to opt out of receiving the study's results.

Feasibility and efficacy of a binge drinking prevention intervention for college students delivered via the Internet versus postal mail

In this study, the authors evaluated the feasibility and efficacy of a binge drinking prevention intervention for college students delivered via the Internet versus a parallel print-based intervention delivered via postal mail. A total of 116 college students completed the baseline survey. The authors then randomized the students into the Web or print group and sent them intervention materials. One hundred and six students completed the posttest survey. The intervention consisted of a series of 4 weekly "newsletters" in electronic or print format. The authors collected data using a standardized online 42-item survey. They found that an Internet-based binge drinking prevention intervention for college students was feasible. Results supported the efficacy of this intervention for those students already binge drinking, regardless of delivery mode. The authors found no significant differences on outcome measures when delivered via the Internet or postal mail. Results lend support to the use of the Internet as a viable alternative to more traditional health intervention delivery methods.

Randomized Trial of Different Screening Strategies for Colorectal Cancer: Patient Response and Detection Rates

BACKGROUND

Although there is general consensus concerning the efficacy of colorectal cancer screening, there is a lack of agreement about which routine screening strategy should be adopted. We compared the participation and detection rates achievable through different strategies of colorectal cancer screening.

METHODS

From November 1999 through June 2001 we conducted a multicenter, randomized trial in Italy among a sample of 55-64 year olds in the general population who had an average risk of colorectal cancer. People with previous colorectal cancer, adenomas, inflammatory bowel disease, a recent (< or =2 years) colorectal endoscopy or fecal occult blood test (FOBT), or two first-degree relatives with colorectal cancer were excluded. Eligible subjects were randomly assigned, within the roster of their general practitioner, to 1) biennial FOBT (delivered by mail), 2) biennial FOBT (delivered by general practitioner or a screening facility), 3) patient's choice of FOBT or "once-only" sigmoidoscopy, 4) "once-only" sigmoidoscopy, or 5) sigmoidoscopy followed by biennial FOBT. An immunologic FOBT was used. Participation and detection rates of the strategies tested were compared using multivariable logistic regression models that adjusted for age, sex, and screening center. All statistical tests were two-sided.

RESULTS

Of 28 319 people sampled, 1637 were excluded and 26 682 were randomly assigned to a screening arm. After excluding undelivered letters (n = 427), the participation rates for groups 1, 2, 3, 4, and 5 were 30.1% (682/2266), 28.1% (1654/5893), 27.1% (970/3579), 28.1% (1026/3650), and 28.1% (3049/10 867), respectively. Of the 2858 subjects screened by FOBT, 122 (4.3%) had a positive test result, 10 (3.5 per 1000) had colorectal cancer, and 39 (1.4%) had an advanced adenoma. Among the 4466 subjects screened by sigmoidoscopy, 341 (7.6%) were referred for colonoscopy, 18 (4 per 1000) had colorectal cancer, and 229 (5.1%) harbored an advanced adenoma.

CONCLUSIONS

The participation rates were similar for sigmoidoscopy and FOBT. The detection rate for advanced neoplasia was three times higher following screening by sigmoidoscopy than by FOBT.

Obtaining health information from farmers: interviews versus postal questionnaires in a New Zealand case study

PURPOSE

To compare the effectiveness of interviewer-led and postal surveys in gathering adequate health data for occupational health programmes among farmers.

METHODS

Two cross-sectional studies of farmers from southern New Zealand were conducted. Farms were randomly selected from the public land valuation roll and all farmers and farm workers invited to participate in the farmers' health study. First, 477 farms were invited to participate in an interviewer administered questionnaire and health check; and second, a further 432 farms were selected and invited to participate in a self-administered postal survey. Both groups completed the same questionnaire.

RESULTS

The response for the interviewer-led and postal surveys was 65.4 % and 51.6 % respectively. The 2 groups differed demographically, with fewer young farm workers in the postal survey, but were similar in all areas of health information collected, except that men in the interviewer-led survey were significantly more likely to have a psychological disturbance than men in the postal survey (chi ( 2 ) =5.06, df=1, p=0.024).

CONCLUSIONS

Despite the interviewer-led survey having a higher response rate, the postal survey produced similar health data, which is adequate for planning occupational health programmes for farmers. Extra effort should be made to recruit younger farm workers in future research.

Increasing response to a postal survey of sedentary patients - a randomised controlled trial [ISRCTN45665423]

Background

A systematic review identified a range of methods, which can influence response rates. However, analysis specific to a healthcare setting, and in particular, involving people expected to be poor responders, was missing, We examined the effect of pre-warning letters on response rates to a postal survey of sedentary patients whom we expected a low rate of response.

Methods

Participants were randomised to receive a pre-warning letter or no pre-warning letter, seven days before sending the main questionnaire. The main questionnaire included a covering letter and pre-paid return envelope. After seven days, non-responders were sent a reminder letter and seven days later, another reminder letter with a further copy of the questionnaire and return envelope.

Results

627 adults, with a mean age of 48 years (SD 13, range 18 to 78) of whom 69.2% (434/627) were women, were randomised. 49.0% (307/627) of patients were allocated to receive a pre-warning letter and 51.0% (320/627) no pre-warning letter, seven days in advance of posting the main questionnaire. The final response rate to the main questionnaire was 30.0% (92/307) amongst those sent a pre-warning letter and 20.9% (67/320) not sent a pre-warning letter, with an adjusted odds ratio of 1.60 (95% CI 1.1, 2.30).

Conclusions

The relatively low cost method of sending a pre-warning letter had a modest impact on increasing response rates to a postal questionnaire sent to a group of patients for whom a low response rate was anticipated. Investigators should consider incorporating this simple intervention when conducting postal surveys, to reduce the potential for nonresponse bias and to increase the study power. Methods other than postal surveys may be needed however when a low response rate to postal surveys is likely.

Internet versus mailed questionnaires: a controlled comparison (2)

Background

Low response rates among surgeons can threaten the validity of surveys. Internet technologies may reduce the time, effort, and financial resources needed to conduct surveys.

Objective

We investigated whether using Web-based technology could increase the response rates to an international survey.

Methods

We solicited opinions from the 442 surgeon–members of the Orthopaedic Trauma Association regarding the treatment of femoral neck fractures. We developed a self-administered questionnaire after conducting a literature review, focus groups, and key informant interviews, for which we used sampling to redundancy techniques. We administered an Internet version of the questionnaire on a Web site, as well as a paper version, which looked similar to the Internet version and which had identical content. Only those in our sample could access the Web site. We alternately assigned the participants to receive the survey by mail (n=221) or an email invitation to participate on the Internet (n=221). Non-respondents in the mail arm received up to three additional copies of the survey, while non-respondents in the Internet arm received up to three additional requests, including a final mailed copy. All participants in the Internet arm had an opportunity to request an emailed Portable Document Format (PDF) version.

Results

The Internet arm demonstrated a lower response rate (99/221, 45%) than the mail questionnaire arm (128/221, 58%) (absolute difference 13%, 95% confidence interval 4%-22%, P<0.01).

Conclusions

Our Internet-based survey to surgeons resulted in a significantly lower response rate than a traditional mailed survey. Researchers should not assume that the widespread availability and potential ease of Internet-based surveys will translate into higher response rates.

Comparison of web and mail surveys in collecting illicit drug use data: a randomized experiment

This randomized experiment examined survey mode effects for self-reporting illicit drug use by comparing prevalence estimates between a Web-based survey and a mail-based survey. A random sample of 7,000 traditional-aged undergraduate students attending a large public university in the United States was selected to participate in the spring of 2001. Students were randomly assigned to self-administer a survey via the Web or U.S. mail. The Web survey produced a significantly higher response rate than the U.S. mail survey. The prevalence estimates of illicit drug use (lifetime and past year) did not differ significantly between the two survey modes. The findings provide preliminary evidence that Web and U.S. mail surveys produce similar results regarding illicit drug use among undergraduate students. Although additional research is needed involving more diverse samples, these findings bode well for using Web surveys in college-based research.

An investigation into low mail survey response rates of information technology users in health care organizations

Surveys conducted by mail can result in a very low response rate raising the possibility of non-response bias that would question the validity of the findings. In this study, we compare the demographic profiles between the respondents and non-respondents, and conduct wave analysis as an alternative way to estimate the non-response bias among the information technology (IT) users in the health care industry. Our findings indicate that there is no significant difference among the respondents when considering the duration (early versus late) of response rate. Likewise, there was no significant difference when the available demographic characteristics (facility type and user's position) of those who responded were compared to the same characteristics of the sample. We were able to reach similar conclusion by using either of the proposed methods; analysis of demographic profiles of respondents versus non-respondents, and wave analysis. Thus our findings support the validity of the results from low response mail survey studies for IT users.

The requirement for prior consent to participate on survey response rates: a population-based survey in Grampian

Background

A survey was carried out in the Grampian region of Scotland with a random sample of 10,000 adults registered with a General Practitioner in Grampian. The study complied with new legislation requiring a two-stage approach to identify and recruit participants, and examined the implications of this for response rates, non-response bias and speed of response.

Methods

A two-stage survey was carried out consistent with new confidentiality guidelines. Individuals were contacted by post and asked by the Director of Public Health to consent to receive a postal or electronic questionnaire about communicating their views to the NHS. Those who consented were then sent questionnaires. Response rates at both stages were measured.

Results

25% of people returned signed consent forms and were invited to complete questionnaires. Respondents at the consent stage were more likely to be female (odds ratio (OR) response rate of women compared to men = 1.5, 95% CI 1.4, 1.7), less likely to live in deprived postal areas (OR = 0.59, 95% CI 0.45, 0.78) and more likely to be older (OR for people born in 1930–39 compared to people born in 1970–79 = 2.82, 95% CI 2.36, 3.37). 80% of people who were invited to complete questionnaires returned them. Response rates were higher among older age groups. The overall response rate to the survey was 20%, relative to the original number approached for consent (1951/10000).

Conclusion

The requirement of a separate, prior consent stage may significantly reduce overall survey response rates and necessitate the use of substantially larger initial samples for population surveys. It may also exacerbate non-response bias with respect to demographic variables.

Centers for Disease Control and Prevention (CDC). Follow-up of deaths among U.S. Postal Service workers potentially exposed to Bacillus anthracis--District of Columbia, 2001-2002

In October 2001, two letters contaminated with Bacillus anthracis spores were processed by mechanical and manual methods at the U.S. Postal Service (USPS) Brentwood Mail Processing and Distribution Center in the District of Columbia. Four postal workers at the Brentwood facility became ill with what was diagnosed eventually as inhalational anthrax; two died. The facility was closed on October 21, and postexposure prophylaxis was recommended for approximately 2,500 workers and business visitors. Subsequent reports of deaths of facility workers prompted concern about whether mortality was unusually high among workers, perhaps related to the anthrax attacks. To evaluate the rates and causes of death among workers at the Brentwood facility during October 12, 2001-October 11, 2002, CDC, in collaboration with state and local health departments, analyzed death certificate data. In addition, these data were compared with aggregate mortality data from the five USPS facilities contaminated with B. anthracis during the fall 2001 anthrax attacks. This report summarizes the results of that analysis, which indicate that rates and causes of death among Brentwood workers during the 12 months after the anthrax attacks of 2001 were not different from rates and causes of deaths that occurred during the preceding 5 years.

Selected characteristics of senior citizens prescription drug payment and procurement in 1998 and 2001

BACKGROUND

People without prescription drug coverage face greater financial burdens and may sometimes be unable to follow the courses of treatment prescribed by their physicians. The U.S. legislature is considering Medicare coverage for prescription drugs and the use of managed care approaches for containing costs associated with senior citizens. prescription drug therapy.

OBJECTIVE

The purpose of this study was to describe selected characteristics of senior citizens. prescription drug payment and procurement.

METHODS

Data were obtained via mailed survey from national random samples of senior citizens in 1998 and in 2001. Descriptive statistics and regression analyses were used to describe relationships among study variables.

RESULTS

Of 2,434 deliverable surveys, 946 (39%) were returned. Of these, 700 (29%) respondents provided usable data for analysis. Results showed that in 2001, compared with 1998, the proportion of senior citizens without any prescription insurance coverage did not change significantly, 29% and 32%, respectively. However, the proportion of respondents with prescription drug coverage who had to share costs of prescriptions through copayments and coinsurance rose significantly, from 69% in 1998 to 89% in 2001. Between 1998 and 2001, the proportion of senior citizens using mail-order pharmacies rose significantly, from 17% to 27%, and the proportion who reported financial hardship also rose, from 19% in 1998 to 31% in 2001. Controlling for year, prescription drug use, and income, logistic regression analysis showed that respondents without any prescription insurance coverage were about 5 times more likely to report financial hardship compared with those having coverage.

CONCLUSIONS

The proportion of senior citizens without any prescription drug insurance coverage did not change significantly between 1998 and 2001, but cost sharing in terms of the proportion that had cost-sharing requirements and the amount of the cost sharing through copayments and coinsurance rose significantly. Self-reported financial hardship and the use of mail-order pharmacies among seniors increased between 1998 and 2001.

Post office box addresses: a challenge for geographic information system-based studies

BACKGROUND

Geographic information system (GIS)-based health studies require information on the physical location of data points, such as subject addresses. In a study of California women diagnosed with breast cancer between 1988 and 1997, we needed to locate the residential addresses of 4,537 women with post office boxes (POBs).

METHODS

We investigated the feasibility of tracing street addresses for the POBs and examined potential selection biases and case attribute misclassifications introduced by different methods of handling POBs in GIS-based health studies.

RESULTS

Our tracing method yielded street addresses for only 34% of POBs in our study. Examination of subjects' case characteristics revealed that boxholders were not representative of the full population. Geocoding using a POB's delivery-weighted five-digit zip code centroid, as a proxy for street address, resulted in case attribute misclassification for 81% of boxholders.

CONCLUSIONS

Disease registries should modernize their infrastructure to complement GIS technologies. Epidemiologists should understand GIS data limitations and consider potential biases introduced by incomplete or inaccurate geocoding.