OBJECTIVES: Among patients unlikely to attend a scheduled colonoscopy, we examined the impact of peer coach versus educational brochure support and compared these with concurrent patients who did not receive support.
METHODS: From health system data, we identified 275 consecutive patients aged >50 who kept <75% of visits to 4 primary care practices and scheduled for a first colonoscopy from February 1, 2005 to August 31, 2006. Using block randomization, we assigned consenting patients to a phone call by a peer coach trained to address barriers to attendance or to a mailed colonoscopy brochure. Study data came from electronic medical records. Odds ratios of colonoscopy attendance were adjusted for demographic, clinical, and health care factors.
RESULTS: Colonoscopy attendance by the peer coach group (N = 70) and brochure group (N = 66) differed by 11% (68.6% vs 57.6%, respectively). Compared with the brochure group, the peer coach group had over twofold greater adjusted odds ratio (AOR) of attendance (2.14, 95% confidence interval [CI] = 0.99-4.63) as did 49 patients who met the prespecified criteria for needing no support (2.68, 95% CI = 1.05-6.82) but the AORs did not differ significantly for 41 patients who declined support (0.61, 95% CI = 0.25-1.45) and 49 patients who could not be contacted (0.85, 95% CI = 0.36-2.02). Attendance was less likely for black versus white race (AOR = 0.37, 95% CI = 0.19-0.72) but more likely for patients with high versus low primary care visit adherence (AOR = 2.30, 95% CI = 1.04-5.07).
CONCLUSION: For patients who often fail to keep appointments, peer coach support appears to promote colonoscopy attendance more than an educational brochure.
The objective of the study was to assess the effect of an invitation letter on the level of participation in a setting of mainly opportunistic screening for cervical cancer and to do a cost analysis of this intervention. We designed a quasi-randomized trial in which a sample of women between the ages of 25 and 64 years and residing in the province of Limburg, Belgium, who had no Pap smear taken in the past 30 months according to LIKAR (Limburg Cancer Registry), were assigned to an intervention group or to a control group. A written invitation was sent to 43 523 women in the intervention group. Baseline participation in cervical screening was recorded in the year before the intervention to determine its effect. Differences in cumulative incidence between the intervention and the control group were used to report the effect. The net effect of a written invitation resulted in 3355 more women undergoing a Pap smear, which is an increase of 6.4% (95% confidence interval: 5.9-6.9). The cost per additional Pap smear taken amounted to euro29.8. Within an opportunistic cervical cancer screening setting, the effect of a registry-based invitational programme to nonattenders increases the participation further, and at no extra cost compared with an invitational programme to all screen-eligible women irrespective of their screening status.
BACKGROUND: Few health promotion trials have evaluated strategies to increase regular mammography screening. We conducted a randomized controlled trial of two theory-based interventions in a population-based, nationally representative sample of women veterans.
METHODS: Study candidates 52 years and older were randomly sampled from the National Registry of Women Veterans and randomly assigned to three groups. Groups 1 and 2 received interventions that varied in the extent of personalization (tailored and targeted vs targeted-only, respectively); group 3 was a survey-only control group. Postintervention follow-up surveys were mailed to all women after 1 and 2 years. Outcome measures were self-reported mammography coverage (completion of one postintervention mammogram) and compliance (completion of two postintervention mammograms). In decreasingly conservative analyses (intention-to-treat [ITT], modified intention-to-treat [MITT], and per-protocol [PP]), we examined crude coverage and compliance estimates and adjusted for covariates and variable follow-up time across study groups using Cox proportional hazards regression. For the PP analyses, we also used logistic regression.
RESULTS: None of the among-group differences in the crude incidence estimates for mammography coverage was statistically significant in ITT, MITT, or PP analyses. Crude estimates of compliance differed at statistically significant levels in the PP analyses and at levels approaching statistical significance in the ITT and MITT analyses. Absolute differences favoring the intervention over the control groups were 1%-3% for ITT analysis, 1%-5% for MITT analysis, and 2%-6% for the PP analysis. Results from Cox modeling showed no statistically significant effect of the interventions on coverage or compliance in the ITT, MITT, or PP analyses, although hazard rate ratios (HRRs) for coverage were consistently slightly higher in the intervention groups than the control group (range for HRRs = 1.05-1.09). A PP analysis using logistic regression produced odds ratios (ORs) that were consistently higher than the corresponding hazard rate ratios for both coverage and compliance (range for ORs = 1.15-1.29).
CONCLUSIONS: In none of our primary analyses did the tailored and targeted intervention result in higher mammography rates than the targeted-only intervention, and there was limited support for either intervention being more effective than the baseline survey alone. We found that adjustment for variable follow-up time produced more conservative (less favorable) intervention effect estimates.
INTRODUCTION: Mammography can reduce breast cancer mortality through routine screening. We tested an intervention to increase re-screening in a county program.
METHODS: The program requires enrollment before screening. We randomized women who had previously been screened by the program to a telephone call reminder for re-enrollment or usual care (postcard reminder). We followed re-enrollment and re-screening rates for both groups.
RESULTS: Compared with the control group (n=610), women in the intervention group (n=599) had higher rates of initial re-enrollment at one month (10% vs. 24%, p<.001) and re-screening at two months (11% vs. 19%, p<.001). These effects persisted over time (five-month re-enrollment: 24% vs. 35%, p<.001; six-month re-screening: 23% vs. 31%, p=.004). The intervention did not alter the odds of a woman's being re-screened once re-enrolled.
CONCLUSION: The increase in our re-screening rate after this simple intervention was as great or greater than the rates reported in other studies. A telephone reminder for women previously enrolled in a county breast screening program can increase re-enrollment and subsequent re-screening rates.
BACKGROUND: Colorectal cancer (CRC) screening is underutilized. Effective methods to increase screening use are needed. This study sought to determine the impact of tailored navigation on CRC screening in primary care.
METHODS: The study included 154 primary care practice patients who were 50 or more years of age, were eligible for CRC screening, and had an office visit within 2 years before study initiation. Baseline telephone survey data were collected on participant sociodemographic characteristics, psychosocial factors, and screening test [fecal occult blood test (FOBT) or colonoscopy] decision stage. By comparing decision stage data, we identified that test with the highest decision stage (ie, preferred screening test). Participants who preferred FOBT were sent an FOBT kit and a reminder. Those preferring colonoscopy were sent colonoscopy instructions. After this mailing, a study patient navigator made a telephone call to guide participants towards screening. Six-month end point survey and medical records data were obtained. Univariable and multivariable analyses were performed to identify predictors of screening and of change in preferred screening test decision stage.
RESULTS: At end point, 63 (41%) study participants had screened. From baseline to end point, overall screening preference increased for 75 (63%) participants. Age and perceived salience and coherence (ie, screening is important and sensible) were positive, significant predictors of screening use (P = 0.02 and P = 0.05, respectively); while only age predicted change in overall screening preference (P = 0.03).
CONCLUSIONS: Study participant screening use and preference increased. Age and attitudes predicted outcomes. Randomized trials are needed to determine intervention impact at the population level.
BACKGROUND: Few interventions to increase colorectal cancer screening have used a stage of change model to promote screening adoption. None have used computer-assisted tailored telephone counseling calls. This study's purpose was to implement and evaluate stage-based computer-assisted tailored telephone counseling to promote colorectal cancer screening in a primary care population.
METHODS: This randomized controlled trial used a two-stepped intervention that included a mailed booklet on colorectal cancer screening followed by computer-assisted telephone counseling that was based on the Precaution Adoption Process Model. Chart audit was used to document completion of colonoscopy, sigmoidoscopy or fecal occult blood testing.
RESULTS: Record audits were completed on 2,474 (88%) of the 2,817 eligible participants. There was no significant difference in the frequency and nature of the screening tests completed in the study arms. In a sub-analysis, stages of adoption were evaluated pre- and post-telephone counseling. Over half those receiving counseling reported a change in stage towards screening adoption.
CONCLUSION: Overall, the intervention did not increase colorectal screening compared to control. Two possible reasons for the absence of a screening effect include: (a) the focus of the protocol on education for most patients rather than motivation, and (b) the requirement that patients interested in screening seek further information and a referral on their own from their providers. While those receiving telephone counseling improved their stage of adoption, we cannot rule out selection bias. Stronger physician recommendation to speak with the counselors could improve call acceptance. Future colorectal screening should address these weaknesses.
BACKGROUND: National cervical screening rates have plateaued at around 60%. Each method of recruitment has an upper limit to uptake and the benefits of multiple strategies are additive. There is debate about reallocating Pap testing to nurses in general practice.
OBJECTIVE: To assess the effects on cervical screening rates in one small general practice.
METHODS: An audit of the effect of: updating Pap test details in electronic records; active recruitment by letter; follow up telephone call if no appointment made; altering the letter to invite women to separate themselves into Pap test 'plus other issues' or 'screening test only'; and the offer of a Pap test for the 'Pap test only' group to be performed by a nurse.
RESULTS: Over 18 months there was a 27% improvement from a biannual screening rate of 53% at baseline to 67.5% at the end of the audit. Over the past 6 months, 49% of women elected for the 'screening only' test provided by a nurse.
DISCUSSION: All four strategies are feasible and associated with a considerable increase in screening rates. Patients can choose to have their test performed by a nurse in general practice. This study suggests that each strategy's improvement in uptake is independently additive.
OBJECTIVE: To assess both feasibility and short term outcomes of a population based colorectal cancer screening programme using a biennial guaiac based faecal occult blood test (gFOBT).
METHOD: All participants were invited by mail to take part in a screening programme using a non-rehydrated gFOBT. The gFOBTs were first provided by general practitioners (GPs) and then directly mailed to individuals who failed to comply after two invitations. The setting was a French administrative district: Haut-Rhin (710,000 inhabitants). 182,981 residents aged 50-74 years were invited to participate.
RESULTS: 19,274 people (10.5%) were excluded from gFOBT screening and 90,706 completed a gFOBT, so that the participation rate was 55.4% of those eligible. 76.5% of the completed gFOBTs were provided by GPs and 15.5% by direct mailing. The gFOBT positivity rate was 3.4%. The positive predictive value was 42.7% for neoplasia (women 30.8%, men 52.5%), 23.6% for advanced adenoma, and 7.6% for cancer. The number of normal colonoscopic procedures (without neoplasia) needed to be performed for each colonoscopy detecting an advanced neoplasia was 1.8, lower in men (1.2) than in women (3.4), and decreasing with age. Detection rates for neoplasia and cancer were 12.8 and 2.3 per 1000 people screened. 206 adenocarcinomas were detected: 47.6% were stage I and 23.8% stage II. The direct cost was estimated at euro 29.3 per screened person and euro 13,466 per cancer detected.
CONCLUSIONS: Participation and diagnostic yield of controlled trials of gFOBT screening are reproducible in the real world at an acceptable cost through an organised population based programme involving GPs.
OBJECTIVE: The purpose of this intervention was to increase mammography adherence in women who had not had a mammogram in the last 15 months.
METHODS: A prospective randomized intervention trial used four groups: (1) usual care, (2) tailored telephone counseling, (3) tailored print, (4) tailored telephone counseling and print. Participants included a total of 1244 women from two sites-a general medicine clinic setting serving predominately low-income clientele and a Health Maintenance Organization (HMO). Computer-tailored interventions addressed each woman's perceived risk of breast cancer, benefits and/or barriers and self-efficacy related to mammography screening comparing delivery by telephone and mail.
RESULTS: Compared to usual care all intervention groups increased mammography adherence significantly (odds ratio 1.60-1.91) when the entire sample was included.
CONCLUSIONS: All interventions groups demonstrated efficacy in increasing mammography adherence as compared to a usual care group. When the intervention analysis considered baseline stage, pre contemplators (women who did not intend to get a mammogram) did not significantly increase in mammography adherence as compared to usual care.
PRACTICE IMPLICATIONS: Women who are in pre contemplation stage may need a more intensive intervention.
An analysis of the Norwegian Breast Cancer Screening Programme, including 1,390,310 screening examinations, showed an attendance rate of 71.7% in response to one invitation letter (ordinary attendees) and a further 4.5% increase only after an additional reminder (reminded attendees). Our aim was to examine the prevalence of breast cancer in ordinary and reminded attendees, the frequency of positive mammograms, and the positive predictive value in the two groups. The prevalence of breast cancer in ordinary attendees was 5.6 per 1000 screens compared with 6.3 per 1000 screens in reminded attendees (p<0.001). The frequencies of positive mammograms were 3.5% and 4.0% (p<0.001), and the positive predictive values were 15.9% and 15.2% (p=0.387), respectively, in ordinary and reminded attendees. The risk of breast cancer is higher in women who respond only after a reminder letter, indicating that the value of sending a reminder should be assessed in the light of these results, as well as by the increase in the attendance rate.
Among patients unlikely to attend a scheduled colonoscopy, we examined the impact of peer coach versus educational brochure support and compared these with concurrent patients who did not receive support.
METHODS:
From health system data, we identified 275 consecutive patients aged >50 who kept <75% of visits to 4 primary care practices and scheduled for a first colonoscopy from February 1, 2005 to August 31, 2006. Using block randomization, we assigned consenting patients to a phone call by a peer coach trained to address barriers to attendance or to a mailed colonoscopy brochure. Study data came from electronic medical records. Odds ratios of colonoscopy attendance were adjusted for demographic, clinical, and health care factors.
RESULTS:
Colonoscopy attendance by the peer coach group (N = 70) and brochure group (N = 66) differed by 11% (68.6% vs 57.6%, respectively). Compared with the brochure group, the peer coach group had over twofold greater adjusted odds ratio (AOR) of attendance (2.14, 95% confidence interval [CI] = 0.99-4.63) as did 49 patients who met the prespecified criteria for needing no support (2.68, 95% CI = 1.05-6.82) but the AORs did not differ significantly for 41 patients who declined support (0.61, 95% CI = 0.25-1.45) and 49 patients who could not be contacted (0.85, 95% CI = 0.36-2.02). Attendance was less likely for black versus white race (AOR = 0.37, 95% CI = 0.19-0.72) but more likely for patients with high versus low primary care visit adherence (AOR = 2.30, 95% CI = 1.04-5.07).
CONCLUSION:
For patients who often fail to keep appointments, peer coach support appears to promote colonoscopy attendance more than an educational brochure.
