Comparing Telephone Counseling With Reminding to Promote On-Time Repeated Mammography: A Randomized Trial in a Cohort With 4 Years Follow-Up.

Background. Long-term continuous adherence to biennial screening mammograms as guidelines recommend remains low. Limited evidence suggests that reminder calls may increase short-term adherence as much as telephone counseling, but research is needed comparing the long-term effects of these two approaches. Purpose. To compare the impacts of two telephone outreach interventions and mailed reminders on 4-year continuous mammography adherence. Method. A cohort of 3,215 women, age 50 to 81 years, was selected from 30,160 women from a 4-year randomized trial of three interventions to promote biennial mammography: reminder letter only (LO), letter plus reminder call (RC), and two letters plus educational material and a counseling call (CC). Women selected remained eligible for the trial all 4 years and received annual interventions as needed. The proportion with a mammogram in the last 24 months was determined at baseline and four annual time points. Results. Continuous adherence at all four time points was higher in the RC (78.8%) and CC arms (78.8%) than in the LO arm (75.1%; p < .001). Multivariable analysis confirmed this finding: CC (odds ratio = 1.27; 95% confidence interval = [1.01, 1.61]) and RC (odds ratio = 1.23; 95% confidence interval = [0.98, 1.56]). Only 27.8% of women eligible for an initial counseling call actually received counseling. Conclusions. Compared with letters alone, outreach calls can modestly increase continuous mammography adherence among insured women with consistent primary care. Telephone counseling was no more effective than a reminder call, possibly due to limited acceptance of counseling calls by women who may find them unwelcome or unnecessary.

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

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

Implementation and process evaluation of three interventions to promote screening mammograms delivered for 4 years in a large primary care population.

The optimal form of outreach to promote repeated, on time screening mammograms in primary care has not been established. The purpose of this study is to assess the implementation process and process outcomes for three interventions for promoting biannual screening mammography in a randomized trial. In a large urban primary care practice over a 4-year period, we randomized women aged 40-85 and eligible for mammograms to three interventions: reminder letter only (LO), reminder letter + reminder call (RC), and reminder letter + counseling call (CC). We tracked information system development, staff training, patient and provider recruitment, reach, dose delivered and received, fidelity, and context measures. Ninety-three of 95 providers approved participation by 80% (23,999) of age-eligible patients, of whom only 207 (0.9%) opted not to receive any intervention. Of 9161 initial reminder letters mailed to women coming due or overdue for mammograms, 0.8% were undeliverable. Of women in the RC and CC arms unresponsive to the first reminder letter (n = 3982), 71.4% were called and reached, and of those, 49.1% scheduled a mammogram. Only 33.4% of women reached in the CC arm received full counseling, and women in the CC arm were less likely to schedule a mammogram than those in the RC arm. Implementing mail and telephone mammography reminders is feasible and acceptable in a large urban practice and reaches a majority of patients. Many schedule a mammogram when reached. A reminder letter followed by a simple reminder call if needed may be the optimal approach to promoting screening mammograms.

Referring patients for telephone counseling to promote colorectal cancer screening.

OBJECTIVE: To determine the feasibility, acceptability, and outcomes of a telephone counseling intervention promoting colorectal cancer (CRC) screening when patients are referred for counseling by primary care providers (PCPs). STUDY DESIGN: Interventional cohort study with no formal control group. METHODS: PCPs in 3 practices were prompted to address CRC screening in patient encounters and, if appropriate, to recommend referral for telephone counseling. A telephone counselor called referred patients, made an appointment for a counseling call, and mailed an educational booklet to patients. Counseling included education about CRC and screening tests, motivational interviewing, barrier counseling, and facilitated referral for colonoscopy or mailing of a fecal occult blood testing kit. About 7 months following counseling, electronic records were searched for evidence of colonoscopy. RESULTS: PCPs addressed CRC screening with 1945 patients, most of whom were up-to-date with CRC testing, recommended counseling referral to 362, and of these 180 (49.7%) accepted the referral. A total of 140 (77.8%) of referred patients were contacted and 67 (37.2%) received counseling. After counseling 93.9% were planning on CRC screening compared with 54.6% at the beginning of the call. Of those planning a colonoscopy, 53.2% received one within 7 months. CONCLUSIONS: Referring patients for telephone counseling to promote CRC screening may be feasible and acceptable to PCPs and to some patients, and may increase CRC screening. Further evaluation of the intervention may be warranted to compare the rate of screening associated with the intervention to rates related to usual care and to other interventions.

Design and methods for a randomized clinical trial comparing three outreach efforts to improve screening mammography adherence.

BACKGROUND: Despite the demonstrated need to increase screening mammography utilization and strong evidence that mail and telephone outreach to women can increase screening, most managed care organizations have not adopted comprehensive outreach programs. The uncertainty about optimum strategies and cost effectiveness have retarded widespread acceptance. While 70% of women report getting a mammogram within the prior 2 years, repeat mammography rates are less than 50%. This 5-year study is conducted though a Central Massachusetts healthcare plan and affiliated clinic. All women have adequate health insurance to cover the test. METHODS/DESIGN: This randomized study compares 3 arms: reminder letter alone; reminder letter plus reminder call; reminder letter plus a second reminder and booklet plus a counselor call. All calls provide women with the opportunity to schedule a mammogram in a reasonable time. The invention period will span 4 years and include repeat attempts. The counselor arm is designed to educate, motivate and counsel women in an effort to alleviate PCP burden.All women who have been in the healthcare plan for 24 months and who have a current primary care provider (PCP) and who are aged 51-84 are randomized to 1 of 3 arms. Interventions are limited to women who become ≥ 18 months from a prior mammogram. Women and their physicians may opt out of the intervention study.Measurement of completed mammograms will use plan billing records and clinic electronic records. The primary outcome is the proportion of women continuously enrolled for ≥ 24 months who have had ≥ 1 mammogram in the last 24 months. Secondary outcomes include the number of women who need repeat interventions. The cost effectiveness analysis will measure all costs from the provider perspective. DISCUSSION: So far, 18,509 women aged 51-84 have been enrolled into our tracking database and were randomized into one of three arms. At baseline, 5,223 women were eligible for an intervention. We anticipate that the outcome will provide firm data about the maximal effectiveness as well as the cost effectiveness of the interventions both for increasing the mammography rate and the repeat mammography rate. TRIAL REGISTRATION: http://clinicaltrials.gov/NCT01332032.

Implementing state tobacco treatment services: lessons from the Massachusetts experience.

This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP's focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states' policies in their design of tobacco treatment services in community health settings.

Randomized trial of a literacy-sensitive, culturally tailored diabetes self-management intervention for low-income latinos: latinos en control.

OBJECTIVE: To test whether a theory-based, literacy, and culturally tailored self-management intervention, Latinos en Control, improves glycemic control among low-income Latinos with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 252 patients recruited from community health centers were randomized to the Latinos en Control intervention or to usual care. The primarily group-based intervention consisted of 12 weekly and 8 monthly sessions and targeted knowledge, attitudes, and self-management behaviors. The primary outcome was HbA(1c). Secondary outcomes included diet, physical activity, blood glucose self-monitoring, diabetes knowledge and self-efficacy, and other physiological factors (e.g., lipids, blood pressure, and weight). Measures were collected at baseline and at 4- and 12-month follow-up. Change in outcomes over time between the groups and the association between HbA(1c) and possible mediators were estimated using mixed-effects models and an intention-to-treat approach. RESULTS: A significant difference in HbA(1c) change between the groups was observed at 4 months (intervention -0.88 [-1.15 to -0.60] versus control -0.35 [-0.62 to 0.07], P < 0.01), although this difference decreased and lost statistical significance at 12 months (intervention -0.46 [-0.77 to -0.13] versus control -0.20 [-0.53 to 0.13], P = 0.293). The intervention resulted in significant change differences in diabetes knowledge at 12 months (P = 0.001), self-efficacy (P = 0.001), blood glucose self-monitoring (P = 0.02), and diet, including dietary quality (P = 0.01), kilocalories consumed (P < 0.001), percentage of fat (P = 0.003), and percentage of saturated fat (P = 0.04). These changes were in turn significantly associated with HbA(1c) change at 12 months. CONCLUSIONS: Literacy-sensitive, culturally tailored interventions can improve diabetes control among low-income Latinos; however, strategies to sustain improvements are needed.

Helping men make an informed decision about prostate cancer screening: a pilot study of telephone counseling.

OBJECTIVE: Evaluate a computer-assisted telephone counseling (CATC) decision aid for men considering a prostate specific antigen (PSA) test. METHODS: Eligible men were invited by their primary care providers (PCPs) to participate. Those consenting received an educational booklet followed by CATC. The counselor assessed stage of readiness, reviewed booklet information, corrected knowledge deficits and helped with a values clarification exercise. The materials presented advantages and disadvantages of being screened and did not advocate for testing or for not testing. Outcome measures included changes in stage, decisional conflict, decisional satisfaction, perceived vulnerability and congruence of a PSA testing decision with a pros/cons score. Baseline and final surveys were administered by telephone. RESULTS: There was an increase in PSA knowledge (p<0.001), and in decisional satisfaction (p<0.001), a decrease in decisional conflict (p<0.001), and a general consistency of those decisions with the man's values. Among those initially who had not made a decision, 83.1% made a decision by final survey with decisions equally for or against screening. CONCLUSIONS: The intervention provides realistic, unbiased and effective decision support for men facing a difficult and confusing decision. PRACTICE IMPLICATIONS: Our intervention could potentially replace a discussion of PSA testing with the PCP for most men.

Translational research at community health centers: challenges and successes in recruiting and retaining low-income Latino patients with type 2 diabetes into a randomized clinical trial.

PURPOSE: To describe methods used to recruit and retain low-income Latinos in a randomized clinical trial (RCT) of a diabetes self-management intervention at 5 community health centers (CHCs) in Massachusetts. METHODS: Consent from primary care providers (PCPs) was obtained to screen their patients. Trained site research coordinators (SRCs) screened, recruited, and enrolled participants following a multistep process (medical record reviews, PCP approval, a patient eligibility interview) and provided support for retention efforts. Assessment staff were trained in motivational strategies to facilitate retention and received ongoing support from a retention coordinator. Electronic tracking systems facilitated recruitment and retention activities. RESULTS: Of an initial pool of 1176 patients, 1034 were active at the time of screening, 592 (57%) were eligible by medical record review, and 487 received PCP approval (92% of reviewed patients). Of these, 293 patients completed the patient screening interview (60% of patients with PCP approval, and 76% of those reached), and 276 were eligible. Sixteen percent of all active patients refused participation, and 8% of contacted patients were unreachable. Two hundred fifty-two patients were randomized after completion of baseline assessments. Clinical, behavioral, and psychosocial assessment completion rates were 92%, 77%, and 86% at 12-month follow-up, respectively, and 93% of patients completed at least one study assessment at 12 months. CONCLUSIONS: CHCs are a prime setting for translation research aimed to eliminate diabetes health disparities. Successful recruitment and retention efforts must address institutional/organizational, research team, and patient-related challenges.

Design and methods for a randomized clinical trial of a diabetes self-management intervention for low-income Latinos: Latinos en Control.

BACKGROUND: US Latinos have greater prevalence of type 2 diabetes (diabetes), uncontrolled diabetes and diabetes co-morbidities compared to non-Latino Whites. They also have lower literacy levels and are more likely to live in poverty. Interventions are needed to improve diabetes control among low-income Latinos. METHODS AND DESIGN: This randomized clinical trial tested the efficacy of a culturally- and literacy-tailored diabetes self-management intervention (Latinos en Control) on glycemic control among low-income Latinos with diabetes, compared to usual care (control). Participants were recruited from five community health centers (CHCs) in Massachusetts. The theory-based intervention included an intensive phase of 12 weekly sessions and a follow-up maintenance phase of 8 monthly sessions. Assessments occurred at baseline, and at 4 and 12 months. The primary outcome was glycosylated hemoglobin (HbA1c). Secondary outcomes were self-management behaviors, weight, lipids and blood pressure. Additional outcomes included diabetes knowledge, self-efficacy, depression and quality of life. The study was designed for recruitment of 250 participants (estimated 20% dropout rate) to provide 90% power for detecting a 7% or greater change in HbA1c between the intervention and control groups. This is a difference in change of HbA1c of 0.5 to 0.6%. DISCUSSION: Low-income Latinos bear a great burden of uncontrolled diabetes and are an understudied population. Theory-based interventions that are tailored to the needs of this high-risk population have potential for improving diabetes self-management and reduce health disparities. This article describes the design and methods of a theory driven intervention aimed at addressing this need.

Moving mammogram-reluctant women to screening: a pilot study.

BACKGROUND: Effective interventions are needed for women long overdue for screening mammography. PURPOSE: The purpose of this study is to pilot test an intervention for motivating overdue women to receive a mammogram. METHODS: Subjects aged 45-79 without a mammogram in > or =27 months and enrolled in study practices were identified from claims data. The intervention included a mailed, educational booklet, computer-assisted barrier-specific tailored counseling and motivational interviewing, and facilitated, short-interval mammography scheduling. RESULTS: Of 127 eligible women, 45 (35.4%) agreed to counseling and data collection. Most were > or =3 years overdue. Twenty-six (57.8%) of the counseled women got a mammogram within 12 months. Thirty-one (72.1%) of 43 counseled women moved > or =1 stage closer to screening, based on a modified Precaution Adoption Process Model. CONCLUSION: It is feasible to reach and counsel women who are long overdue for a mammogram and to advance their stage of adoption. The intervention should be formally evaluated in a prospective trial comparing it to control or to proven interventions.

Staging mammography nonadherent women: a qualitative study.

BACKGROUND: Few studies have related stages of mammography screening nonadherence with the rationale used by overdue women. METHODS: We used a grounded theory approach to obtain and analyze data from focus groups, telephone interviews, and surveys. Emergent specific themes were compared with emerging decision levels of nonadherence. Each decision level was then compared with the Precaution Adoption Process Model and the Transtheoretical Model. RESULTS: A total of 6 key themes influencing mammogram nonadherence emerged as did 6 decision levels. Variability within themes was associated with specific decision levels. The decision levels were not adequately classified by either stage model. CONCLUSIONS: Stage-based educational strategies may benefit by tailoring interventions to these 6 decision levels.

Basic skills for working with smokers: a pilot test of an online course for medical students.

BACKGROUND: Online learning can be an excellent method for presenting clinical skills to address health behaviors. METHODS: Medical students pilot tested a skills-building course consisting of an online component and a practical application. RESULTS: A total of 38 students were registered, 25 (66%) completed the online component, and 22 (58%) completed both course components. Students reported they were adequately trained to administer the brief 5A intervention to patients who smoke and they intended to deliver the intervention routinely. CONCLUSIONS: Online skills-building courses can have a positive effect on students' knowledge and skills and can be used across health behaviors promote healthy lifestyles.

Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening.

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.

Implementing a computer-assisted telephone interview (CATI) system to increase colorectal cancer screening: a process evaluation.

OBJECTIVE: Computer-assisted telephone interviewing (CATI) systems used by telephone counselors (TCs) may be efficient mechanisms to counsel patients on cancer and recommended preventive screening tests in order to extend a primary care provider's reach to his/her patients. The implementation process of such a system for promoting colorectal (CRC) cancer screening using a computer-assisted telephone interview (CATI) system is reported in this paper. METHODS: The process evaluation assessed three components of the intervention: message production, program implementation and audience reception. RESULTS: Of 1181 potentially eligible patients, 1025 (87%) patients were reached by the TCs and 725 of those patients (71%) were eligible to receive counseling. Five hundred eighty-two (80%) patients agreed to counseling. CONCLUSIONS: It is feasible to design and use CATI systems for prevention counseling of patients in primary care practices. PRACTICE IMPLICATIONS: CATI systems have the potential of being used as a referral service by primary care providers and health care organizations for patient education.

Applying a stage model of behavior change to colon cancer screening.

BACKGROUND: There has been limited use of stages of change models in characterizing colorectal cancer (CRC) screening. We assess the applicability of the Precaution Adoption Model (PAPM) by determining the distribution of stages of adoption and by elucidating differences among stages. METHODS: The study is based on 1394 responses (69%) to a survey mailed in 2002 to patients in a primary care population. Survey measures included: self-reported CRC screening, sociodemographic characteristics, health system characteristics, attitudes and beliefs about CRC screening, perceived vulnerability to CRC, and worry about CRC. The main outcome was PAPM stage of adoption of CRC screening based on the ACS preferred guidelines: colonoscopy every 10 years alone or the combination annual FOBT plus sigmoidoscopy every 5 years. RESULTS: 57% were up-to-date with at least one test; 36% were up-to-date with the ACS preferred guidelines; provider recommendation, positive family history of CRC, and positive decisional balance score were significantly associated with higher compared to lower PAPM stages. CONCLUSIONS: The combination of PAPM stage assignment and other factors provides useful information for designing tailored interventions. There are special challenges in developing and interpreting PAPM stage assignments when a guideline offers multiple pathways to adherence and recommends a combination of two tests as a preferred option.

Organizational systems to support publicly funded tobacco treatment services.

BACKGROUND: Professional societies and government organizations have promoted guidelines and best practices that encourage clinicians to routinely integrate cessation counseling into patient encounters. While research in health maintenance organizations has demonstrated that the development and maintenance of office systems do enable clinicians' smoking-cessation services, little is known about the adoption of system strategies in diverse organizations serving disadvantaged populations. METHODS: Data were collected via face-to-face interviews from November 2001 to October 2002 using a standardized systems assessment checklist at service delivery sites of 83 funded community health service agencies, which included hospitals, community health centers, and other organizations (e.g., substance abuse, mental health, and multiservice). The content of the structured assessment reflected system elements with proven effectiveness that have been included in guidelines and best practices recommendations. Detailed information was collected on the implementation strategies. RESULTS: This study found considerable attention to systems that support cessation services in diverse healthcare organizations, but much remains to be done. There is a wide diversity of implementation strategies employed, with varied degrees of sophistication. CONCLUSIONS: A major challenge is to develop systems capable of providing population-based feedback to, and between, providers, which will enable further quality improvement efforts.

Interdisciplinary collaboration for health professional education in cancer control.

BACKGROUND: Overlapping responsibilities of health care delivery professionals in the United States has propelled medical, graduate nursing, and public health schools to rethink their curricula. The University of Massachusetts Medical School implemented the Cancer Prevention and Control Education (CPACE) initiative, an interdisciplinary curriculum focusing on behavioral and psychosocial aspects of cancer prevention, control, and research. METHODS: An interdisciplinary Operations Committee developed courses, clerkships, and programs. Continuing education programs stressed the team approach. RESULTS AND DISCUSSION: CPACE teaching objectives were congruent in the three schools, but logistical issues were challenging. Positive preevaluations and postevaluations indicated potential for shaping a collaborative attitude among health care providers.

Surveying physicians: do components of the "Total Design Approach" to optimizing survey response rates apply to physicians?

BACKGROUND: Surveys serve essential roles in clinical epidemiology and health services research. However, physician surveys frequently encounter problems achieving adequate response rates. Research on enhancing response rates to surveys of the general public has led to the development of Dillman's "Total Design Approach" to the design and conduct of surveys. The impact of this approach on response rates among physicians is uncertain. OBJECTIVE: To determine the extent to which the components of the total design approach have been found to be effective in physician surveys. DESIGN: A systematic review. RESULTS: The effectiveness of prepaid financial incentives, special contacts, and personalization to enhance response rates in surveys of physicians have been confirmed by the existing research. There is suggestive evidence supporting the use of first class stamps on return envelopes and multiple contacts. The optimum amount for incentives and the number of contacts necessary have not been established. Details of questionnaire design and their impact on response rates have received almost no attention from researchers. Few studies have assessed the usefulness of combinations of components of the total design approach. CONCLUSIONS: Despite the number of surveys conducted among physicians, their cost, the level of interest in their findings, and in spite of inadequate response rates, there have been few randomized trials conducted on important aspects of enhancing response in this population. Until this gap has been filled, researchers conducting surveys of physicians should consider including all components of the total design approach whenever feasible.

Caffeine, cajoling, and other strategies to maximize clinician survey response rates.

An ongoing objective in health services research is to increase response rates to clinician surveys to ensure generalizability of findings. Three HMOs in the Cancer Research Network participated in a primary care clinician survey to better understand organizational characteristics affecting adoption and implementation of breast and cervical cancer screening guidelines. A four-stage data collection strategy was implemented to maximize response. This included careful attention to survey design and layout, extensive piloting, choice of token incentive, use of "local champions," and denominator management. An overall response rate of 91% was attained, ranging from 83 to 100% among the plans (N = 621). Although the response rate after the second stage of data collection met commonly used standards, the authors argue for the four-stage method due to the possibility of differences when comparing early and late responders. This is important when multiple plans with differing structure and internal characteristics are surveyed.