The effect of patient reminders on the use of screening mammography in an urban health department primary care setting.

Mammography screening continues to be under-utilized, especially among women from lower socioeconomic groups. In order to determine whether having direct access to health care services has an effect on mammography use among low income women, we conducted a randomized trial of two alternative letter reminders among 1,717 women who were enrolled at two locations of a multi-site inner city health department in Detroit. All participants were 39(1/2) years of age and older and were due for a screening mammogram at randomization. A physician-directed reminder form was placed in each of the participant's medical records at the beginning of the study. In addition participants were randomized to receive either a letter directing them to visit their primary care physician, a letter directing them to contact the clinic directly to schedule a mammogram, or no letter. Study participants were predominantly African-American, two-thirds of whom were over age 50, and who had minimal health insurance coverage. During the intervention year, mammograms were completed by 179 out of 967 study women at site one (18.5%), and 90 out of 750 study women at site two (12%). A multivariate model controlling for the simultaneous effect of age, insurance type, visit history and past mammography use, showed no significant independent effect of either type of letter reminder on mammography completion during the study year. In conclusion, letters targeted at women due for screening mammograms did not have a beneficial effect on mammography utilization above and beyond that of a physician medical record reminder.

Mammography use among women as a function of age and patient involvement in decision-making.

OBJECTIVE: To assess the extent to which self-reported patient involvement in decision-making for initiation of mammography differs with age. DESIGN: Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement were evaluated. Prevalences were weighted and variances were adjusted using SUDAAN software to account for the complex, multistage sampling probability design of the NHIS. Logistic regression was used to evaluate the relative likelihood of self-reported involvement in the decision to have a mammogram within the preceding year as a function of age and other covariates. PARTICIPANTS: Mammography use was assessed among 3,863 NHIS female respondents 40 years of age or older. The analysis of decision-making was restricted to the subgroup of 1,064 women who reported a screening mammogram within the preceding year and who provided information on the other relevant variables. MEASUREMENTS AND MAIN RESULTS: The probability of reported mammography use within the preceding year declines among older groups of interviewees. Among women with a mammogram in the preceding year, the weighted percentage of women reporting active involvement in the decision (patient decision or decided jointly with a physician) declines from 51% among women 40 to 45 years of age to 19% among those aged 75 years or older. The adjusted odds ratio comparing the likelihood of participating in the decision to have a mammogram for the oldest women, compared with the youngest, was 0.31 (95% confidence interval 0.15 to 0.61). CONCLUSIONS: Older women are substantially less likely than younger women to report active involvement in the mammography decision-making process. Increased use of screening mammography among older women will require greater promotion by physicians. Other interventions, such as directed educational efforts, may also be needed to increase mammography demand among older women.

Follow-up among women with an abnormal mammogram in an HMO: is it complete, timely, and efficient?

OBJECTIVE: To describe the extent to which women with seriously abnormal mammograms complete indicated follow-up, the timeliness of this follow-up, and variations in the pattern of use of diagnostic procedures. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: Ninety-two women enrolled in a single urban health maintenance organization (HMO) with an abnormal index mammogram (mass or suspicious calcifications) during 1995 or 1996 were identified by review of all HMO mammography reports. Data were abstracted from medical records concerning all clinical services received over the 11 months after the date of the abnormal mammogram. Procedure costs were estimated based on 1997 Medicare relative-value units. Logistic regression and a multivariate accelerated failure-time model were used to evaluate the association between predictor variables and the occurrence and timing of completion of follow-up. RESULTS: Follow-up was not completed by 31 (34%) of the 92 study women and was delayed beyond 60 days for another 32 (35%). In adjusted analysis, factors associated with completion within 60 days included age less than 50 years and inclusion of a specific follow-up recommendation in the mammogram report. Completion by the end of the study (a minimum of 11 months after the index mammogram) was associated only with the presence of a specific follow-up recommendation. The follow-up process (i.e., the diagnostic procedures used) was highly variable but almost always included surgical evaluation. The average cost among those completing follow-up was about $1900 (in 1997 dollars). CONCLUSIONS: Incomplete follow-up after a potentially seriously abnormal mammogram constitutes an important barrier to breast cancer control efforts in the study HMO, but its explanation remains incompletely understood. The follow-up process itself is highly variable, and improvement in its efficiency and timely completion will require a better understanding of its determinants.

Screening for prostate cancer. The challenge of promoting informed decision making in the absence of definitive evidence of effectiveness.

Evidence demonstrating the burden of prostate cancer upon men in the United States is incontrovertible; less compelling, however, is proof of benefit from early detection efforts. Nevertheless, the absence of definitive evidence does not lessen the interest of men in prostate testing or the obligation of physicians to help interested men make well-informed decisions, which integrate personal circumstance and preference with the best available data. This article provides the counseling physician with the information required to frame the current prostate testing debate and an approach to support informed decision making by men who can benefit from their assistance.

A randomized design for repeated binary outcomes used to evaluate continued effectiveness of a breast cancer control intervention strategy.

The literature has not discussed in detail design and evaluation strategies for the assessment of continued effectiveness of intervention strategies. In this article we present an approach to evaluating continued effectiveness with two repeated binary outcomes that are related to the use of preventive services. We present a two-stage design with independent randomization procedures for each of two successive controlled trials and discuss the implications of the randomization plan for the statistical evaluation. Intervention effectiveness for each year is determined by an adjusted odds ratio that compares the odds of procedure use for those who received the intervention to those who did not. Changes in the two adjusted odds ratios between successive years are assessed within the context of a regressive logistic model. We demonstrate these methods by applying them to the Metropolitan Detroit Project to Reduce Avoidable Mortality from Breast Cancer. In this project, computer-generated physician mammography reminders placed prominently in medical records were used to promote mammography referrals among women visiting primary care clinics during a 2-year intervention period. An assessment of the change in intervention effectiveness as well as an adjusted estimate of the overall intervention effectiveness for the 2 years were obtained from a multivariate regressive logistic model. The advantage of this approach was its potential for reducing bias and producing a balanced comparison between intervention groups during the second year of intervention. This issue was important because previous work indicated that having had a mammogram had a significant impact on subsequent mammography use. An important component in the implementation of this design was an information management system that facilitated doing two randomization procedures efficiently. As information and computer technology advance, and as more sophisticated information systems are used for data management, designs such as these become reasonable alternatives to consider.

How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial.

BACKGROUND: Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention. METHODS: The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use. RESULTS: In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38). CONCLUSIONS: Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect.

Health status and mammography use among older women.

OBJECTIVE: To assess the extent to which an age-associated reduction in mammography use can be explained by declining self-reported health status. DESIGN: We analyzed data from the 1992 National Health Interview Survey (NHIS) and Cancer Control Supplement. Logistic regression analysis was used to evaluate the association between age, health status (self-reported health and limitations in major activity), and other variables potentially related to mammography use within the past 1 year (recent mammography). PARTICIPANTS: Of 12,035 NHIS respondents we restricted our analysis to the 1,772 women aged 50 years or older who reported one or more lifetime mammograms. We excluded women without a mammogram (n = 937) because we were interested in factors related to recent use versus past use of mammography. MEASUREMENTS AND MAIN RESULTS: The percentage of women with a recent mammogram declined with increasing age, and the age association was independent of other factors including health status (adjusted odds ratio [OR] comparing women aged 75 years or older with those aged 50 to 64 years was 0.54; 95% confidence interval [CI] 0.41, 0.70). This age effect persisted in an analysis restricted to women reporting good or better health (adjusted OR was 0.60, 95% CI 0.44, 0.80). CONCLUSION: The observed decline in recent mammography use with advancing age was not explained by variation in health status. Because healthy elderly women may live long enough to realize the potential benefit of screening mammography, factors responsible for its reduced use should be identified. Doing so will allow for the selective promotion of screening mammography among those older women most likely to benefit.

Factors affecting participation in a mammography screening program among members of an urban Detroit health maintenance organization.

Breast cancer mortality rates remain disproportionately high among black women despite recent improvements in mammography screening utilization. We conducted a telephone survey among a sample of women (N = 202) participating in a randomized controlled trial investigating the effectiveness of a mammography reminder letter that was one component of a breast cancer control intervention strategy. The objectives of the survey were to ascertain the extent to which the letter reminder was received and acted upon, and to determine attitudes and breast cancer control practices in the target population. The study was conducted among members of a large health maintenance organization serving predominantly black women in Detroit, Michigan. Forty-eight percent of the participants completed a mammogram during the year after the letter was sent. While 72% of the women remembered receiving the letter reminder, only 5% responded to the recommendations in the letter. Important predictors of mammography completion included past mammogram utilization (OR: 2.49; 95% CI: 1.05-5.93), a prior physician recommendation for a mammogram (OR: 1.99; 95% CI: 1.00-3.95) and subject's knowledge of her primary physician's name (OR: 2.05; 95% CI: 0.91-4.60). Letter reminders promoting primary care visits were relatively ineffective since few women reported being prompted by the letter recommendation. Strategies which target physician mammography referral behavior may have an important impact on mammography utilization among inner-city women.

Promoting screening mammography in inner-city settings. The sustained effectiveness of computerized reminders in a randomized controlled trial.

OBJECTIVES: The authors conducted a randomized controlled trial to evaluate the sustained effectiveness of a computerized reminder system in promoting mammography during a second year of continuing intervention at three primary care practices of a Health Department and a health maintenance organization in Detroit, Michigan. METHODS: Out-of-pocket mammography cost was eliminated for all participants (limited intervention). Computer-generated reminders promoting physician referral for mammography were placed in the medical records of women due for mammography 1 month in advance of their due date (full intervention). RESULTS: Among 1,225 year 2 visitors, mammography rates were 44% for full intervention versus 28% for limited intervention at the health department (adjusted odds ratio [OR] for effect of full intervention 1.84; 95% confidence interval [CI]: 1.40-2.40) and 45% for full versus 46% for limited at the health maintenance organization (adjusted OR 1.06; 95% CI 0.80-1.42). These second year results contrasted with those observed for year 1, during which a significant effect of full intervention was demonstrated for both organizations. After controlling for patient characteristics and site, the effect sizes of full intervention were reduced significantly in the second year compared with the first year (P = 0.05). CONCLUSIONS: The effect of computerized mammography reminders can be sustained in a second year of continued intervention, but individual practice sites and organizations vary in their responsiveness to the intervention. Strategies to promote periodic and repetitive procedure use must identify and address time-varying barriers to their effectiveness.

The effect of patient and physician reminders on use of screening mammography in a health maintenance organization. Results of a randomized controlled trial.

BACKGROUND: Despite its demonstrated efficacy in reducing breast carcinoma mortality, screening mammography remains underutilized and its promotion in the primary care setting provides an important opportunity for intervention. METHODS: A randomized controlled trial was conducted in two sites of a health maintenance organization (HMO) serving an urban, minority population to evaluate the impact of patient and physician reminders on site visitation and mammography use. Eligible women (n = 2368) were randomly assigned to 1 of 4 intervention combinations (patient and physician reminders individually, together, or neither). The patient reminder letter invited mammography-due women to visit. The physician reminder was a notice placed in the medical record of mammography-due women. Logistic analysis and survival analysis were used to investigate the relationship of intervention status to visitation, time to a visit, and mammography use. RESULTS: The patient reminder intervention had no effect upon rates of study year visitation or mammography at either site. However, among HMO Site 2 enrollees with entitlement insurance, the median time to the next visit was reduced from 12 to 9 weeks in association with assignment to patient reminder intervention. The physician reminder intervention was also effective in increasing the rate of completed mammography at Site 2 among all assignees (36% vs. 22% for those with vs. those without physician reminders) and among assignees who visited (59% vs. 43%). CONCLUSIONS: Patient reminder letters had limited impact on visitation in this setting. Physician reminders are more effective but sites vary in their responsiveness. Further improvement in mammography utilization will require a better understanding of the determinants of patient and physician behavior.

Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography.

In a one-year randomized controlled trial, we assessed the effectiveness of a computerized mammography reminder system as a component of a program to increase the use of screening mammography in three health care organizations serving inner-city women in Detroit, Michigan (two sites of a health department, one HMO site, and two sites of a private hospital). Four thousand four hundred and one women older than 40 who had visited a study site in the preceding year were randomly assigned to one of two treatment groups. Limited intervention (LI) included physician and staff breast cancer control education, facilitated mammography appointment scheduling procedures, and elimination of out-of-pocket patient cost for mammography (at three of five sites). Full intervention (FI) included all components of limited intervention plus an additional series of "cues-to-action." These included a mammography reminder form inserted in the medical record of women who were due to have mammography, intended to increase physician referral for mammography appointments, and patient reminders intended to increase completion of mammography among referred women. During the one-year intervention period 2,725 randomized women visited a study site. The 6-month mammography appointment rates among FI women vary from 38% to 65% and the FI rate exceeds the LI rate at each site with differences from 13% (95% CI, 6 to 20) to 29% (21 to 38). The annual completed mammography rate among FI women extends from 43% to 64% and exceeds the LI rate at each site by 12% (5 to 19) to 25% (16 to 34). After age-adjustment, the mammography intervention effect sizes among the five sites were not significantly different. The average increase in FI compared to LI was 18%. The computerized reminder system is effective in increasing the use of mammography in each of the study institutions and the major effect is on physician referral for mammography.

Patterns of use of mammography among inner-city Detroit women: contrasts between a health department, HMO, and private hospital.

This study assessed the pattern of utilization of mammography among 2,880 inner-city minority women 40 years of age or older who received ongoing primary care services during 1988 or 1989 at four practice sites operated by a health department (two sites), Health Maintenance Organization (HMO), and private hospital. Mammography referral could be documented for 23% to 32% of age eligible women and completed mammograms for 15% to 26%. Among women without a mammogram, 85% had never been referred while 15% were referred but unable to complete the procedure. In multiple logistic regression analysis, factors associated with mammography include age less than 70 years, presence of a breast cancer risk factor and more frequent clinic visits. Mammography was somewhat more frequent at the HMO and hospital clinic than at the health department, but this relationship varied with the women's previous visit and mammography experience. At sites serving uninsured women, mammography use was not associated with the presence or absence of health insurance. It is concluded that the underutilization of mammography is a substantial barrier to the early detection of breast cancer in each of the three different health care organizations studied, and that interventions to improve breast cancer control should focus upon facilitating physician referral practices.

Detroit's avoidable mortality project: breast cancer control for inner-city women.

Mammography remains substantially under-used in low-income minority populations despite its well-established efficacy as a means of breast cancer control. The Metropolitan Detroit Avoidable Mortality Project is a 2-year controlled clinical trial of coordinated interventions which seek to improve the use of early breast cancer detection services at five clinical sites providing primary health care services to inner-city women. Baseline assessment for two of the five participating clinic populations demonstrated that only one-quarter of women who visited these clinics were referred for mammography in 1988, and only half of those who were referred were able to complete the procedure. Patient characteristics including age, marital status, ethnicity, and insurance status were not associated with use of mammography during the baseline period. Each of the project's intervention components is a cue to action: a physician prompt for mammography referral within the medical record of procedure-due women, a reminder postcard for scheduled appointments, and a telephone call to encourage rescheduling of missed appointments. The interventions are initiated by a computerized information management system in the existing network of health care services. The patient's out-of-pocket mammography expense has been eliminated in three of the five sites. Although their efficacy as individual interventions has been well established, a controlled trial of computer prompts to physicians, reduced expense for patients, and patient appointment reminders as an integrated system in inner-city medical care settings has not been previously described. We have implemented the prompting, facilitated rescheduling procedures, and eliminated patient expense for mammography at three of five eventual clinical sites. This report provides an overview of the study's design, data management system, and methodology for evaluation.

The acceptance and completion of mammography by older black women.

We assessed the relation of patient characteristics, knowledge and beliefs to the utilization of mammography in an inner-city setting by 187 Black women over the age of 50. Thirty per cent of those who were offered mammography initially declined the offer and 40 per cent were subsequently unable to complete the procedure. Patient interviews were used to derive 27 potential knowledge and health belief predictor scales. In multiple regression analysis, two health belief scales and two knowledge scales accounted for 15 per cent of the observed variance in the model of acceptance. The strongest predictor of subsequent completion was initial acceptance. The presence of breast symptoms and two health belief scales together with initial acceptance accounted for 26 per cent of variance in the model of completion. These results suggest that the successful accomplishment of mammography requires coordinated efforts at the level of the provider, patient, and setting. Health beliefs may influence the patient's behavior in this process, but their effect appears to be modest.

Barriers to clinical preventive medicine.

The successful integration of preventive services into the primary care setting requires the effective interaction of the patient, physician and health care delivery system. This article defines barriers to preventive service delivery operating at each of these levels and provides an introduction to subsequent articles which address their resolution.

The early detection of cancer in the primary-care setting: factors associated with the acceptance and completion of recommended procedures.

Effective cancer control efforts in the primary-care setting require that patients accept and are able to complete recommended early detection procedures. We thus assessed the extent to which procedure nonacceptance or noncompletion limited accomplishment of detection procedures offered as components of routine health care. We also examined the relationship of provider and patient factors to successful procedure accomplishment. Of 221 patients offered procedures by their primary-care provider, 58 (27%) initially declined at least one recommendation, with acceptance rates ranging from 98% for breast exam to 59% for sigmoidoscopy. Furthermore, only 50% of patients offered stool occult blood testing or sigmoidoscopy, 61% offered mammography, and 69% offered Pap smear were able to complete the procedures. Pap smear and mammography were more likely to be initially accepted by those patients with more years of formal education and were less likely to be completed by those with private insurance coverage. Among a subgroup of 76 patients completing a telephone interview, personal health beliefs were not consistently associated with procedure acceptance or completion. These results suggest that both the initial nonacceptance of procedures and the subsequent barriers to their completion limit the efficacy of cancer screening efforts in the primary-care setting. Future research will be required to develop an explanatory model or to propose a targeted intervention.

Interrelationships of general internal medicine and preventive/community medicine.

Clinical preventive medicine, efforts by clinicians to prevent disease in individual patients, is an important component of preventive medicine as a whole. Yet clinicians, including internists, apparently do not provide many preventive services of established effectiveness. This paper describes one approach to improving the practice of clinical preventive medicine: increased cooperation between general internists--one of the nation's largest groups of primary care physicians--and specialists in preventive/community medicine. The paper summarizes a larger report prepared by two societies representing these disciplines: the Society for Research and Education in Primary Care Internal Medicine and the Association of Teachers of Preventive Medicine. It was found that the two disciplines have many common goals, and much to offer each other, but do not often collaborate. The report concludes with 14 recommendations for improving the practice of clinical preventive medicine, which suggest that such improvement can be achieved in part through strengthening working relationships between general internists and preventive/community medicine specialists.