Breast cancer screening outreach effectiveness: Mammogram-specific reminders vs. comprehensive preventive services birthday letters.

We compared the effectiveness of two outreach strategies on timely mammography adherence: a mammogram-specific reminder letter (sent just before a woman was due) to a birthday letter (addresses multiple preventive services and not timed around due dates). We evaluated screening mammography adherence following 79,848 mammogram-specific and 151,626 birthday letters mailed between 2002 and 2012 to women aged 40-74years enrolled in Kaiser Permanente Washington. Screening mammogram adherence was specifically tied to due date and was evaluated separately by age group and up-to-date or overdue status at the time of mailing. We used generalized estimating equations to account for correlation between repeated observations, to model the odds of screening mammography adherence by letter type. Among women up-to-date, adherence following birthday letters was 22-76% lower compared to the mammogram-specific reminders, with the greatest decreases in adherence in women aged 70-74. Birthday letters were more effective at activating screening uptake among some subgroups of overdue women aged 50-69 and most overdue women aged 70-74, but universally low adherence rates were observed in overdue women. Increasing number of recommended services for women aged 50-74 who were up-to-date resulted in 12-17% lower mammography adherence, but had no effect in women aged 40-49 or in overdue women. Birthday letters are less effective than mammogram-specific reminder letters at prompting women to undergo timely breast cancer screening, particularly among women up-to-date with screening. Birthday letters may be effective at increasing overall preventive care; however, supplemental outreach may be needed around the due date to increase timely preventive services receipt.

Comparative effectiveness of two outreach strategies for cervical cancer screening.

OBJECTIVE: Test-specific reminder letters can improve cancer screening adherence. Little is known about the effectiveness of a reminder system that targets the whole person by including multiple screening recommendations per letter. METHODS: We compared the effectiveness of a Pap-specific reminder letter sent 27months after a woman's last Pap, to a reminder letter that included up to seven preventive service recommendations sent before a woman's birthday ("birthday letter") on Pap smear adherence from a natural experiment occurring in routine clinical care. Participants included 82,016 women from Washington State who received 72,615 Pap-specific letters between 2003 and 2007 and 100,218 birthday letters between 2009 and 2012. We defined adherence as having a Pap test within a six month window around the Pap test due date. Using logistic regression, we calculated adjusted odds ratios (OR) for adherence with 95% confidence intervals (CI) following the birthday letter with 1-2 recommendations, 3-5 recommendations, and 6-7 recommendations compared to the Pap-specific letter. All analyses were stratified by whether a woman was up-to-date or overdue for screening at the time she received a letter. RESULTS: Adjusted ORs showed reduced adherence following the birthday letter compared with the Pap-specific letter for up-to-date women whether the letter had 1-2 recommendations (OR=0.37, 95%CI=0.36-0.39), 3-5 recommendations (OR=0.44, 95%CI=0.42-0.45), or 6-7 recommendations (OR=0.36, 95%CI=0.32-0.40). We noted no difference in Pap-test adherence between letter types for overdue women. CONCLUSIONS: In conclusion, for women regularly adherent to screening, an annual birthday letter containing reminders for multiple preventive services was less effective at promoting cervical cancer screening compared with a Pap-specific letter.

Improvement in the diagnostic evaluation of a positive fecal occult blood test in an integrated health care organization.

BACKGROUND: Screening for fecal occult blood can be effective in reducing colorectal cancer mortality only if positive tests are appropriately followed up with complete diagnostic evaluation (ie, colonoscopy or flexible sigmoidoscopy with double contrast barium enema) and treatment. OBJECTIVES: To examine whether rates of complete diagnostic evaluation after a positive fecal occult blood test (FOBT) have improved over time after the implementation of tracking systems and physician guidelines within a large integrated health care organization. RESEARCH DESIGN: From 1993 to 2005, 8513 positive FOBTs were identified on 8291 enrollees aged 50-79 of a large health care system. Automated records were used to identify repeat FOBTs, colonoscopy, flexible sigmoidoscopy, and double-contrast barium enema within 1 year after the positive FOBT. National rates of complete diagnostic evaluation were estimated from the 2005 National Health Interview Survey. RESULTS: In this integrated health care organization, the percentage of positive FOBTs followed by complete diagnostic evaluation within 1 year increased from 57-64% in 1993-1996 to 82-86% from 2000-2005. Use of repeat FOBT after a positive FOBT decreased from 28-31% in 1993-1996 to 6-11% in 2000-2005. Based on the National Health Interview Survey, only 52% of positive FOBTs in 2000-2005 were followed by complete diagnostic evaluation nationally. CONCLUSIONS: Adherence to recommendations for complete diagnostic evaluation after a positive FOBT has greatly improved over time in an integrated group medical practice. Through the use of tracking systems and screening guidelines, it may be possible to reach levels of follow-up that are comparable to those observed in randomized trials.

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.

Latina and Black/African American Women's Perspectives on Cancer Screening and Cancer Screening Reminders.

INTRODUCTION: Racial and ethnic disparities continue to exist in cancer screening rates, especially among US Latina and Black/African American populations. We conducted six focus groups among 41 women from these communities in order to better understand their preferences about cancer screening reminders and the motivators and deterrents they face in obtaining recommended breast, cervical, and colon cancer screening. METHODS: Using self-reported patient race/ethnicity from electronic medical records of a large, integrated health care system in Seattle, we recruited women ages 30-60 to participate in one of five 2-hour focus groups. Using verbatim transcripts from these discussions, we conducted a qualitative analysis to identify common themes. RESULTS: The focus group participants were primarily strong endorsers and utilizers of recommended breast, cervical, and colon cancer screening services. Insurance and belief in preventive care were the most common motivators that they cited in obtaining cancer screening. However, they still reported multiple barriers to getting recommended cancer screening for themselves and community members, including lack of time, conflicting information about screening intervals, distrust in the health care system, and a lack of understanding of the benefits of preventive care. CONCLUSIONS: Efforts to improve understanding about the benefits of cancer screening, clarify cancer screening guideline recommendations, increase cultural competency among health care professionals, and expand the times and locations where cancer screening is available are all options that may improve cancer screening rates among Latinas and Black/African American women.