Participation rates for organized colorectal cancer screening programmes: an international comparison.

OBJECTIVE: Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates. METHODS: Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round. RESULTS: Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30-100%, coverage by the screening programme from 7-67.7%, overall uptake/participation rate from 7-67.7%, and first invitation participation from 7-64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation. CONCLUSION: Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

Sorting out measures and definitions of screening participation to improve comparability: the example of colorectal cancer.

Participation is a key indicator of the potential effectiveness of any population-based intervention. Defining, measuring and reporting participation in cancer screening programmes has become more heterogeneous as the number and diversity of interventions have increased, and the purposes of this benchmarking parameter have broadened. This study, centred on colorectal cancer, addresses current issues that affect the increasingly complex task of comparing screening participation across settings. Reports from programmes with a defined target population and active invitation scheme, published between 2005 and 2012, were reviewed. Differences in defining and measuring participation were identified and quantified, and participation indicators were grouped by aims of measure and temporal dimensions. We found that consistent terminology, clear and complete reporting of participation definition and systematic documentation of coverage by invitation were lacking. Further, adherence to definitions proposed in the 2010 European Guidelines for Quality Assurance in Colorectal Cancer Screening was suboptimal. Ineligible individuals represented 1% to 15% of invitations, and variable criteria for ineligibility yielded differences in participation estimates that could obscure the interpretation of colorectal cancer screening participation internationally. Excluding ineligible individuals from the reference population enhances comparability of participation measures. Standardised measures of cumulative participation to compare screening protocols with different intervals and inclusion of time since invitation in definitions are urgently needed to improve international comparability of colorectal cancer screening participation. Recommendations to improve comparability of participation indicators in cancer screening interventions are made.

Increasing screening mammography among immigrant and minority women in Canada: a review of past interventions.

Screening mammograms are important to detect breast cancer at earlier and more treatable stages. Immigrant and minority women report low participation rates due to barriers related to cultural beliefs and norms, privacy/modesty, and language. This review examines whether screening mammogram interventions in Canada and other countries with comparable health-care systems have addressed the needs of these women. Our systematic literature search identified studies that focused on increasing screening mammogram participation among immigrant and/or minority women. We used the Health Belief Model and the PRECEDE-PROCEED Model to guide our critical synthesis of the reviewed interventions and the recommendations for the future. Eight studies met the search criteria. Overall, interventions showed some increase in mammogram participation rates. The barriers targeted were relatively similar across studies and there was a focus on increasing cues to screening. This review illustrates that it is essential to develop and implement programs to overcome the unique barriers to screening mammography if we are to increase participation among immigrants and minority women. We suggest other potentially effective health promotion strategies as a starting point for discussion and future research.

Impact of age-specific recommendation changes on organized breast screening programs.

BACKGROUND: Recent changes in recommendations for mammography screening for women in their forties could have an impact on organized screening programs, as these require clear definition of target and eligible populations. CURRENT STATUS: Internationally, a majority of programs target women fifty and over, and so the recent USPSTF age recommendations for screening are quite consistent with this practice. However, there is a good deal of variability in the availability of population-based screening programs to women in their forties should they choose to participate. FUTURE IMPACT: Several programs are reviewing recommendations regarding the eligibility of women in their forties; as guidelines indicate women in this age group should be eligible for screening, even if not targeted, there is discussion as to whether they should be allowed in programs so that they benefit from the same programmatic quality assurance afforded to the target population of women over 50. Clear communication of the evidentiary basis for the eligibility criteria and target populations is required, so that the public is aware that programs are designed to deliver maximal population impact, while minimizing population risk.

Pay-for-performance incentives for preventive care: views of family physicians before and after participation in a reminder and recall project (P-PROMPT).

OBJECTIVE: The Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) project was designed to increase the rates of delivery of 4 targeted preventive care services to eligible patients in primary care network and family health network practices eligible for pay-for-performance incentives. DESIGN: Self-administered fax-back surveys completed before and after participation in the P-PROMPT project. SETTING: Southwestern Ontario. PARTICIPANTS: A total of 246 physicians from 24 primary care network or family health network practices across 110 different sites. INTERVENTIONS: The P-PROMPT project provided several tools and services, including physician and patient reminders, office management tools, and administrative database integration. MAIN OUTCOME MEASURES: Physicians' views about the delivery of preventive health services and pay-for-performance incentives before and after participation in the P-PROMPT project. RESULTS: The preintervention survey was completed by 86.2% (212 of 246) of physicians and the postintervention survey was completed by 53.3% (131 of 246) of physicians; 46.7% (114 of 246) of the physicians completed both surveys. Overall, 80.5% of physicians indicated that the P-PROMPT project was useful (scores of 5 or higher on a 7-point Likert scale). Patient reminder letters (89.1%), physician approval lists of eligible patients (75.6%), administrative assistance with management fees (79.8%), and annual bonus calculations (75.2%) were rated as the most useful features of the program. Compared with the preintervention survey, there were statistically significant increases in the mean agreement scores that the established target levels and bonuses provided appropriate financial incentive to substantially increase the uptake of mammography (P=.012) and Papanicolaou tests (P=.003) but not to increase uptake of annual influenza vaccination or childhood immunizations. There were statistically significant changes in the mean ratings of relying on an opportunistic approach (P<.001), increased agreement about the effectiveness of the current approach to delivery of preventive care (P<.001), and increased use of preventive management fees to recall patients (P<.001). CONCLUSION: The preventive care management program and P-PROMPT were viewed favourably by most respondents and were perceived to be useful in improving delivery of preventive health care services.

Satisfaction with initial screen and compliance with biennial breast screening at centers with and without nurses.

BACKGROUND: A woman's experience during her initial breast screen can influence her participation in subsequent screening. OBJECTIVE: The purpose of this study was to determine the association between a woman's satisfaction with her initial screening experience and compliance to biennial screening at centers with and without nurses. METHODS: A stratified random sample of compliers and noncompliers to biennial screening was selected from a cohort of 16 858 eligible women aged 50 to 65 years attending centers with and without nurses for their initial screen at the Ontario Breast Screening Program in 2002. Of these eligible women, 3387 were sent questionnaires, 2640 (77.9%) were contacted, and 1901 (72.0%) were interviewed. The association between satisfaction with initial screen and compliance was estimated separately for centers with and without nurses using logistic regression. RESULTS: Women attending centers with nurses were significantly less likely to comply with their next screen after their clinical breast examination if they were not completely satisfied with the service they received (odds ratio, 0.21; 95% confidence interval, 0.08-0.57) or agreed that the clinical breast examination caused discomfort to their breasts (odds ratio, 0.65; 95% confidence interval, 0.45-0.94). In addition, women attending centers with or without nurses were significantly less likely to comply if they did not understand why they needed to return for screening. CONCLUSIONS: : Nurses at screening centers have an opportunity to significantly impact a woman's compliance to biennial breast screening by providing a positive initial screening experience. IMPLICATIONS FOR PRACTICE: Emphasis should be placed on improving a woman's overall satisfaction with her initial screening experience.

Influence of nurses on compliance with breast screening recommendations in an organized breast screening program.

BACKGROUND: Evidence from breast screening trials has shown that a significant reduction in breast cancer mortality from screening can be achieved by regular attendance. Few studies have evaluated the influence of nurses on compliance with breast screening recommendations. METHODS: The cohort included 157,788 women ages 50 to 69 years who were screened at 1 of 9 regional cancer centers or 57 affiliated centers with nurses or 26 affiliated centers without nurses between January 1, 2002, and December 31, 2002, within the Ontario Breast Screening Program. These women were followed up prospectively for at least 30 months to compare compliance for annual and biennial screening recommendations among women who attended centers with and without nurses. The associations between type of screening center and the odds of compliance were modeled using mixed-effect logistic regression models. All P values are two-sided. RESULTS: Women attending a regional cancer center [odds ratios (OR), 1.96; 95% confidence interval (95% CI), 1.07-3.58] or affiliated center with nurses (OR, 1.75; 95% CI, 1.38-2.22) were significantly more likely to return within 18 months of their annual screening recommendation than women attending affiliated centers without nurses. In addition, women attending regional cancer centers (OR, 2.28; 95% CI, 1.34-3.89) or affiliated centers with nurses (OR, 2.30; 95% CI, 1.86-2.83) were significantly more likely to make a timely return within the recommended biennial screening interval of between 18 and 30 months. CONCLUSIONS: Breast screening programs should consider methods of integrating educational activities as provided by the nurses to improve compliance with screening.

Breast cancer screening program in Canada: successes and challenges.

This paper describes breast screening program development in Canada and the current status of screening in Canada. Programs have been implemented in most of Canada, beginning in the late 1980's. Certain components are common to all the programs, but others, such as personal invitation letters for recruitment and clinical breast examination vary across the country. Key successes in organized breast screening in Canada include the development of a comprehensive set of screening performance indicators, which are reported on regularly, and the downward trend in mortality rates observed over the past 20 years. Challenges include the continued prevalence of opportunistic screening; the need to better manage follow-up; dealing with changing evidence; and supporting informed decision-making about screening. Approaches to breast screening are dependent on the health care services available in countries, but regardless of the approach, good evaluation is necessary.