Two randomized controlled trials for colorectal cancer screening invitations developed using a behavioral science approach.

The effectiveness of behaviorally informed, targeted invitations to standard invitations and to no invitation (control arm, primary analysis) were compared in the context of an organized colorectal cancer (CRC) screening program. Two multi-arm, pragmatic randomized controlled trials in men (arms: male-specific, unisex, standard invitation, or no invitation) and in women (arms: unisex, standard invitation, or no invitation), were conducted in Ontario, Canada. Eligible persons aged 50-74, due for CRC screening, were randomized. Primary and secondary outcomes were completion of the guaiac fecal occult blood test (gFOBT) and uptake of any colorectal test, respectively, within 5 months of mailing. Impact of invitation type was assessed using logistic regression. Letters were mailed to 75,810 men and women; 38,673 males and 34,453 females were included in the analyses. Men who received the male-specific letter were most likely to screen with gFOBT compared to controls (odds ratio (OR) 7·24, 95% CI: 5·77, 9·09), followed by those receiving the unisex letter (OR 6·75, 95% CI: 5·37, 8·47) and the standard letter (OR 5·99, 95% CI: 4·76, 7·53). Women who received the unisex letter were most likely to be screened with gFOBT compared to controls (OR 7·07, 95% CI: 5·83, 8·59), followed by those receiving the standard letter (OR 6·76, 95% CI: 5·56, 8·21). In both trials, the findings were similar for the secondary outcome. Mailed invitations were effective for both men and women. With greater targeting using the behaviorally informed invitations, the magnitude of benefit relative to no invitation appeared to increase. (ClinicalTrials.gov, NCT02364895).

Evaluation of the effect of an audit and feedback reporting tool on screening participation: The Primary Care Screening Activity Report (PCSAR).

Participation in cancer screening is critical to its effectiveness in reducing the burden of cancer. The Primary Care Screening Activity Report (PCSAR), an electronic report, was developed as an innovative audit and feedback tool to increase screening participation in Ontario's cancer screening programs. This study aims to assess its impact on patient screening participation. This study used a retrospective cohort design to evaluate the effectiveness of the 2014 PCSAR on screening participation in Ontario's three screening programs (breast, cervix and colorectal). The 3 cohorts comprised all participants eligible for each of the programs enrolled with a primary care physician in Ontario. Two exposures were evaluated for each cohort: enrollment with a physician who was registered to receive the PCSAR and enrollment with a registered physician who also logged into the PCSAR. Logistic regression modelling was used to assess the magnitude of the effect of PCSAR on participation, adjusting for participant and physician characteristics. Across all three screening programs, 63% of eligible physicians registered to receive the PCSAR and 38% of those registered logged-in to view it. Patients of physicians who registered were significantly more likely to participate in screening, with odds ratios ranging from 1.06 [1.04;1.09] to 1.15 [1.12;1.19]. The adjusted odds ratios associated with PCSAR log-in were 1.07 [1.03;1.12] to 1.18 [1.14;1.22] across all screening programs. Implementation of the PCSAR was associated with a small increase in screening participation. The PCSAR appears to be modestly effective in assisting primary care physicians in optimizing cancer screening participation among their patients.

Impact of invitation and reminder letters on cervical cancer screening participation rates in an organized screening program.

Study's Objective was to explore the impact of invitation and reminder letters on cervical cancer screening participation among eligible Ontario women 30 to 69years of age. A cross-sectional study was used to describe factors and screening patterns for 1,150,783 eligible women. A cohort design was used to compare the impact of invitation and reminder letters on Pap uptake comparing women who received the intervention (n=99,278) with a historical non-intervention group (n=130,181). Factors that might influence screening participation were included as covariates in a multivariable logistic regression models. Overall, 26.7% of women who had a Pap test 3 to 5years prior and 9.8% of women with no Pap test in the previous 5years were screened within 9months after the intervention. On cohort analysis, 14.1% of women in the intervention group and 8.5% of women in the non-intervention group were screened within 9months. Being mailed an invitation letter was associated with greater likelihood of screening (OR=1.8, CI 1.7-1.8). Controlling for covariates, the letter intervention was associated with 9month screening for both women with a Pap test 3 to 5years prior (AOR=1.7, CI 1.6-1.8) and those with no Pap test in the previous 5years (AOR=1.8, CI 1.7-1.9). There was a significant effect of all covariates on the participation. The invitation and reminder letter strategy increased cervical cancer screening participation. Additional strategies that could encourage eligible women to participate and/or removing barriers to screening for eligible women may be necessary.

Outcomes in multiple gestation pregnancies among Canadian women age 35 years and older.

Multiple gestations are associated with an increased risk of maternal morbidity and mortality independent of maternal age. Previous reports by the Canadian Institute for Health Information established the overall association between advanced maternal age and complications related to pregnancy and childbirth. This article takes a more focused look at the association between advanced maternal age and maternal outcomes in multiple gestation pregnancies. We found, for mothers aged 35 years and older carrying multiples--after adjusting for mothers' parity, neighbourhood income and residence (rural/urban)--an increased risk of pregnancy complications including pre-existing hypertension, gestational hypertension, pre-eclampsia/eclampsia, gestational diabetes and placenta previa and an increased risk for Caesarean delivery.

Babies admitted to NICU/ICU: province of birth and mode of delivery matter.

Neonatal intensive care units (NICUs) and intensive care units (ICUs) provide care for newborns in need of specialized medical attention. Across Canada, rates of NICU/ICU admission vary. Due to the high cost of monitoring and interventions these admissions cost more than general newborn stays - whether the newborn is in a specialized NICU or in an ICU in those facilities without specialized units for newborns. This study explores the variation in NICU/ICU admissions and the characteristics of mothers and newborns associated with an increased likelihood of NICU/ICU admission. We focus further on the association between NICU/ICU admission and Caesarean section (C-section). After excluding multiple births, preterm births, small for gestational age births and those delivered by women with select complications, we find an increased risk for NICU/ICU admission for babies born by C-section as their only indication. NICU/ICU admission following C-section alone may not represent the most desirable pathway of care for these newborns.

Doctors' views of clinical practice guidelines: a qualitative exploration using innovation theory.

RATIONALE, AIMS AND OBJECTIVES: The authors undertook this qualitative study as part of a larger evaluation of the effect of eight clinical practice guidelines issued by an arm's-length government agency in a Canadian province. Using Orlandi and colleagues' version of the Rogers diffusion of innovation model as a framework, the authors mapped doctors' views on implementation of clinical practice guidelines. METHODS: In semi-structured interviews with 45 representative doctors, the authors elicited doctors' framework of meaning for behaviour change in general and for clinical practice guideline uptake in particular. These were then compared with the adapted Orlandi/Rogers diffusion of innovation model to confirm, amend or challenge that model. RESULTS: Doctors identified the following influences on changes to their clinical practice and on clinical practice guideline uptake, within a five-step innovation model: 1 innovation: evidence change is required, perceived need for change; 2 communication: awareness of innovation; 3 adoption: evidence of improved outcomes without increased patient risk, opinion leader support, consistency with current trends; 4 implementation: patient and family acceptability; and 5 maintenance: system support, patient and family support, observed improved patient outcomes without increased risk. CONCLUSIONS: Innovation for doctors is a complex decision process rather than a single decision point. Change occurs in the context of professional networks and patient and family support and demand.