Impact of Mailed and Automated Telephone Reminders on Receipt of Repeat Mammograms: A Randomized Controlled Trial

doi:10.1016/j.amepre.2009.01.032

American Journal of Preventive Medicine

Volume 36, Issue 6, June 2009, Pages 459-467

https://doi.org/10.1016/j.amepre.2009.01.032 Get rights and content

Background

This study compares the efficacy of three types of reminders in promoting annual repeat mammography screening.

Design

RCT.

Setting and participants

Study recruitment occurred in 2004–2005. Participants were recruited through the North Carolina State Health Plan for Teachers and State Employees. All were aged 40–75 years and had a screening mammogram prior to study enrollment. A total of 3547 women completed baseline telephone interviews.

Intervention

Prior to study recruitment, women were assigned randomly to one of three reminder groups: (1) printed enhanced usual care reminders (EUCRs); (2) automated telephone reminders (ATRs) identical in content to EUCRs; or (3) enhanced letter reminders that included additional information guided by behavioral theory. Interventions were delivered 2–3 months prior to women's mammography due dates.

Main outcome measures

Repeat mammography adherence, defined as having a mammogram no sooner than 10 months and no later than 14 months after the enrollment mammogram.

Results

Each intervention produced adherence proportions that ranged from 72% to 76%. Post-intervention adherence rates increased by an absolute 17.8% from baseline. Women assigned to ATRs were significantly more likely to have had mammograms than women assigned to EUCRs (p=0.014). Comparisons of reminder efficacy did not vary across key subgroups.

Conclusions

Although all reminders were effective in promoting repeat mammography adherence, ATRs were the most effective and lowest in cost. Health organizations should consider using ATRs to maximize proportions of members who receive mammograms at annual intervals.

Introduction

Breast cancer is a major public health concern. The American Cancer Society (ACS) projects about 182,000 new breast cancer cases and 40,000 breast cancer deaths in 2008.¹ Mammography is the most effective method to detect breast cancers early, when they are smaller and potentially more treatable. Routine mammography screening reduces breast cancer mortality among women aged 40–74 years.2, 3, 4 Although most major medical organizations advise regular mammograms for women aged ≥40 years, they differ on the recommended interval between screenings. The research reported here is consistent with the ACS recommendation⁵ for annual mammography screening for women aged ≥40 years and is supported by research showing that annual, rather than biennial, screening may be optimal.6, 7, 8, 9

Widespread adoption of mammography in the U.S. is a public health success. About 66% of U.S. women now report having mammograms in the past 1–2 years (referred to as recent mammography).10, 11 However, there are areas of concern. The proportion of women with recent mammograms is slightly lower than previous assessments, signaling that mammography use may be in decline. Also, most women do not get regular mammograms at recommended intervals, referred to as repeat mammography. Receipt of repeat mammograms is crucial to achieving population-level reductions in breast cancer morbidity and mortality.¹² The average repeat mammography rate (defined here as receipt of two consecutive mammograms on an annual interval) has been found to be only 38%.¹³ More extensive use of reminder systems might help to increase the proportion of women who get repeat mammograms.

Reminders typically are printed messages advising women that they are due for mammograms. An extensive literature documents the effectiveness of reminders in increasing mammography use14, 15, 16, 17, 18, 19, 20 and shows that these effects generally apply across diverse population groups.21, 22 Fewer studies have tested the effect of reminders on repeat mammography use.15, 16, 17, 18, 21, 23, 24 Women who received printed reminders in one study¹⁵ had greater adherence to repeat mammography screening compared to women who received no intervention. Another study¹⁶ showed that mammography facilities using reminder systems had higher rates of repeat mammography adherence compared to facilities that did not use reminders. Studies17, 18 have also found that simple printed reminders are as effective as more complex interventions. Results of these studies suggest that simple reminders can be powerful tools for promoting repeat mammography adherence.

Automated telephone reminders (ATRs) are a potentially promising strategy to increase repeat mammography adherence. Although they have received little attention for cancer screening,25, 26 ATRs are effective for promoting health behaviors such as immunization27, 28, 29 and medication adherence.30, 31 Automated telephone reminders may be a desirable communication channel for several reasons. They can potentially reach large numbers of people at relatively low cost, can be delivered at times convenient for intended recipients, and can be customized by content or language preference. Although no previously published study has compared the efficacy of ATRs to printed reminders on mammography adherence, one study³² found that reminder telephone calls made by office staff were more effective than printed reminders for promoting mammography use, but they have also been shown to be less cost effective.³³

Analyses are from Personally Relevant Information on Screening Mammography (PRISM), a 4-year, randomized intervention trial funded by NIH. The overarching aim of PRISM is to find the minimal intervention needed for sustained annual-interval mammography use among a population of insured women. That is, although some women may need only to be reminded to have mammograms, others may have barriers that require more intensive interventions. Novel aspects of the current study are that it tested effects of manipulating message content and channel on repeat mammography adherence.

The specific aims of the current report were to: (1) assess change in annual repeat mammography adherence rates before and after delivery of interventions; (2) compare the efficacy of enhanced letter reminders (ELRs) to enhanced usual care reminders (EUCRs; manipulating reminder content); and (3) compare the efficacy of ATRs to EUCRs (manipulating reminder channel). A nonintervention control group was not included in PRISM for ethical reasons and because a large body of research documents the efficacy of reminders compared to nonintervention controls. A secondary aim was to test whether comparisons of reminder efficacy varied by population subgroup.

Section snippets

Study Overview

Researchers identified potential PRISM participants through the North Carolina State Health Plan (SHP) for Teachers and State Employees. Eligible participants had a previous mammogram within a specified window and were due for their next mammogram. Those who consented to participate (n=3547) completed baseline telephone interviews and were re-contacted at 12, 24, 36, and 42 months for follow-up interviews. They also agreed to participate in various interventions over the course of the study.

The

Study Response and Sample Characteristics

Of 9087 women initially eligible for recruitment (Figure 2), 3547 completed baseline telephone interviews; 2051 refused to participate; and 747 were classified as ineligible because they did not meet additional study requirements (working telephone, previous mammography dates inside the range of eligible dates, or no breast cancer history). The remaining 2742 women were classified as being of unknown eligibility either because call attempts were exhausted (n=2570) or their enrollment was no

Discussion

This study assessed efficacy of three reminder types (EUCRs, ATRs, and ELRs) on repeat mammography adherence for women with previous mammograms who were due for their next screening. Interventions produced adherence proportions ranging from 72% to 76%. These rates reflect an absolute increase of nearly 18% when compared to pre-intervention rates of repeat mammography adherence. Findings confirm previous research documenting the effectiveness of reminders on mammography use,14, 15, 16, 17, 18, 19

Conclusion

Although all types of reminders were effective in promoting repeat mammography, ATRs were the most promising. Along with having a greater impact, ATRs were also lower in cost compared to mailed materials. Findings also suggest that communication channel may be a more influential factor than content. This study is, to the best of our knowledge, the first published report to assess efficacy of ATRs to promote regular mammography. Because of their efficacy, ability to reach large numbers of women,

References (56)

L. Tabar et al.
Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening
Lancet
(2003)
S.M. Moss et al.
Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial
Lancet
(2006)
R.C. Baron et al.
Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screeningA systematic review
Am J Prev Med
(2008)
J.A. Mayer et al.
Patient reminder letters to promote annual mammograms: a randomized controlled trial
Prev Med
(2000)
J. Quinley et al.
Mammography-facility-based patient reminders and repeat mammograms for Medicare in New York state
Prev Med
(2004)
W. Rakowski et al.
Reminder letter, tailored stepped-care, and self-choice comparison for repeat mammography
Am J Prev Med
(2003)
B.K. Rimer et al.
Effects of a mammography decision-making intervention at 12 and 24 months
Am J Prev Med
(2002)
T.H. Wagner
The effectiveness of mailed patient reminders on mammography screening: a meta-analysis
Am J Prev Med
(1998)
M.A. Clark et al.
The effect of a stage-matched and tailored intervention on repeat mammography
Am J Prev Med
(2002)
I.M. Lipkus et al.
Can tailored interventions increase mammography use among HMO women?
Am J Prev Med
(2000)

R. Corkrey et al.

Pressing the key pad: trial of a novel approach to health promotion advice

Prev Med

(2005)

M.W. Kreuter et al.

Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers

Prev Med

(2005)

V. Champion et al.

Comparison of tailored interventions to increase mammography screening in nonadherent older women

Prev Med

(2003)

V. Champion et al.

The effect of telephone versus print tailoring for mammography adherence

Patient Educ Couns

(2007)

G.H. Rauscher et al.

How consistently do women report lifetime mammograms at successive interviews?

Am J Prev Med

(2002)

K. Glanz et al.

Participant reactions to a computerized telephone system for nutrition and exercise counseling

Patient Educ Couns

(2003)

B. Kaplan et al.

Personal relationships with an intelligent interactive telephone health behavior advisor system: a multimethod study using surveys and ethnographic interviews

Int J Med Inform

(2003)

A. Jemal et al.

Cancer statistics, 2008

CA Cancer J Clin

(2008)

D.A. Berry et al.

Effect of screening and adjuvant therapy on mortality from breast cancer

N Engl J Med

(2005)

L.L. Humphrey et al.

Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force

Ann Intern Med

(2002)

R.A. Smith et al.

American Cancer Society guidelines for breast cancer screening: update 2003

CA Cancer J Clin

(2003)

K. Blanchard et al.

Mammographic screening: patterns of use and estimated impact on breast carcinoma survival

Cancer

(2004)

J. Michaelson et al.

The pattern of breast cancer screening utilization and its consequences

Cancer

(2002)

E. White et al.

Biennial versus annual mammography and the risk of late-stage breast cancer

J Natl Cancer Inst

(2004)

N. Breen et al.

Reported drop in mammography: is this cause for concern?

Cancer

(2007)

Use of mammograms among women aged ≥40 years—United States, 2000–2005

MMWR Morb Mortal Wkly Rep

(2007)

T. Byers et al.

The American Cancer Society challenge goalsHow far can cancer rates decline in the U.S. by the year 2015?

Cancer

(1999)

M.A. Clark et al.

Repeat mammography: prevalence estimates and considerations for assessment

Ann Behav Med

(2003)

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A systematic review of interventions to improve breast cancer screening health behaviours
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Citation Excerpt :
Fifty-four full text articles met the inclusion criteria. Of these, 45 were RCTs and 9 were quasi-experimental (including pre-post studies) (Abood et al., 2005; Ahmed et al., 2010; Allen and Bazargan-Hejazi, 2005; Beauchamp et al., 2020; Bodurtha et al., 2009; Bowen et al., 2017; Carney et al., 2005; Chambers et al., 2016; Champion et al., 2006; Champion et al., 2007; Champion et al., 2016; Champion et al., 2020; Chan et al., 2018; Cuellar et al., 2017; Cohen and Azaiza, 2010; DeFrank et al., 2009; Dietrich et al., 2006; Fernández et al., 2009; Goldzahl et al., 2018; Han et al., 2009; Hegenscheid et al., 2011; Highfield et al., 2015; Icheku and Arowobusoye, 2015; Kearins et al., 2009; Kerrison et al., 2015; Kregting et al., 2020; Kreuter et al., 2005; Lakkis et al., 2011; Larkey et al., 2012; Lee et al., 2014; Lee et al., 2017a; Lee et al., 2017b; Luckmann et al., 2018; Marshall et al., 2016; Merrick et al., 2015; Michielutte et al., 2005; Mishra et al., 2007; Moskowitz et al., 2007; Nanda et al., 2020; Nguyen et al., 2009; Page et al., 2006; Paskett et al., 2006; Phillips et al., 2011; Puschel and Thompson, 2011; Russell et al., 2010; Sadler et al., 2011; Schapira et al., 2019; Secginli and Nahcivan, 2011; Slater et al., 2017; Tuzcu et al., 2016; Vernon et al., 2008; Vidal et al., 2014; Wang et al., 2012; Wu and Lin, 2015). Various measures of attendance were reported by studies, with 42.3% using health record data, 44.4% self-report measures, 9.3% a combination of the two, and 3.7% not stating how attendance was derived.
Whilst breast cancer screening has been implemented in many countries, uptake is often suboptimal. Consequently, several interventions targeting non-attendance behaviour have been developed. This systematic review aims to appraise the successes of interventions, identifying and comparing the specific techniques they use to modify health behaviours.
A literature search (PROSPERO CRD42020212090) between January 2005 and December 2020 using PubMed, Medline, PsycInfo, EMBASE and Google Scholar was conducted. Studies which investigated patient-facing interventions to increase attendance at breast cancer screening appointments were included. Details regarding the intervention delivery, theoretical background, and contents were extracted, as was quantitative data on the impact on attendance rates, compared to control measures. Interventions were also coded using the Behavioural Change Techniques (BCT) Taxonomy.
In total fifty-four studies, detailing eighty interventions, met the inclusion criteria. Only 50% of interventions reported a significant impact on screening attendance. Thirty-two different BCTs were used, with ‘prompts/cues’ the most commonly incorporated (77.5%), however techniques from the group ‘covert learning’ had the greatest pooled effect size 0.12 (95% CI 0.05-0.19, P < 0·01, I² = 91.5%). ‘Problem solving’ was used in the highest proportion of interventions that significantly increased screening attendance (69.0%). 70% of the interventions were developed using behavioural theories.
These results show interventions aimed at increasing screening uptake are often unsuccessful. Commonly used approaches which focus upon explaining the consequences of not attending mammograms were often ineffective. Problem solving, however, has shown promise. These techniques should be investigated further, as should emerging technologies which can enable interventions to be feasibly translated at a population-level.
Determinants Associated With Longitudinal Adherence to Annual Lung Cancer Screening: A Retrospective Analysis of Claims Data
2021, Journal of the American College of Radiology
Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors.
Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden.
After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities.
This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.
Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review
2019, American Journal of Preventive Medicine
Citation Excerpt :
The body of evidence (Figure 2) included 53 studies14–66 distributed as nine studies14,16,17,19–23,26 for breast cancer, six studies28–33 for cervical cancer, 33 studies34–66 for colorectal cancer, two studies15,25 for both breast and cervical cancers, and three studies18,24,27 for both breast and colorectal cancers. A total of 40 studies14–21,24–27,29,31–33,35–38,40–42,45,46,48,50,52,54–65 were conducted in the U.S., and 13 studies22,23,28,30,34,39,43,44,47,49,51,53,66 were conducted in other high-income countries.13 The U.S. studies were distributed in the following geographic regions: Northeast,15,18,24,37,38,46,50,52,58,62,63 Southeast,17,18,26,27,55,64,65 Midwest,14,16,25,36,42,45,54 Southwest,19,20,29,33,35,56,59–61 and West.21,29–32,40,41,48,57
The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions.
A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018.
Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817.
Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.
It's the Amount of Thought that Counts: When Ambivalence Contributes to Mammography Screening Delay
2012, Women's Health Issues
This study examines whether ambivalence toward mammography screening, as moderated by total amount of thought given to the reasons for and against getting mammograms at recommended intervals, predicts greater delay in obtaining subsequent screening mammograms.
A sample of 3,430 insured women with recent (within the last 8–9 months) screening mammograms completed telephone interviews as part of a 5-year intervention study to achieve sustained adherence to annual-interval mammography. Delay was assessed by the number of days between mammograms.
Controlling for demographic factors and perceived screening barriers, days between mammograms increased as ambivalence and thought increased. Thought moderated ambivalence: Among women who were most ambivalent, women obtained mammograms 1 month earlier for each unit increase in thought.
Future studies should test innovative ways to resolve ambivalence and increase thought about consequences of getting mammograms as a strategy to promote mammography screening adherence.
Prioritization of evidence-based preventive health services during periodic health examinations
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Although personal health records are often lacking in terms of ideal functionality,60 preliminary studies have shown that patients using even a basic interactive personal health record that interfaces with an EMR are more up to date on preventive care (www.ahrq.gov/about/annualconf10/krist_rosenthal/krist.HTM). Finally, population-based approaches such as mailed reminders and automated telephone calls have been shown to improve preventive screenings.61–63 The current study has some important limitations and considerations.
Delivery of preventive services sometimes falls short of guideline recommendations.
To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs).
Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011.
Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50–80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient–physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months.
A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.
Process outcomes from a randomized controlled trial comparing tailored mammography interventions delivered via telephone vs. DVD
2011, Patient Education and Counseling
Citation Excerpt :
Participants were members of Methodist Medical Group (MMG) in Indiana and Blue Cross/Blue Shield of North Carolina (BCBSNC), ages 41–65, could read English, had no mammogram within 15 months, no previous breast cancer or bilateral mastectomies, and no physician advice to forego mammography. The 15-month adherence cut-off is consistent with US annual screening guidelines at the time of enrollment [17–19], plus a customary “grace period”[20–22]. Of 3469 women reached who had not had a mammogram within 15 months, 1705 (49.1%) consented and were randomly assigned (Fig. 1).
Tailored, interactive mammography-promotion interventions can increase adherence if women are exposed to and find them usable. We compare exposure to and usability of interventions delivered via telephone vs. DVD.
Process evaluation measures from 926 women randomly assigned to telephone or DVD intervention and completing post-intervention surveys.
∼83% of each group reported exposure to all content. Partial exposure was higher for DVD (9% vs. 0.4%; p < .01); no exposure was higher for phone (15% vs. 8%; p < .01). There were no differences in exposure by age or race. Full phone exposure was less likely for women who already made mammography appointments. Usability rating was higher for DVD (p < .05), driven by ratings of understandability and length. Usability of both interventions was correlated with lower baseline barriers, and higher fear, benefits, and self efficacy. Higher ratings for phone were associated with lower knowledge and contemplating mammography. Non-whites rated DVD better than whites.
Both tailored interactive interventions had wide reach and favorable ratings, but DVD recipients had greatest exposure to at least partial content and more favorable ratings, especially among non-white women.
This first evaluation of a tailored, interactive DVD provides promise for its use in mammography promotion.

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Research articleImpact of Mailed and Automated Telephone Reminders on Receipt of Repeat Mammograms: A Randomized Controlled Trial

Background

Design

Setting and participants

Intervention

Main outcome measures

Results

Conclusions

Introduction

Section snippets

Study Overview

Study Response and Sample Characteristics

Discussion

Conclusion

Lancet

Lancet

Am J Prev Med

Prev Med

Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Prev Med

Prev Med

Prev Med

Patient Educ Couns

Am J Prev Med

Patient Educ Couns

Int J Med Inform

Cancer statistics, 2008

CA Cancer J Clin

Effect of screening and adjuvant therapy on mortality from breast cancer

N Engl J Med

Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force

Ann Intern Med

American Cancer Society guidelines for breast cancer screening: update 2003

CA Cancer J Clin

Mammographic screening: patterns of use and estimated impact on breast carcinoma survival

Cancer

The pattern of breast cancer screening utilization and its consequences

Cancer

Biennial versus annual mammography and the risk of late-stage breast cancer

J Natl Cancer Inst

Reported drop in mammography: is this cause for concern?

Cancer

Use of mammograms among women aged ≥40 years—United States, 2000–2005

MMWR Morb Mortal Wkly Rep

The American Cancer Society challenge goalsHow far can cancer rates decline in the U.S. by the year 2015?

Cancer

Repeat mammography: prevalence estimates and considerations for assessment

Ann Behav Med

Research article
Impact of Mailed and Automated Telephone Reminders on Receipt of Repeat Mammograms: A Randomized Controlled Trial