Skip to main content

Advertisement

SpringerLink
Log in

Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice

  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

Background

Cancer screening rates are suboptimal for low-income patients.

Objective

To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.

Design

Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors.

Subjects

All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients’ ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance.

Intervention

The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.

Main Measures

Rates of cancer screening at 1 year.

Key Results

Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n = 185) or usual care (n = 181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p = 0.034) and 37.7 % vs. 16.7 % for CRC screening (p = 0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different.

Conclusions

A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.
Figure 2.
Figure 3.

Similar content being viewed by others

REFERENCES

  1. Lees KA, Wortley PM, Coughlin SS. Comparison of racial/ethnic disparities in adult immunization and cancer screening. Am J Prev Med. 2005;29:404–411.

    Article  PubMed  Google Scholar 

  2. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54:78–93.

    Article  PubMed  Google Scholar 

  3. Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med. 2008;168:1317–1324.

    Article  PubMed  Google Scholar 

  4. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control. 2009;20:417–435.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Spadea T, Bellini S, Kunst A, Stirbu I, Costa G. The impact of interventions to improve attendance in female cancer screening among lower socioeconomic groups: a review. Prev Med. 2010;50:159–164.

    Article  PubMed  Google Scholar 

  6. Holden DJ, Jonas DE, Porterfield DS, Reuland D, Harris R. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152:668–676.

    Article  PubMed  Google Scholar 

  7. Michielutte R, Sharp PC, Foley KL, et al. Intervention to increase screening mammography among women 65 and older. Health Educ Res. 2005;20:149–162.

    Article  CAS  PubMed  Google Scholar 

  8. Earp JA, Eng E, O’Malley MS, et al. Increasing use of mammography among older, rural African American women: results from a community trial. Am J Public Health. 2002;92:646–654.

    Article  PubMed  Google Scholar 

  9. Phillips CE, Rothstein JD, Beaver K, Sherman BJ, Freund KM, Battaglia TA. Patient navigation to increase mammography screening among inner city women. J Gen Intern Med. 2011;26:123–129.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Lasser KE, Murillo J, Lisboa S, et al. Colorectal cancer screening among ethnically diverse, low-income patients: a randomized controlled trial. Arch Intern Med. 2011;171:906–912.

    Article  PubMed  Google Scholar 

  11. Varkey AB, Manwell LB, Williams ES, et al. Separate and unequal: clinics where minority and nonminority patients receive primary care. Arch Intern Med. 2009;169:243–250.

    Article  PubMed  Google Scholar 

  12. Wells KJ, Luque JS, Miladinovic B, et al. Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiol Biomarkers Prev. 2011;20:1580–1598.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med. 2009;169:364–371.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Hewitson P, Ward AM, Heneghan C, Halloran SP, Mant D. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Br J Cancer. 2011;105:475–480.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone calls improved completion of fecal occult blood testing. Med Care. 2010;48:604–610.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Simon SR, Zhang F, Soumerai SB, et al. Failure of automated telephone outreach with speech recognition to improve colorectal cancer screening: a randomized controlled trial. Arch Intern Med. 2010;170:264–270.

    Article  PubMed  Google Scholar 

  17. Tseng DS, Cox E, Plane MB, Hla KM. Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis. J Gen Intern Med. 2001;16:563–568.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–651.

    Article  PubMed  Google Scholar 

  19. Kempe KL, Shetterly SM, France EK, Levin TR. Automated phone and mail population outreach to promote colorectal cancer screening. Am J Manage Care. 2012;18:370–378.

    Google Scholar 

  20. Ahmed NU, Haber G, Semenya KA, Hargreaves MK. Randomized controlled trial of mammography intervention in insured very low-income women. Cancer Epidemiol Biomarkers Prev. 2010;19:1790–1798.

    Article  PubMed  Google Scholar 

  21. Fiscella K, Yosha A, Hendren SK, et al. Get screened: a pragmatic randomized controlled trial to increase mammography and colorectal cancer screening in a large, safety net practice. BMC Health Serv Res. 2010;10:280.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Yabroff KR, Mandelblatt JS. Interventions targeted toward patients to increase mammography use. Cancer Epidemiol Biomarkers Prev. 1999;8:749–757.

    CAS  PubMed  Google Scholar 

  23. Hoerger TJ, Ekwueme DU, Miller JW, et al. Estimated effects of the National Breast and Cervical Cancer Early Detection Program on breast cancer mortality. Am J Prev Med. 2011;40:397–404.

    Article  PubMed  Google Scholar 

  24. Liles EG, Perrin N, Rosales AG, et al. Change to FIT increased CRC screening rates: evaluation of a US screening outreach program. Am J Manage Care. 2012;18:588–595.

    Google Scholar 

  25. Fiscella K, Humiston S, Hendren S, et al. A multimodal intervention to promote mammography and colorectal cancer screening in a safety-net practice. J Natl Med Assoc. 2011;103:762–768.

    PubMed  Google Scholar 

  26. Jean-Jacques M, Kaleba EO, Gatta JL, Gracia G, Ryan ER, Choucair BN. Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial. Ann Fam Med. 2012;10:412–417.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Department of Health and Human Services, Public Health Service; 1990.

  28. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–130.

    Article  PubMed  Google Scholar 

  29. Liu MJ, Hawk H, Gershman ST, et al. The effects of a National Breast and Cervical Cancer Early Detection Program on social disparities in breast cancer diagnosis and treatment in Massachusetts. Cancer Causes Control. 2005;16:27–33.

    Article  PubMed  Google Scholar 

  30. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351:575–584.

    Article  CAS  PubMed  Google Scholar 

  31. Shen JJ, Wan TT, Perlin JB. An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations. Health Serv Res. 2001;36:711–732.

    CAS  PubMed  Google Scholar 

  32. Fiscella K, Epstein RM. So much to do, so little time: care for the socially disadvantaged and the 15-minute visit. Arch Intern Med. 2008;168:1843–1852.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Shankaran V, McKoy JM, Dandade N, et al. Costs and cost-effectiveness of a low-intensity patient-directed intervention to promote colorectal cancer screening. J Clin Oncol. 2007;25:5248–5253.

    Article  PubMed  Google Scholar 

  34. Vernon SW, McQueen A, Tiro JA, del Junco DJ. Interventions to promote repeat breast cancer screening with mammography: a systematic review and meta-analysis. J Natl Cancer Inst. 2010;102:1023–1039.

    Article  PubMed  Google Scholar 

  35. Fiscella K, Humiston S, Hendren S, et al. Eliminating disparities in cancer screening and follow-up of abnormal results: what will it take? J Health Care Poor Underserved. 2011;22(1):83–100.

Download references

Acknowledgments

This study was funded by the American Cancer Society (RSGT-08-077-01-CPHPS).

Conflict of Interest

The authors declare that they do not have any conflict of interest.

Author information

Authors and Affiliations

  1. Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    Michael Mendoza MD, MPH & Kevin Fiscella MD, MPH

  2. Department of Surgery, University of Michigan, 2124 Taubman Center, 1500 E. Medical Center Dr., SPC-5343, Ann Arbor, MI, 48109, USA

    Samantha Hendren MD, MPH

  3. Department of Family Medicine, Highland Hospital, Rochester, NY, USA

    Paul Winters MS, Amna Idris MPH, Patricia Ford MS, Raymond Specht MPA & Stephen Marcus MS

  4. Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas, MO, USA

    Sharon Humiston MD, MPH

  5. Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    Shirley X. L. Li B Sci & Kevin Fiscella MD, MPH

Authors
  1. Samantha Hendren MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul Winters MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sharon Humiston MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Amna Idris MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Shirley X. L. Li B Sci
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Patricia Ford MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Raymond Specht MPA
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Stephen Marcus MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Michael Mendoza MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Kevin Fiscella MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Samantha Hendren MD, MPH.

Additional information

Clinical Trial Registry: The trial was registered at Clinical Trials.gov (NCT00818857)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hendren, S., Winters, P., Humiston, S. et al. Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice. J GEN INTERN MED 29, 41–49 (2014). https://doi.org/10.1007/s11606-013-2506-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-013-2506-1

KEY WORDS

Search

Navigation