Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Cancer screening rates are suboptimal for low-income patients.
To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.
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.
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.
The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.
Rates of cancer screening at 1 year.
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.
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.
- 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. CrossRef
- Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54:78–93. CrossRef
- Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med. 2008;168:1317–1324. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone calls improved completion of fecal occult blood testing. Med Care. 2010;48:604–610. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- Yabroff KR, Mandelblatt JS. Interventions targeted toward patients to increase mammography use. Cancer Epidemiol Biomarkers Prev. 1999;8:749–757.
- 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. CrossRef
- 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.
- 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.
- 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. CrossRef
- Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Department of Health and Human Services, Public Health Service; 1990.
- Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–130. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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.
- Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice
Journal of General Internal Medicine
Volume 29, Issue 1 , pp 41-49
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- breast neoplasms
- colorectal neoplasms
- cancer screening
- healthcare disparities
- Industry Sectors
- Author Affiliations
- 2. Department of Surgery, University of Michigan, 2124 Taubman Center, 1500 E. Medical Center Dr., SPC-5343, Ann Arbor, MI, 48109, USA
- 3. Department of Family Medicine, Highland Hospital, Rochester, NY, USA
- 4. Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas, MO, USA
- 5. Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- 1. Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA