Article

Zapka JG, Lemon SCInterventions for patients, providers, and health care organizations. Cancer 101(Suppl S5): 1165-1187

Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
Cancer (Impact Factor: 4.89). 09/2004; 101(5 Suppl):1165-87. DOI: 10.1002/cncr.20504
Source: PubMed
ABSTRACT
Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Full-text

Available from: Stephenie C Lemon, Nov 10, 2014
Promoting Cancer Screening: Lessons Learned and Future
Directions for Research and Practice
Supplement to Cancer
Interventions for Patients, Providers, and Health Care
Organizations
Jane G. Zapka,
Sc.D.
Stephenie C. Lemon,
Ph.D.
Division of Preventive and Behavioral Medicine,
University of Massachusetts Medical School,
Worcester, Massachusetts.
Address for reprints: Jane G. Zapka, Sc.D., Division
of Preventive and Behavioral Medicine, University
of Massachusetts Medical School, 55 Lake Avenue
North, Worcester, MA 01655; Fax: (508) 856-
3840; E-mail: jane.zapka@umassmed.edu
Received April 22, 2004; accepted May 4, 2004.
Clinicians and the organizations within which they practice play a major role in
enabling patient participation in cancer screening and ensuring quality services.
Guided by an ecologic framework, the authors summarize previous literature
reviews and exemplary studies of breast, cervical, and colorectal cancer screening
intervention studies conducted in health care settings. Lessons learned regarding
interventions to maximize the potential of cancer screening are distilled. Four
broad lessons learned emphasize that multiple levels of factors—public policy,
organizational systems and practice settings, clinicians, and patients—influence
cancer screening; that a diverse set of intervention strategies targeted at each of
these levels can improve cancer screening rates; that the synergistic effects of
multiple strategies often are most effective; and that targeting all components of
the screening continuum is important. Recommendations are made for future
research and practice, including priorities for intervention research specific to
health care settings, the need to take research phases into consideration, the need
for studies of health services delivery trends, and methods and measurement
issues. Cancer 2004;101(5 Suppl):1165–87. © 2004 American Cancer Society.
KEYWORDS: cancer screening, interventions, organizations, providers.
A
growing body of behavioral and health services research has
developed and tested the efficacy and effectiveness of strategies
within health care settings to improve cancer screening rates. This
article summarizes lessons learned from interventions based in health
care settings to improve screening for breast cancer (mammography),
cervical cancer (Papanicolaou [Pap] tests), and colorectal cancer
(CRC) (with fecal occult blood test [FOBT], sigmoidoscopy, and
colonoscopy).
Conceptual Framework
An ecologic framework,
1–3
as depicted in Figure 1, guides the concep-
tual model of this report. This model highlights ways that factors at
the public policy level, the community level, and the organization and
practice setting levels interact in a synergistic manner to hinder or
enhance providers’ delivery and patients’ utilization of prevention
services. This multisectorial, multilevel approach—congruent with
the Behavioral Model of Utilization,
4
the Quality in the Continuum of
Cancer Care (QCCC) model,
5
and the Chronic Care Model
6
—illus-
trates the need to recognize and understand the complexity of the
context in which processes of care occur. Figure 2 describes organi-
zational strategies that affect clinician behavior and patient screening
participation, which are the focus of numerous studies reported in
this article.
1165
© 2004 American Cancer Society
DOI 10.1002/cncr.20504
Published online 27 July 2004 in Wiley InterScience (www.interscience.wiley.com).
Page 1
Both Figures 1 and 2 highlight a systems perspec-
tive that integrates a range of individual, provider-
related, and environmental variables associated with
decisions of individuals to seek care.
4
A systems model
perspective incorporates numerous factors that affect
patients’ use of services. Individual patient-related
factors include 1) predisposing (e.g., knowledge, be-
liefs), 2) enabling (e.g., ability to pay), and 3) perceived
health needs. Provider-related variables include 1) fac-
tors that may be influenced by providers and that
enable patients to obtain services (e.g., whether indi-
viduals have a regular source of care, the convenience
of obtaining care, previous use of services, and the
out-of-pocket expenditures for services), and 2) pro-
FIGURE 1. Levels of intervention re-
lated to cancer screening interventions
in health service settings.
FIGURE 2. Organizational strategies
(at practice setting, group, and/or plan
level) to improve quality of care.
1166 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 2
vider characteristics that may interact with patient
characteristics to influence utilization (e.g., specialty
or gender of physician). Certainly, the characteristics
of the screening test itself are important. Within the
immediate realm of health services delivery, the QCCC
model emphasizes that effective service requires at-
tention to processes within the care continuum (e.g.,
quality of test interpretation) and between the pro-
cesses of care (e.g., assuring access, communication of
abnormal results). Organizational strategies, including
delivery system design and patient self-management
support (Fig. 2), must address all processes to ensure
the central goal—productive interactions between pa-
tients and providers. The health care delivery system
characteristics (e.g., the policies, resources, organiza-
tion, and financial arrangements) influence the acces-
sibility, availability, and acceptability of medical care
services. These, in turn, are affected by external envi-
ronmental factors that reflect aspects such as the eco-
nomic climate, norms of the society, and community-
level enabling variables (e.g., health promotion
activities, mass media, level of reinforcing services).
Community-based interventions to promote screen-
ing are discussed in this supplement by Pasick et al.,
7
in a report on lessons learned from community-based
cancer screening.
Screening Opportunities and Trends in Health Care
Settings: The Context of Processes of Care
Because most adults in the U.S. report having a usual
source of health care,
8
health care organizations and
the providers who work in them have extraordinary
opportunities to affect cancer screening participation.
Periodic health assessment visits in the primary care
setting represent an obvious opportunity to imple-
ment cancer screening services. To a lesser extent,
chronic care visits and acute care visits also are
screening opportunities.
9
Although inpatient visits
may provide opportunities to address cancer screen-
ing, interventions thus far have focused on the pri-
mary care setting, and on the periodic health exami-
nation in particular.
Consonant with the ecologic framework, several
trends over the last several decades in health service
delivery contribute to our overall understanding of
screening participation. These trends reflect the con-
tinuing challenge to the health care system to provide
effective care while maintaining reasonable cost and
assuring equity.
10
The early 1990s witnessed attention for appropri-
ate care based on efficacy and effectiveness of inter-
ventions.
11,12
The appropriateness of population-
based breast, cervical, and CRC screening is now well
established.
13,14
Before the emphasis on evidence-
based practice, however, the health services consumer
movement in the 1960s, fueled by the women’s move-
ment, focused attention on consumer demand and
satisfaction with medical care.
15
This focus continued
through the 1970s and 1980s
16,17
and, coupled with
increasing concern about the impact of managed care,
reinforced efforts to develop quality indicators as well
as plan and organization report cards.
18
In the ambulatory care arena, the most prominent
effort to define plan performance has been the Health
Plan Employer Data and Information Set (HEDIS) ini-
tiative.
19
HEDIS, a core set of health plan performance
measures covering quality, access, patient satisfaction,
membership and utilization, and finance, includes
measures of screening performance.
Concern about communications between patients
and providers has been voiced for decades,
20
but the
past few years have witnessed much enthusiasm, spe-
cifically regarding informed patient decision-mak-
ing.
21
Achieving adequate involvement of consumers
is now seen as an important goal for screening pro-
grams.
22
Aspects of choice involve understanding
risk,
23
the balance of risks and benefits,
24
and choices
among tests
25
(for more discussion of these issues, see
the article by Rimer et al.
26
in this issue.).
Racial and ethnic disparities continue to challenge
policy makers and providers.
27–29
For virtually every
cancer reviewed in this report, certain ethnic and ra-
cial minorities are less likely to be screened initially or
periodically, and they are less likely to obtain follow-
up.
30,31
The challenge in reducing disparities is to un
-
derstand more clearly the roles played by socioeco-
nomic status, comorbidity, and other factors in these
disparities.
32
In keeping with these trends, over the last several
decades, interventions have evolved to realize the
benefits of population screening. These interventions
have focused on overcoming barriers related to facil-
itating public policy, addressing shortcomings in sys-
tems of care, enabling provider behavior, and ensur-
ing individual patient participation. Strategies must
consider the synergistic effect of focusing on multiple
targets (Fig. 1) and using multiple intervention strat-
egies (Fig. 2). These strategies are reflected in the next
section on lessons learned (for a list of these four
lessons, see. Table 1).
LESSONS LEARNED
This discussion of lessons learned is organized around
four major themes that are pertinent to all major
screening initiatives for breast cancer, cervical cancer,
and CRC. The lessons learned include the importance
of reducing barriers to screening; the evidence sup-
porting specific intervention strategies; the impor-
Health Care Settings Interventions/Zapka and Lemon 1167
Page 3
tance of planned, tailored, multilevel, and multitarget
interventions; and the need to view screening as an
ongoing process of care. Within each topic are sub-
themes and lessons.
Lesson 1
Barriers to screening uptake in health care settings
have consistent themes: 1) public policy, 2) organiza-
tional systems and practice setting, 3) provider, and 4)
patient.
Public policy and payer barriers
Lack of insurance results in inadequate access. A fun-
damental barrier to cancer screening for a significant
proportion of the eligible population is lack of access
or intermittent access to health care. Policy issues
surrounding the lack of health insurance for more
than 40 million Americans are beyond the scope of
this report but clearly constitute a fundamental chal-
lenge to optimizing the potential of cancer screening.
Inadequate reimbursement hinders screening
among providers and patients. Provision of and ad-
herence to prevention services is enabled when such
services are benefits covered by private and public
payers.
33–35
In recent years, various factors have con
-
tributed to more widespread coverage for cancer
screening tests. Despite increased coverage, however,
other financial issues affect both patients and physi-
cians.
36,37
These issues include significant patient co
-
payments, which may discourage screening, and low
clinician reimbursement rates, which affect the feasi-
bility of maintaining a service.
38,39
It also has been
shown that screening rates differ by type of insurance
coverage.
33–35,40,41
For example, health maintenance
organization (HMO) members are more likely than
indemnity plan members to have screening.
33,40
Among Medicare enrollees, those with supplemental
or HMO coverage have a greater likelihood of receiv-
ing preventive screenings.
42
Organizational systems and practice setting barriers
Organizational factors at the setting level can affect
availability, access to, and provision of services and
may act as barriers to clinicians’ provision of services.
The organization and delivery capacity of a practice
can inhibit cancer screening. Both the lack of available
onsite resources and the staffing patterns of the prac-
tice can reduce screening participation. Logistic bar-
riers include difficulties with the appointment book-
ing process, insufficient office hours, and prohibitive
waiting times.
43–45
Inadequate organization of ser
-
vices or the physical plant (e.g., lack of privacy in
dressing rooms and examining suites) may result in
decreased utilization because of their unacceptability
to patients. Location difficulties, such as inadequate
availability of a particular technology in certain geo-
graphic areas, also inhibit screening.
46
Initiatives such
as Put Prevention into Practice offer practical advice
and resources to address these considerations.
47
Inadequate enabling systems and policies in the
practice setting can inhibit screening. Competing pri-
orities and time restraints, among other barriers, are
compounded when medical records, administrative
data, and other management systems do not facilitate
provider behavior. Poor record systems and lack of
easily accessible medical information within the prac-
tice setting may not support the provider in perform-
ing cancer screening activities.
45
Provider barriers
Providers fail to recommend screening. The literature
emphatically underscores the importance of a provid-
er’s recommendation for patient participation with
breast cancer, cervical cancer, and CRC screening.
Studies have found consistently that individuals who
report provider recommendation or encouragement
are more likely to complete screening
48
and that pa
-
tients with no recent screening report the lack of a
provider recommendation as a common barrier.
49–53
For example, Grady et al.
54
found that provider rec
-
ommendation had a stronger association with mam-
mography participation compared with demographic
variables, health care utilization, attitudes, or health
status.
Guideline dissemination fails to motivate practice.
Promulgation of clinical practice guidelines by plans
and practices has been promoted widely as a strategy
to improve quality of care. Implementation of guide-
lines alone, however, has only a limited effect on prac-
tice.
55,56
Providers tend to have poor knowledge and
retention of evidence-based practice guidelines
57
and
are unlikely to implement guidelines if they do not
believe that the guidelines are credible, if the guide-
lines are too complex, if guideline implementation
requires clinical resources and systems that are not
available, or if the guidelines differ significantly from
perceived existing norms.
58
Physicians may distrust
TABLE 1
Key Lessons Learned Regarding Health Care Settings Interventions
Lesson 1: Barriers to screening uptake in health care settings have consistent
themes, including 1) public policy, 2) organizational systems and practice
setting, 3) provider, and 4) patient
Lesson 2: A diverse set of strategies in health care settings can improve screening
uptake
Lesson 3: Multiple strategies aimed at multiple targets generally are necessary to
have large effects on screening uptake at the population level
Lesson 4: A successful screening program requires high rates of uptake, follow-up
of abnormal results, and continued participation at regular intervals
1168 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 4
guidelines in part because they believe that they have
insufficient input into guideline development.
59
Lack
of consensus about efficacy has been cited as a barrier
to primary care physicians’ recommending screening
procedures.
60,61
This is particularly true with respect
to debates regarding the relative value of colonoscopy
versus sigmoidoscopy
62
and about the value of mam
-
mography for women ages 40 –50 years.
Lack of training and skills inhibits delivery of can-
cer screening. Practicing physicians report lack of
both training and confidence as barriers to delivering
cancer screening interventions. For example, in a sur-
vey of 426 New York family physicians and internists,
46% of respondents reported that primary care physi-
cians need more continuing medical education (CME)
regarding how to manage suspicious mammography
findings and how to counsel patients about their in-
dividual risk.
63
The consensus is that physicians are
not trained adequately to deliver the continuum of
cancer screening care.
64
Lack of time (perceived and actual) is a barrier to
delivery of cancer screening. One of the reasons cited
most frequently by clinicians for not implementing
cancer screening is a real or perceived lack of time,
given other demands of primary care practice.
37,39,65,66
Response to the patient’s presenting complaints and
concerns often takes precedence; these demands vary,
depending on the type of visit and the patient’s exist-
ing medical conditions.
67
The clinician’s commitment
to recommend screening apparently increases with
the awareness that recommendation by physicians is a
powerful predictor of patient participation.
68
Patient barriers.
Lack of knowledge and related beliefs hinder screen-
ing participation. Incorrect knowledge and negative
perceptions of both cancer itself and specific screen-
ing tests are barriers to breast cancer, cervical cancer,
and CRC screening.
52,69
Conversely, knowledge of can
-
cer risk factors and screening guidelines, and positive
perceptions of screening effectiveness and the tests
themselves, are associated with intentions to be
screened and higher screening rates.
70–78
Perception
of more benefits (pros) to screening tests is a facilitator
to screening, whereas perceiving more barriers (cons)
is associated with decreased use.
50,72,7982
Having a
perceived, heightened susceptibility to the specific
cancer also has been associated with screening.
70,83–85
Cultural characteristics may present unique chal-
lenges. A growing body of evidence suggests that
unique cultural characteristics need to be understood
and addressed to reduce inequalities in screening
rates that are observed consistently among ethnic mi-
nority groups. The level of acculturation has been
associated with each type of cancer screening in stud-
ies of many diverse ethnic populations,
31,86,87
even
when controlling for demographic, socioeconomic,
and health system characteristics as well as attitudes
and beliefs. Beyond that, however, specific cultural
barriers need to be understood and addressed in tar-
geted interventions. In addition to access to care,
other important factors may be communication issues
with non-English-speaking patients,
88,89
lack of pre
-
ventive care experience, lack of orientation among
new immigrants,
31
and challenges posed by cultural or
gender discordance between patients and provid-
ers.
90,91
Inadequate access to and utilization of the health
care system continue. Lack of health insurance, as
discussed earlier, is a fundamental barrier to screen-
ing for cervical cancer, breast cancer, and CRC.
29,92
Even among individuals who have health insurance,
however, economic barriers to cancer screening per-
sist. Having a higher income and/or reporting having
money to spend on health care are associated strongly
with screening completion.
93–95
Although they are
sparse, studies assessing the effect of cost-sharing
generally have found that the two major forms of
cost-sharing—deductibles or coinsurance and copay-
ments—decrease cancer screening use
96
; further
-
more, they have the most negative effect on individu-
als of lower socioeconomic status.
97
Numerous studies have shown that patients with
a regular source of care are more likely to participate
in cancer screening.
29,71,76,83,94,98
Screening also in
-
creases with the number of physicians seen,
99
the
number of appointments kept,
94
the number of years
of clinic attendance,
100
and receipt of regular medical
check-ups.
101
Cancer screening participation also is
related consistently to the use of other preventive
services and behaviors.
93,101,102
The perception that it is inconvenient to have a
cancer screening test also may decrease use.
46
For
example, mammography use was lower among
women who preferred to have it performed during
weekend or evening hours.
94
Sigmoidoscopy rates
were improved by offering onsite testing
103
and were
higher among patients of primary care physicians who
performed the test.
104
Lesson 2
A diverse set of strategies in health care settings can
improve screening uptake. In general, strategies to
increase cancer screening that have been tested fall
into four categories that relate to the barriers dis-
cussed above: 1) public policy and payer strategies, 2)
provider education and professional standards, 3) or-
ganizational systems and practice setting strategies
Health Care Settings Interventions/Zapka and Lemon 1169
Page 5
that target providers, and 4) organizational systems
and practice settings that target patients. Other con-
ceptual dimensions that can be helpful when catego-
rizing interventions include the mechanism of action
(behavioral, cognitive, sociologic, or combination)
105
and the mode of delivery (static or interactive).
106
A
summary of review articles that apply various organiz-
ing strategies has been assembled for the reader’s
convenience (see the National Cancer Institute’s Ap-
plied Cancer Screening Research Branch Website,
available from URL: http://dccps.nci.nih.gov/acsrb).
Public policy and payer strategies
Implementation of coverage and reimbursement
strategies improves cancer screening. Not surpris-
ingly, private and public (i.e., Medicare and Medicaid)
health insurance payers have a clear role in enabling
provision and access to cancer screening services. Al-
though it is not amenable to testing by randomized
controlled trial, the implementation of widespread
coverage (and mandated benefits in particular) appar-
ently has resulted in increases in screening. For exam-
ple, state laws related to screening mammography
were virtually nonexistent in the 1980s. By the 1990s,
they varied greatly with respect to whether the benefit
was required or optional and with respect to payment
limits, eligibility, and referral requirements.
107
Since
then, most states have passed comprehensive legisla-
tion, and federal legislation has been enacted.
108
Over
this period, mammography rates have increased sub-
stantially. A similar pattern was observed for Pap tests.
In 1998, the Health Care Financing Administra-
tion expanded Medicare coverage to include CRC
screening tests
109
and, more recently, to include
colonoscopy screening. Commercial health plans are
following suit. We can expect to observe increases in
overall CRC cancer screening tests, and the use of
colonoscopy in particular. Federal and state program
initiatives, notably the Breast and Cervical Cancer
Control Program, have increased access to screening
among underserved populations.
To our knowledge, few patient-incentive strate-
gies to improve patient compliance with screening
have been tested to date, but they generally have been
effective. Vouchers distributed for free mammograms
were effective in several studies conducted in migrant
health clinics
110
; in inner-city public hospitals
111
; and
with financially vulnerable, out-of-compliance wom-
en.
112
Prepaid postage had a modestly positive effect
on the rate of FOBT packet returns by indigent and
private insurance patients.
113
Quality-improvement strategies and benchmark-
ing improve screening prevalence. Regulatory reform
and changes in the medical marketplace have stimu-
lated extensive “performance improvement initia-
tives.” These reflect the perspectives of the multiple
stakeholders, payers, providers, and consumers. One
externally based improvement effort was labeled “re-
port cards.”
18
Continuous quality improvement (CQI)
approaches represent a more “internal” strategy for
focusing on critical processes of care.
114
These two
orientations, taken together, have prompted bench-
marks for health insurance plans, particularly HMOs,
and organizations such as hospitals.
In the ambulatory care arena, the most prominent
effort to define sets of plan performance measures has
been the HEDIS measures,
19
which include measures
for cervical and mammography screening. Measures
for CRC screening will be included in the 2004 data
set. HEDIS data, collected from nearly 600 managed
care plans covering approximately 51 million Ameri-
cans, confirm that breast and cervical cancer screen-
ing rates continue to rise and are slightly higher than
those reported by the general population.
29,115
It is
interesting to note that the results from trials of the
effectiveness of CQI in improving preventive services
largely have been negative.
116
It may not be surprising,
however, to have no measured effect, given the com-
plexity of the CQI process, the chaos in the current
external health care environment, and the resulting
internal turmoil in health care delivery organiza-
tions.
117
Provider education and professional standards
Provider education and professional standards are
cornerstones for improving practice. Educational op-
portunities during medical school and residency train-
ing, along with subsequent CME and academic detail-
ing, can provide knowledge, attitudes, and skills that
predispose physicians to promote screening tests.
Clearly, however, education alone is not sufficient to
maintain appropriate behavior by providers. Tradi-
tional education and training programs designed to
increase physicians’ predisposing factors are the most
effective in improving implementation of preventive
interventions when combined with enabling strategies
(e.g., office reminders) and reinforcing strategies (e.g.,
feedback).
118
Organizational systems and practice-setting interventions
targeted at providers
Evidence is growing for several strategies that enable
provider behavior and, thus, improve cancer screen-
ing rates among patients. Reminder systems enable
provider action. Numerous studies to date have eval-
uated the effectiveness of prompts and reminders for
physicians in improving cancer screening.
105,119
Meth
-
ods include chart-based or manual reminders and
1170 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 6
computerized reminders. Age-appropriate health
maintenance checklists, which include cancer screen-
ing recommendations, have been designed as readily
accessible cues for physicians, thus eliminating time-
consuming record reviews. The forms are placed con-
spicuously in patient charts to give physicians a cue
and a quick reference to guide cancer screening rec-
ommendations at health maintenance visits. Interven-
tion studies have shown that forms are effective in
improving physicians’ promotion of cancer screen-
ing.
120
Patients of physicians who use manual check
-
lists have demonstrated greater rates of appropriate
cancer screening utilization over long follow-up dura-
tions compared with patients whose physicians do not
use the checklists.
121,122
Similarly, computerized reminders prompt physi-
cians to promote a wide range of preventive services.
Studies examining provider recommendation and re-
ferral as the outcome have shown improvements
among physicians who receive computerized
prompts.
123
Increased utilization of screening tests
that can be given by the physician at the time of the
visit (e.g., FOBT, clinical breast examination, and Pap
smears) has been observed consistently.
124,125
In con
-
trast, for tests that require a referral and an additional
appointment (e.g., mammography and sigmoidos-
copy), either minimal improvement or no differences
in screening rates have been shown.
124–126
Despite the
large economic, time, and manpower resources
needed to implement and maintain computer track-
ing systems properly, they have become an essential
tool in medical practice. Studies comparing comput-
erized and manual prompting systems found that
computerized prompts were somewhat more effec-
tive.
125,127
Goal setting, benchmarking, audits, and feedback
improve screening rates. Periodic chart audits have
been used to summarize and to provide feedback con-
cerning provider performance with respect to screen-
ing guidelines. Advances in computerized manage-
ment information systems and automated medical
records have increased the feasibility of providing
feedback on screening rates to individual clinicians,
practices, and plans. Recent studies have demon-
strated that such feedback systems, whether per-
formed by peers or supervisors, encourage providers
to promote cancer screening,
119,128,129
and both face-
to-face and written evaluations appear to be effective.
To date, chart audits have focused more on mammog-
raphy and Pap smears than on CRC screening. In
addition, the studies have targeted medical residents
or providers in rural practice settings, so the findings
may not have general applicability. Longitudinal stud-
ies that assess the optimal frequency for audit feed-
back are lacking.
To our knowledge, the effect of financial incen-
tives on plans and providers is unknown. Financial
incentives can influence physicians’ treatment behav-
ior,
130,131
but financial incentives’ ability to affect pre
-
ventive care delivery is less clear.
132
Financial incen
-
tives (either to an individual clinician, a medical
group, or an organization, such as staff in an HMO)
are distinguished from reimbursement by payers. The
effectiveness of a financial bonus strategy is difficult to
estimate because of difficulties in conducting con-
trolled trials. Issues such as the effect of the size of the
incentive, the proportion of covered individuals in a
particular physician’s panel or practice, and competi-
tion with secular trends are examples of reasons for a
lack of understanding of the unique role of financial
incentives.
Organizational systems and practice-setting interventions
targeted at patients
Practice-setting interventions include strategies to re-
mind, educate, and motivate patients about screening.
Patient reminders (outreach) are effective strategies.
Numerous health plans and practice settings have im-
plemented systems to remind patients when they are
due for prevention services (outreach). Reviews of pa-
tient-targeted interventions to increase mammogra-
phy use
133,134
have concluded that telephone and let
-
ter or postcard reminders significantly improve
screening rates compared with usual care. This same
pattern of impact is evident for reminders on CRC
screening.
135
Authors of reviews of patient-targeted
interventions to increase cervical cancer screen-
ing
43,136
stress that success in patient outreach is well
documented, and personalized letters may be espe-
cially effective in promoting interval screening. A re-
view of intervention studies aimed at improving fol-
low-up to abnormal Pap smears emphasizes the
importance of these contacts, particularly telephone
reminders and confirmation
137
(see the article by Bas
-
tani et al. in this issue
138
). Subgroup analyses, how
-
ever, suggest that patient reminders may have less
efficacy in lower socioeconomic groups.
136
Comparisons of the relative effectiveness of the
type of reminder indicate a possible, slight advantage
for telephone reminders versus mailed remind-
ers.
139,140
Saywell et al. tested the cost-effectiveness of
five interventions with HMO members; they con-
cluded that the combination of a tailored telephone
reminder and letter from members’ personal physi-
cians was the most effective and economic interven-
tion to increase mammography.
141
Patient information and education can improve
Health Care Settings Interventions/Zapka and Lemon 1171
Page 7
screening participation, but they are most effective
when combined with enabling or reinforcing strate-
gies. Considerable evidence has been accumulated
regarding the effect of organized patient education
programs. These programs include the distribution of
print materials, the use of questionnaires concerning
patients’ health habits, in-person counseling, tele-
phone counseling, patient-held minirecords and
checklists, group workshops or classes, and (more re-
cently) videotaped and Internet-delivered interven-
tions. In a recent meta-analysis by Stone et al.,
142
the
independent effect of patient education on the use of
cancer screening is described as positive but weak.
The effectiveness of education varies according to tar-
get audience characteristics, particularly the level of
education. This finding highlights the necessity of
choosing the information vehicle (i.e., print, video-
tape) and tailoring materials to the literacy level of the
audience. However, similar to provider education, pa-
tient education is most effective when it is coupled
with enabling or reinforcing strategies. For example,
Pignone et al.
143
demonstrated that a brief videotape
for patients regarding CRC screening, accompanied by
a chart marker to cue the physician, resulted in
screening of 47% of participants compared with 23%
in the control group.
Organizational interventions to improve access
The use of prevention services also can be improved
by reorganizing a practice and improving delivery ca-
pacity. These changes, in turn, improve patient access
and acceptance. Strategies aimed at improving
needed follow-up care are discussed in the article by
Bastani et al.
138
in this issue.
Increased availability of onsite service improves
screening rates. Capacity difficulties are a continued
challenge to delivering cancer screening tests that
cannot be delivered by primary care providers during
regular office visits (i.e., mammography, sigmoidos-
copy, colonoscopy). Several studies have assessed the
effectiveness of improving access to mammography
through expanded hours and mobile facilities.
68,144,145
These methods were effective, but the financial as-
pects make them difficult to sustain.
146,147
Another
study of CRC screening demonstrated that an educa-
tional seminar, combined with implementation of on-
site sigmoidoscopy services by gastroenterologists,
significantly improved referrals by primary care phy-
sicians in a community health center (CHC).
103
Lesson 3
Multiple strategies aimed at multiple targets generally
are necessary to have large effects on screening uptake
at the population level. Primary care clinicians, as
noted earlier, have considerable opportunities to re-
duce cancer morbidity and mortality through the de-
livery of screening services that affect patient behav-
iors. Both patient and provider behaviors are affected,
however, by a complex set of enabling, reinforcing,
and predisposing factors, as emphasized in Figure 1.
Several reviews of intervention effectiveness have
noted the importance of multifaceted interventions,
because they address more barriers.
142,148,149
Complex
interventions may be more effective (and also more
costly), but to our knowledge few economic evalua-
tions have been reported to date.
Several characteristics determine the nature and
intensity of change at each level, which, in turn can
facilitate or hinder greater provision of services by
providers and increased adherence by patients. One
characteristic is the incremental nature of public pol-
icy development in the U.S. It is well recognized by
policy analysts that public policy at all levels—na-
tional, state, and local—by nature is incremental, de-
veloping in small steps, with change occurring
through the interaction of numerous stakeholders and
constituencies.
150,151
For example, policies related to
mandated coverage for breast cancer screening, by
both public and private payers, have developed over
time.
152
Second, consensus regarding the efficacy and
effectiveness of clinical guidelines evolves and
changes over time.
153–156
Third, an iterative process
occurs in developing and proving the effectiveness of
intervention strategies to encourage adherence to the
guidelines. Each strategy must be proven effective in
multiple studies, across varying settings and samples,
before adequate evidence generates a consensus of
effectiveness. Fourth, the complexity of organizational
change generally is underestimated. Institutionaliza-
tion of evidence-based intervention strategies is a ma-
jor challenge, given limited resources.
157
Finally, dif
-
ferential readiness of organizations to adopt and
differential enabling factors are found in various de-
livery settings. The transection of these characteristics
varies, so there is no “one-size-fits-all” approach. For
example, programs that rely on established structures
and sophisticated processes and that implement mul-
tiple strategies (offered, for instance, at staff model or
group HMOs early in a screening method’s diffusion)
are unlikely to be possible at a CHC. Such centers
generally have far fewer administrative resources, they
experience greater patient turnover, and many lack
the capability to link providers (e.g., primary care pro-
viders and specialists) through medical information
systems.
Clearly, and perhaps most important, all these
characteristics and processes evolve and interact over
time, and they do so differentially in specific settings.
1172 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 8
“Model programs” or “model interventions” effec-
tively incorporate the unique needs of a given popu-
lation at a given time. What may be considered a
model program in one setting may not be ideal in
another setting—or, indeed, for the same setting at
another time or for a different cancer prevention ser-
vice. The body of evidence suggests that the most
effective programs include: 1) strategies that target
multiple levels (e.g., strategies can enable and rein-
force both provider and patient behavior, for example,
both policy-level changes and organizational changes
are access-enhancing strategies
149
); 2) strategies that
consider enabling factors outside the individual clini-
cian’s control (e.g., reimbursement, availability, and
accessibility of services); 3) strategies (and expecta-
tions about performance standards) that reflect
awareness of the state of science, professional consen-
sus, and professional norms about a certain screening
technology; and 4) strategies that reflect the need to
modify program components as patient needs and
environmental factors change.
Lesson 4
A successful screening program requires high rates of
uptake, follow-up of abnormal results, and continued
participation at regular intervals. Screening participa-
tion must be viewed, not as a unitary behavior, but
from a longitudinal perspective and across the contin-
uum of care.
5
Although initial screening is important,
according to guidelines to maximize effectiveness in
reducing morbidity and mortality, initial screening
must be followed by appropriate and timely follow-up
of abnormal results (see the article by Bastani et al.
138
in this issue concerning interventions to improve the
follow-up of abnormal findings in cancer screening),
treatment services for those who need them,
158
and
subsequent periodic screening. All these important
processes of care require a systematic approach to
monitoring. In the U.S., the lack of tracking across
health plans and providers is a challenge to longitu-
dinal monitoring. This difficulty is epitomized by CRC
screening. Defining “current screening” according to
the guidelines must consider four evidence-based test
strategies with varying intervals for periodicity, each of
which may be provided by different clinicians in dif-
ferent settings. Follow-up and surveillance also must
be considered after removal of adenomous polyps as
part of colonoscopy screening.
The importance, as well as the challenge, of de-
fining cancer screening across the continuum of care
is exemplified by the National Breast and Cervical
Cancer Early Detection Program (NBCCEDP) of the
Centers for Disease Control and Prevention. This na-
tional initiative was established in response to the
Breast and Cervical Cancer Mortality Prevention Act of
1990 (Public Law 101–354) to improve access to breast
and cervical screening among low-income women
who are uninsured or underinsured.
159
Before the NB
-
CCEDP, public health screening programs targeted at
low-income individuals typically included resources
for screening only.
158
Consequently, individuals with
identified abnormal results had no access to necessary
follow-up diagnostic and treatment services. Treat-
ment became the responsibility of participating agen-
cies. Some effective strategies were used at both state
and local levels, but multiple challenges were appar-
ent, including the provision of fragmented care and
uncertainty regarding the long-term sustainability of
those efforts.
158
For a list of review articles and meta-
analyses related to cancer screening interventions in
the health care setting, see Table 2.
PRIORITIES FOR FUTURE RESEARCH
Broad priorities for research specific to health care
settings include service delivery (intervention) re-
search, attention to research phases, studies of health
services delivery trends, and methods and measure-
ment issues.
Service Delivery (Intervention) Research
Expanded focus on the continuum of care
To reduce cancer morbidity and mortality effectively,
screening procedures must occur at regular intervals,
and early detection must be followed by appropriate
diagnostic, treatment, and surveillance services, as
noted earlier (see Lesson 4). However, to our knowl-
edge, to date intervention research mainly has studied
one-time screening as the primary endpoint. Measur-
ing the continuum of care is very challenging because
it requires following patients over longer periods, re-
sulting in greater difficulty in accessing medical
records and defining endpoints. It may not be feasible
for a single study to follow diagnosed patients through
treatment; therefore, a more reasonable expectation is
that endpoints assess receipt of diagnostic services
and/or periodic rescreening. It is estimated that ap-
proximately 8.9 million Americans who had a history
of cancer were alive in 1997.
160
This fact underscores
the importance of continuing surveillance research,
given the increasing numbers of cancer survivors.
Primary prevention interventions for higher risk individuals
(who have been screened)
Scientific evidence continues to develop regarding the
epidemiology of specific cancers and chemopreven-
tion. Interactions with the health care system may
represent an opportunity to undertake primary pre-
vention interventions targeted to those subpopula-
Health Care Settings Interventions/Zapka and Lemon 1173
Page 9
TABLE 2
Review Articles and Meta-Analyses Related to Cancer Screening Interventions in Health Care Settings
Citation Period and methods Inclusion and exclusion criteria Organization of review
Breast cancer screening
Rimer, 1994
73
01/1990–01/1994: MEDLINE search to
identify published reports; in press
articles were solicited from previously
published researchers, NCI grantees,
and others in the field
Experimental and quasiexperimental designs
to test interventions in which
mammography use was the outcome;
excluded studies of women with abnormal
mammograms
Review of interventions was organized by typology of intervention
(e.g., media campaigns; individual-directed interventions;
systems-directed or physician-directed, access-enhancing,
policy-level, social network, multistrategy interventions) and
by single-intervention and multiple-intervention studies; tables
include the intervention, study design, sample size, and major
findings of the study
Mandelblatt and Kanetsky, 1995
119
01/1980–04/1993: MEDLINE search (1980–
1993) supplemented by a review of all
related bibliographic references and
recent listings in Current Contents
from Nov., 1992 to Apr., 1993
Included only concurrent control studies in
the U.S.; excluded uncontrolled reports,
descriptive studies with historic controls,
preintervention-postintervention studies,
and studies of symptomatic individuals
Review organized according to the following strategy categories:
1) physician reminder systems, 2) office systems, 3) audit with
feedback interventions, 4) physician education, and 5) patient
reminder or education; tables include characteristics of
controlled trials, intervention, control group, setting, sample
size, estimated effect size (% and 95% CI)
Wagner, 1998
210
01/1985–09/1996: MEDLINE search (1985–
1996) supplemented by searches of
Current Contents (07/1989–09/1996),
Magazine and Journal Articles Data
Base (01/1988–09/1996), PsycInfo (01/
1967–11/1996), and ABI/Inform (01/
1971–09/1996)
Included RCTs comparing personalized,
mailed patient reminders or no reminder
with generic letters; excluded studies using
telephone calls and other types of
reminders; also excluded studies
comparing patient reminders with
physician reminders
Meta-analysis; results include pooled estimate of the effect of
mailed reminders on mammography screening; also presented
cost analysis and other factors associated with mammography
screening in pooled analyses; tables include sample size of
intervention and control groups, percent receiving
mammography, and odds ratio
Mandelblatt and Yabroff, 1999
105
01/1980–12/1998: OVID search mechanism
with MEDLINE to identify published
English-language articles on
interventions; reference lists of selected
articles were reviewed, and several
journals were hand searched
Included U.S. studies that had 1) randomized
or concurrent control design, 2) defined
outcomes of the ordering or completion of
mammography, and 3) data available for
reanalysis excluded studies; using
physician estimates of mammography
recommendations
Meta-analysis of 4 categories of interventions: 1) behavioral (e.g.,
reminders), 2) cognitive (e.g., education, audit, and feedback),
3) sociologic (e.g., peers or social norms), and 4) combination;
interventions were classified further according to to the
control group (active control or usual care) and the targeted
group (providers, providers and patients, or communities);
tables include intervention, control group, sample size,
percent screened, estimated effect size, and confidence
interval
Sin and Leger, 1999
211
1980–07/1998: MEDLINE, BIDS-EMBASE,
PsycLit, and Social Sciences Index data
bases were searched; reviewed citations
from relevant articles or letter was sent
to breast screening units and to the
Public Health mail base to identify
unpublished studies
English-language studies only; no limitations
on study design were imposed; included 1)
studies of interventions to increase breast
screening uptake and 2) U.K. studies and
non-U.K. studies as long as they were
“generalizable” to an extent due to the
nature of the research questions or study
design (e.g., free screening, population-
based study); excluded were non-U.K.
studies in which the setting, design, or
findings were not applicable to the U.K.
(e.g., organizational elements did not exist
in the U.K.)
Interventions were grouped into four categories: 1) individual-
directed (aimed at eligible women and health professionals),
2) system-directed (e.g., aimed at the organizational aspects of
service delivery), 3) social network-directed, and 4)
multistrategy interventions; also discussed specific
interventions in general practice settings and inner-city
settings, financial costs of interventions, implications for
future programs, and recommendations for practice and
research; tables summarize interventions along with quality of
evidence and effect; articles outline criteria for assessment of
studies and operational definitions
Yabroff and Mandelblatt, 1999
133
1/1980–12/1998: OVID search mechanism
was used with MEDLINE to identify
published English-language articles on
interventions; reference lists of selected
articles were reviewed, and several
journals were hand searched
Included prospective studies designed to
increase mammography use and
performed in the U.S. that had 1)
randomized or concurrent control design,
2) defined outcomes, and 3) data available
for reanalysis; excluded studies with
insufficient detail for categorizing;
excluded from quantitative analyses
interventions to increase repeat screening
Meta-analysis of 4 categories of interventions: 1) behavioral; 2)
cognitive (generic or theory based), 3) sociologic; and 4)
combination; studies were categorized further by control
group (usual care versus active control), number of
interventions, and mode of intervention (interactive versus
static); tables include study setting (e.g., community, worksite),
sample size, percent screened, effect size, and confidence
interval
Bonfill et al., 2001
134
1966–2000: searches of MEDLINE (1966–
2000), EMBASE (1998–1999), and
CENTRAL (2000); letters to the
European Screening Breast Cancer
Programs (Euref Network) identified 2
additional studies
Included published and unpublished RCTs of
intervention strategies used to recruit
women to a community breast screening
activity or program; outcome measure was
screening attendance; excluded studies
that did not meet the inclusion criteria
and studies with unknown denominators
for estimating attendance, studies with
groups that were not comparable at
baseline, studies with a control group that
was exposed to an intervention, and
studies that featured opportunistic
interventions (e.g., recruiting from women
seeking help in a health care setting)
Described results of different intervention strategies (invitation
letters, mailed educational material, invitation telephone calls,
training activities, reminders, home visits, and various
combinations of the above) compared with a control group
(no intervention); tables compared various intervention
strategies with controls and listed odds ratio of obtaining a
mammogram in the next 12 mos or 24 mos
(continued)
1174 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 10
Citation Period and methods Inclusion and exclusion criteria Organization of review
Ratner et al., 2001
212
1966–06/1997: MEDLINE search (1966–06/
1997) restricted to experimental or
quasiexperimental design with
mammography screening uptake as
dependent variable; browsed journals
known to publish relevant articles;
reviewed published reference lists
Included studies in any language with
experimental or quasiexperimental designs
and mammography screening uptake as a
dependent variable; excluded descriptive
studies, case reports, and opinion pieces
Meta-analysis: primary analysis from randomized studies only;
categorized interventions used in the studies according to
their setting (community or clinic) as well as factors
(predisposing, enabling, reinforcing) addressed, according to
the PRECEDE model; tables include characteristics of studies
(including PRECEDE factors addressed, study design, setting,
and measurement) and multivariate model for meta-analysis
results
Rimer et al., 2001
213
01/1987–01/1998 (see Meissner et al.,
1998
129
)
Included experimental and quasiexperimental
interventions designed to increase
mammography utilization in
asymptomatic women; excluded needs
assessments, pilot interventions, and
reports of preliminary findings without
measures of effects
Review of categorized interventions according to whether they
were 1) individual-directed (counseling, letters, reminders), 2)
system-directed or provider-directed (provider prompts), 3)
community education, 4) access-enhancing (transportation,
facilitated appointment making, reduced-cost screening), 5)
media campaign, 6) social network (peer leaders, lay health
advisors), or 7) policy-level strategies
Yabroff et al., 2001
106
1980–02/2001: Grateful Med to search,
MEDLINE (1980–02/2001); reviewed
reference lists of relevant articles and
hand searched several relevant journals
(01/2000–02/2001)
Included English-language studies using
randomized or “concurrent assignment” to
an intervention or control group,
prospective follow-up, and mammography
use as an outcome measure; included only
patient-targeted interventions; excluded
published abstracts that contained
insufficient information to classify
interventions as well as studies performed
outside the U.S.
Meta-analysis of patient-targeted interventions categorized by
setting (inreach or outreach), mechanism of action
(behavioral, changing stimuli associated with mammograms
[e.g., reminders]; cognitive, providing new information or
education [e.g., tailored messages]; or sociologic, using social
norms or peers [e.g., lay health workers]), type of control
(active or usual care), and mode of delivery (static or
interactive); two tables report studies’ characteristics and
analysis of results of the effectiveness of interventions by
setting and mechanism used
Legler et al., 2002
149
1984–08/2000: Parent data base developed
by using searches of MEDLINE Science
Citation Index, and PsycInfo for
mammography intervention studies;
checked references of published
articles and for additional articles by
authors identified in searches; updated
parent data base through MEDLINE,
Social Science Citation Index, and
EMBASE; checked references of
relevant articles; mailed inquiry to
researchers requesting prepublication
manuscripts or articles not listed in
data bases.
Included experimental or quasiexperimental
studies of interventions to increase the use
of mammography among asymptomatic
women in diverse populations using
receipt of a mammogram as the outcome
measure; diverse population groups
included high school education or less,
low income, ethnic or racial group, age
60 years, and living in a rural or inner-city
area; excluded nonexperimental designs;
needs assessments; pilot studies;
descriptive or process evaluations; studies
that focused on follow-up of abnormal
results, efficacy, or quality control; system-
directed or provider-directed interventions
or outcomes; and studies with insufficient
data
Review categorized interventions according to Rimer intervention
typology: (see Rimer, 1994
73
): 1) individual-directed
(counseling, letters, reminders), 2) system-directed (provider
prompts), 3) community education, 4) access-enhancing
(transportation, facilitated appointment making, reduced-cost
screening), 5) media campaigns, 6) social network (peer
leaders, lay health advisors), and 7) multistrategy
(combinations of above); tables presented include a meta-
analysis of effects per intervention type and descriptive
features of studies included in the analysis; figures present
intervention effects both for population subgroups in
individual studies and for specific intervention types
Cervical cancer screening
Marcus and Crane, 1998
43
01/1951–12/1996: computerized literature
search of peer-reviewed articles in the
Combined Health Information Data
Base, CANCERLINE, MEDLINE,
HEALTHLINE, Psychology Abstracts,
Sociology Abstracts, and The Education
Index
Includes randomized trials, quasiexperimental
studies that incorporate some form of
control or comparison group, and studies
that lack a control group but report
findings that may help assess the viability
of a particular intervention strategy
Report considers outreach strategies, inreach strategies, cost-
reduction strategies, and strategies to reduce loss to follow-up
among women with abnormal Pap smears; summary table is
organized according to type of strategy, including mass media
campaigns, community outreach, patient letters and mailings,
patient checklists/prompts, opportunistic screening
(outpatient, inpatient), and cost reduction
Tseng et al., 2001
136
1966–2000: MEDLINE and CancerLit
search; bibliographies of relevant
articles reviewed; inquiries sent to
authors to locate unpublished articles
Included randomized controlled studies
(published and unpublished) of the
efficacy of patient letter reminders on
increasing rates of Pap smear screening in
populations due for screening; no other
interventions could be used in
combination with letters, and the control
group received no intervention
Meta-analysis of data from 10 eligible studies; tables and figures
include characteristics of studies (setting, population, follow-
up, and outcome measure), results of studies, odds ratios of
individual and combined studies, summary of pooled results
(included subgroup analysis of socioeconomic status)
(continued)
Health Care Settings Interventions/Zapka and Lemon 1175
TABLE 2 (continued)
Page 11
Citation Period and methods Inclusion and exclusion criteria Organization of review
Forbes et al., 2002
214
Up to 03/2000: searched 23 electronic data
bases, including including MEDLINE
(1966–03/2000), BIDS Science Citation
Index (1981–03/2000), BIDS Social
Science Index (1981–03/2000), EconLit
(1969–03/2000), EMBASE
(1985–03/2000), CancerLit (1985–03/
2000), DHSS data (1985–2000);
dissertation abstracts (1985–03/2000),
ERIC (1985–03/2000), HealthSTAR
(1985–03/2000), ASSIA (1985–03/2000,
Pascal (1985–03/2000), SIGLE (1980–03/
2000), CINAHL (1982–03/2000) Sociofile
(1974–03/2000), PsycInfo
(1985–03/2000), SHARE (Kings Fund),
Library of Congress data base NHS
CRD DARE, Cochrane Data Base of
Systematic Reviews, Cochrane
Controlled Trials Register, and the
National Research Register; also
searched bibliographies of related
articles, contacted specialists, and hand
searched 1 journal
Included RCTs, cluster RCTs, or quasi-RCT
studies of interventions targeted at women
eligible to participate in cervical cancer
screening (whether due, overdue, or
returning for follow-up of abnormal
smears); included interventions targeted to
women; excluded interventions targeted to
health professionals and communities;
primary outcome measures included
uptake of cervical cancer screening; no
language restrictions; included
unpublished studies
Describes features and results of studies by intervention type
(e.g., invitation letter or call, education, counseling, risk factor
assessment, procedures, economic incentives); also describes
results of secondary outcomes, booking of appointments,
attitudes to screening, costs of intervention; discusses
methodological qualities of included studies; tables report
results comparing specific interventions with control or a
different intervention
Cervical and breast cancer screening
Kupets and Covens, 2001
128
1966–2000: MEDLINE search (1966–2000)
using MeSH terms; reviewed
bibliographies of relevant articles to
find additional articles; Cochrane data
base Search
Included RCTs conducted in North America of
interventions that assessed receipt of both
breast and cervical screening and that
used primary care physicians (including
family physicians, general practitioners,
gynecologists, and internists); excluded
non-English-language articles
Interventions were divided into 3 categories: 1) physician-based
strategies (computer-generated reminders, manual reminders,
audit and feedback, chart information sheets); 2) physician-
based and patient-based strategies (physician computer-
generated reminders and patient reminders); and 3) patient-
based strategies (mailed reminders, computer touch screen
system); tables list study and outcome measurements for each
of the above strategies
Meissner et al., 1998
129
01/1960–05/1997: searched Science
Citation Index, PsycInfo, and MEDLINE
to identify published reports; to find
any related intervention articles that
did not appear in the original searches,
checked references listed in published
articles and computerized data bases
by authors and coauthors or the
identified intervention articles
Included U.S. studies that measured the effect
of interventions to increase use of
mammography and/or Pap smears in
asymptomatic populations; excluded 1)
interventions to promote clinical breast
examination or breast self-examination as
a single screening modality; 2) studies
focusing on abnormal findings, follow-up,
or treatment; 3) studies addressing efficacy
issues related to screening and age or
quality of life; and 4) articles reporting
needs assessment, pilot interventions,
observational studies, and preliminary
findings not pertaining to outcome
Information was abstracted into 4 study elements: 1) needs
assessment, 2) intervention study design, 3) analysis methods,
and 4) study outcomes; typology (see Rimer, 1994
73
) was used
to categorize intervention strategies (media campaign;
individual-directed, systems-directed, or physician-directed;
access enhancing; policy level; social network; community
education); underserved populations were defined according
to Healthy People 2000 special population targets for cancer
screening institutionalization of interventions and cost-
effectiveness were noted when available; tables report key
elements for needs assessment, study design, and outcomes
CRC screening
Vernon, 1997
84
01/1973–12/1996: Searched MEDLINE,
Cancer Lit, PsycInfo, SSCI, and Current
Contents; also reviewed reference lists
of articles identified through computer
searches
At minimum, study must describe population,
setting, and data collection process;
included a wide range of study designs,
varying in rigor; included only articles
published in English
Describes interventions to increase adherence to screening (FOBT
and sigmoidoscopy); tables list location and date of study,
population, intervention groups/methods, percent adherence,
and comments considering limitations of study; NB: review
also included study of prevalence, factors associated with
adherence, and reasons for nonparticipation
Peterson and Vernon, 2000
135
01/1997–08/1999: Data base searches of
CancerLit, ERIC, MEDLINE, PsycInfo,
Current Contents; searched reference
lists from articles found
Included published, English-language, peer-
reviewed articles on asymptomatic
individuals’ adherence to CRC screening
guidelines (FOBT and sigmoidoscopy); also
included articles on physicians’ adherence
to published CRC screening guidelines
(their performance of as well as referral/
recommendation); includes intervention
studies as well as articles on prevalence
and correlates of adherence; restricted to
studies of physicians who could be
considered primary care physicians;
excluded studies involving medical
students, studies measuring only intention
to adhere or knowledge of guidelines
Reviewed two categories of studies: 1) individual adherence to
CRC screening guidelines and 2) physician adherence to CRC
screening guidelines; review discusses prevalence of
individuals’ use of FOBT and sigmoidoscopy, interventions to
improve individuals’ use of FOBT and sigmoidoscopy,
physician adherence to CRC screening guidelines,
interventions to improve physician adherence to guidelines,
and factors related to physicians’ adherence to guidelines;
tables summarize prevalence rates of physicians’ adherence to
guidelines and intervention studies to improve physicians’
adherence to guidelines
(continued)
1176 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
TABLE 2 (continued)
Page 12
Citation Period and methods Inclusion and exclusion criteria Organization of review
Prevention services interventions (multiple screens)
Hahn and Benger, 1990
215
01/1979–12/1989: MEDLINE search, review
of bibliographies, and personal
correspondence
Included descriptive (audit) studies or or
intervention studies; excluded studies
reporting only physician estimates of
performance or audit results for
nonhealth-maintenance procedures
(illness care)
Review includes physician factors, patient factors, and system
factors; table reports design, setting, patient eligibility criteria,
and preventive service studied (Pap smear, mammography,
FOBT, sigmoidoscopy, breast examination and cholesterol,
tetanus, blood pressure, weight, cigarette use); NB: review
table included in scientific report
McPhee and Detmer, 1993
216
1982–1992 Included experimental and quasiexperimental
studies that tested inreach and outreach
strategies to improve smoking-cessation
counseling and cancer screening (breast
examination, mammography, Pap test,
rectal examination, FOBT, and
sigmoidoscopy)
Review of interventions was organized by target behaviors
(smoking-cessation counseling and quit rates, cancer
screening) and intervention target (physicians, patients, and
office staff); tables of evidence reported intervention type,
outcomes, comparisons of rate of outcomes between
experimental and control groups, or before and after
comparisons
Yano et al., 1995
217
01/1980–12/1992: MEDLINE search to
identify published English-language
evaluations of primary care programs
Included primary care program evaluations
published in English
Primary care goals: access, continuity, comprehensiveness,
preventive care, technical process, humanistic process,
management/coordination, physical environment, patient
outcomes, reduction in physician-ordered services, increase in
appropriate service use, shift of care from inpatient to
outpatient, cost reduction, improved efficiency; tables were
organized by goal and summarize interventions achieving the
goal
Shea et al., 1996
218
01/1966–12/1995: MEDLINE (01/1966–12/
1995), Nursing and Allied Health (01/
1982–10/1995), and Health Planning
and Administration (01/1975–11/1995)
data base searches; supplemented by a
review of bibliographic references
Included RCTs of computerized reminder
systems in ambulatory care settings; only
studies in which the control group
received no intervention were included;
excluded studies using historic controls
Considered 4 intervention conditions: 1) computerized reminders,
2) manual reminders, 3) both, and 4) control as well as two
sampling designs (randomization of providers with their
patients and of individual patients); results include pooled
estimates of the effect of computerized reminder systems
according to category of preventive service; specific preventive
services were organized into categories; review table lists study
setting, intervention (patient and/or physician), and
preventive services included; meta-analysis tables include
sample sizes, number of intervention conditions, number of
preventive services, odds ratios (95% CI), and P values
Snell and Buck, 1996
219
01/1989–12/1994: searched MeSH, the
online National Library of Medicine
data base (1989–1994), and relevant
references listed in bibliographies and
in literature reviews
Included studies of interventions that could
be implemented in a physician’s practice,
with the objective of increasing
compliance with established guidelines;
studies must have analyzed intervention
effect on 1 cancer screening activities,
including mammograms, Pap smears,
breast examinations, FOBTs, or rectal
examinations
Meta-analysis; categories included 1) physician-focused strategies
(both during a visit, such as reminders, and outside the visit,
such as education or chart audit), 2) patient-focused
strategies, and 3) both physician-focused and patient-focused
strategies; within each category, studies were categorized
further by specific intervention type, total number of
interventions, setting, outcome measure, and cancer-screening
outcome measured; tables report intervention(s), number of
studies, effect size, and confidence interval
Hiatt, 1997
220
Not reported Not reported Includes 3 categories of research: 1) outreach (directed at general
population), 2) inreach (directed at clinical setting and
provider/patient interaction), and 3) systems (directed at
medical care delivery and policy); describes types of
interventions used in each category as well as effects and
limitations; also discusses future challenges and needs
Cabana et al., 1999
56
01/1966–01/1998: Searched MEDLINE,
ERIC, and HealthSTAR, bibliographies,
textbooks on health behavior/public
health, and references supplied by
experts (NB: studies that describe
barriers to guideline adherence)
Articles focused on clinical practice
guidelines, practice parameters, clinical
policies, national recommendations, or
consensus statements; included articles
that examined at least 1 barrier to
adherence; studies investigated guidelines
on a variety of topics, including preventive
care, adherence to USPSTF guidelines,
clinical breast examination, fat and
cholesterol intake, asthma treatment, and
immunizations; included only English-
language articles
Review organized according to types of barriers and their effect
on physician knowledge, attitude, or behavior:
comprehensiveness of surveys, characteristics of physician
surveys, adherence barriers identified by studies, qualitative
studies; figure shows relation of barriers to behavior change;
tables are available online
Dickey et al., 1999
221
01/1980–12/1998: Selective review from
MEDLINE searches (starting in 1980),
secondary sources from reference lists,
and documents in files
Selective review with few inclusion/exclusion
criteria because of the diverse
methodology, modest scope, and lack of
randomization and control groups of
many studies in this area (primarily
focuses on smoking, weight, exercise, and
alcohol use)
Reviews considered: Office Tools (developed to assist providers
with health-risk assessment, prompting and reminding, and
education) and Teamwork (coordination and delegation of
tasks between providers and staff); table of evidence for Office
Tools reports on tool/intervention, setting/design, and results;
addresses behavioral risk-factor counseling, although many
reviewed articles address screening
(continued)
Health Care Settings Interventions/Zapka and Lemon 1177
TABLE 2 (continued)
Page 13
Citation Period and methods Inclusion and exclusion criteria Organization of review
Hulscher et al., 1999
222
1966–1995: Searched MEDLINE
(1966–1995) using MeSH and keywords
to identify published reports of
preventive activities in primary care;
manual review of tables of contents of
21 scientific journals (1980–1995) for
studies on implementation of
guidelines; also used Cochrane
Effective Practice and Organization of
Care Register of Trials (11/1995)
Intervention studies aimed at improving
clinicians’ preventive activities were
included; further inclusion criteria
included 1) RCT or controlled before/after
study, 2) participants are primary care
clinicians responsible for patient care, 3)
availability of guidelines for recommended
action, 4) objective measures of clinicians’
performance as outcome measure (no
attitude or knowledge outcomes included),
5) articles written in English, German, or
Dutch
Analyzed comparisons between intervention and control groups
describing both single and multifaceted interventions;
preventive care measures included mammography, digital
rectal examination, FOBT, Pap smear, dietary counseling,
hypertension monitoring, smoking-cessation counseling,
cholesterol history, alcohol monitoring, and vaccinations;
tables report results of interventions; some tables are
categorized by type of intervention (e.g., professional, such as
reminder and feedback, or organizational); tables also list 1)
types of interventions used to promote preventive care among
clinicians and 2) characteristics of studies
Balas et al., 2000
223
01/1966–01/1996: Searched Columbia
Registry at University of Missouri
School of Medicine, MEDLINE,
CINAHL; reviewed monographs,
unindexed publications, and reference
lists; made informal contacts
Included only RCTs in which the intervention
was a physician prompt and that
measured the effect on a number of
preventive care activities, including cancer
screening (FOBT, mammogram, Pap
smear), influenza, tetanus, and
pneumococcal vaccinations
Report considers the effect of 1) provider prompting on the
provision of preventive care and 2) clinician characteristics
and specialty, reimbursement type, and computerization;
tables report quality rating of intervention, intervention
delivery method, targeted action, and procedure and rate
difference with confidence interval; report addresses selected
procedures, some counseling
McBride and Rimer, 1999
224
01/1985–01/1997: MEDLINE and PsycInfo
searches to identify studies written in
English
Included randomized trials in which the
telephone was used to deliver a health-
related intervention message relating to
mammography completion, Pap smear,
smoking cessation, lower fat diet, infant
care, breast feeding, exercise, or
vaccination
Reviews the role of telephone-delivered intervention in 1)
reaching the underserved; 2) motivating and sustaining health
behaviors, including cancer screening; 3) increasing the
efficacy of health services; and 4) practice implications; tables
include information on intervention, target population,
whether the telephone-delivered intervention was a primary or
adjunct goal of the study, type of counselors, number and
timing of calls, outcomes, and cost
Stone et al., 2002
142
1996–02/1999: used data base of previous
systematic reviews, HCQIP data base,
Cochrane EPOC Special Register
(developed through searches of
MEDLINE [since 1966], EMBASE [since
1980], HealthSTAR [since 1975], and
the Cochrane Controlled Trials Register
[since 1996])
Selected controlled clinical trials that assessed
the effects of interventions to increase the
use of 5 prevention services (influenza and
pneumonia vaccination and breast,
cervical, and CRC screening); excluded
studies that 1) did not list sample size or
had a unit of analysis that was not the
patient, 2) focused on colon visualization
(flexible sigmoidoscopy or colonoscopy)
due to insufficient due to insufficient
numbers, 3) assessed the effect of mass
mailings (due to large sample sizes), or 4)
had data that could not be pooled
(because the studies assessed different
forms of the same intervention component
or were “idiosyncratic” comparisons of
multiple intervention components)
Meta-analysis of the effects of specific intervention components
and key features on the receipt of 5 prevention services;
defined 7 types of intervention components: 1) reminders
(computer or manually generated provider or patient
prompts), 2) provider feedback, 3) education (targeting
providers or patients and including mailings, conferences,
educational sessions), 4) financial incentives (reductions in
patient payment or copayment, direct compensation to
providers), 5) regulatory and legislative actions; 6)
organizational change (changes in facility, procedures or
infrastructure), and 7) mass media campaigns; also defined 7
key intervention features: 1) social influence; 2) marketing and
outreach; 3) visual appeal and clarity; 4) collaboration and
teamwork; 5) design based on needs, barriers, incentives,
assessments, or theory; 6) top management support; and 7)
active learning strategies; tables included a list of intervention
components by service target, regression analysis for meta-
analysis of the effectiveness of individual intervention
components of the effects of key intervention features
Grimshaw et al., 2001
225
01/1966–01/1998: MEDLINE, HealthSTAR,
and Cochrane library searches;
reviewed personal reference lists
Included systematic reviews of educational or
quality-assurance interventions targeted at
health care professionals; reported
measures of professional performance
and/or patient outcomes
Reports on systematic reviews were organized by focus: broad
strategies (e.g., continuing medical education credits, guideline
dissemination and implementation, quality enhancement,
physician-nurse collaboration), improvement of specific
behaviors, including cancer screening, and specific
intervention strategies (e.g., use of educational materials, local
opinion leaders, educational outreach); tables report focus,
inclusion criteria, main results, authors’ main conclusions, and
a quality score (range, 1–7) derived from a validated checklist
NCI: National Cancer Institute; 95% CI: 95% confidence interval; ABI: Area-Based Initiatives; RCTs: randomized controlled trials; BIDS: Bath Information Data Service; EMBASE: Excerpta Medica Data Base; CENTRAL:
Cochrane Central Register of Controlled Trials; PRECEDE: Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation; Pap: Papanicolaou; DHSS: Department of
Health and Social Security; ERIC: Educational Resource Information Center; ASSIA: Applied Social Science Index and Abstracts; SIGLE: System for Information on Grey Literature in Europe; CINAHL: Cumulative
Index to Nursing and Allied Health Literature; SHARE: Secure Health Information Sharing System; NHS: National Health Service; CRD: Centre for Review and Dissemination; DARE: Database of Abstracts of Reviews
of Effects; MeSH: Medical Subject Headings; CRC: colorectal cancer; SSCI: Social Science Citation Index; FOBT: fecal occult blood test; USPSTF: U.S. Preventive Services Task Force; HCQIP: Health Care Quality
Improvement Projects; EPOC: Effective Practice and Organization of Care.
1178 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
TABLE 2 (continued)
Page 14
tions of individuals known to be at higher risk because
of previous screening findings. These individuals are
deserving of increased research attention. For exam-
ple, women who have positive human papillomavirus
(HPV) tests may benefit from counseling on sexual
behavior and discussion of barrier and spermicidal
contraception.
161
Individuals who have had colonic
adenomas detected may consider the use of calcium
supplements
162
or the use of low-dose aspirin or other
nonsteroidal antiinflammatory drugs.
163
They could
be counseled regarding lifestyle changes, including
physical activity; weight reduction
164
; and increased
intake of vegetables, fruit, and fiber.
165,166
Expanded focus on comprehensive cancer screening
To our knowledge, to date studies to improve screen-
ing have focused primarily on promoting a single
screening test. An important role of primary care is to
coordinate delivery of comprehensive preventive ser-
vices. Strategies to encourage the use of comprehen-
sive cancer screening are a logical next step for inter-
vention research. This step is particularly important
because some strategies are effective consistently
across screening modalities and across varied tests,
yet not using particular tests is consistent across indi-
viduals. A recent study by Burack et al.
167
tested the
effectiveness of adding Pap smear reminders (in pa-
tient charts and in mailings to patients) to mammog-
raphy reminders at three urban HMO practice sites.
The results support intervention strategies that pro-
mote multiple screening tests, the authors concluded,
because the Pap smear and mammography reminders
had a procedure-specific effect and increased the
screening rates of both tests. Intervention strategies
should build on the existing knowledge base, particu-
larly with respect to organizational strategies designed
to enable provider behavior and to increase access. To
be sure, however, research will need to determine
whether, as the number of screening test recommen-
dations increases, the effectiveness of interventions to
promote them decreases, given the cumulative time
and action required of both providers and patients.
168
Greater emphasis on practice settings and organizations in
which the majority of individuals receive care
Health insurance plans can be a major catalyst of
quality improvement efforts, given their important re-
lationships with other key players, including provid-
ers, members, and purchasers/employers. Plans play
an important role in improving screening through
benefit design, practice guideline development and
dissemination, provider contracting and payment pol-
icies, and member education and outreach. Much of
the cancer control research conducted in health plans
has been done in staff and group model HMOs be-
cause of their captive patient and provider popula-
tions and the relative ease of access to administrative
and medical records data.
44,169–173
The majority of
Americans, however, are covered by other types of
insurance, particularly indemnity plans, some of
which have managed care components. These insur-
ance types are more difficult to involve in cancer con-
trol research because of small practice sizes, low num-
bers of patients with a particular insurer within each
practice, and nonuniform record-keeping systems. All
these aspects make it difficult to capture provider and
patient populations, to make assessments, and to im-
plement changes. Nevertheless, because such plans
are a major part of the U.S. health care delivery sys-
tem, research in these settings is essential to the uni-
form improvement of preventive care. Other settings
that have received inadequate research attention are
highlighted below.
Despite the difficulties, the next generation of
cancer screening intervention research should include
studies in the real-world settings in which most Amer-
icans receive their health care. Substantial formative
and feasibility work will be required to overcome the
enormous challenges to research and to develop tai-
lored strategies that will be most effective in a given
setting. Greater monetary and manpower resources
certainly will be involved.
Expanded focus and intervention modifications to reduce
disparities
In addition to further work needed in diverse health
plans, more research in practice settings that serve the
poor and underserved is a high priority. Reducing
disparities both in health outcomes and in health ser-
vices delivery is a continuing challenge in the U.S.
Researchers have tackled this important issue and nu-
merous studies have targeted minority and under-
served populations,
174,175
but disparities in the use of
cancer screening persist.
29
Many practices and orga
-
nizations that care for predominantly minority and
other underserved populations are relatively small
and pose organizational challenges to conducting re-
search on effectiveness. CHCs, which have a deep
history of commitment to providing care to vulnerable
populations, are a notable example.
176,177
Research
using randomized designs may be very difficult and
costly in these settings because researchers and pro-
viders are challenged by small sample sizes, weak
infrastructure, and multiethnic populations. Support
for alternative research designs, such as descriptive
and quasiexperimental research designs, is essential.
Eliminating disparities will require adaptation of ex-
isting organizational strategies and development of
Health Care Settings Interventions/Zapka and Lemon 1179
Page 15
new strategies targeted at patients. Interventions and
research based in the health care setting should ex-
pand to involve community organizations and leaders
to maximize credibility and, ultimately, health out-
comes (see the report in this issue by Glasgow et al.
172
on disseminating effective cancer screening interven-
tions).
Promotion of informed and shared decision-making models
Recent commentaries have called for a shift toward
promoting informed and shared decision-making
among patients.
25,178–180
Patient participation in deci
-
sion-making is particularly important for situations in
which scientific evidence is inconclusive and guide-
lines reflect a lack of consensus. Promotion of in-
formed decision-making well may prompt patient as-
sertiveness in requesting needed services, including
prevention services.
181
This important process within
the delivery system is discussed in the article in this
issue by Rimer et al.
26
on informed decision making.
Effective uses of information technology
A continually increasing proportion of Americans has
access to personal computers, including access to the
Internet and E-mail. Recent studies report that many
patients, particularly those with higher education and
income levels, rely on the Internet as a source of
health care information.
182,183
Although the Internet
must be tested concerning its reach to diverse popu-
lations, this medium is a potential delivery method for
patient education interventions to increase cancer
screening.
184
Systems that remind patients about screening
tests have generally been effective, as summarized in
Lesson 2 of this article. Individuals who use e-mail are
willing to receive electronic mail reminders.
185
This
method should be tested and compared with mail and
telephone reminders in terms of effectiveness and
cost-effectiveness.
Emerging technologies and their adoption into practice
New screening technologies undoubtedly will emerge,
and predictions regarding their diffusion and adop-
tion by organizations, providers, and the public can be
informed by previous experience as well as by adopt-
ing the principles of Diffusion of Innovation The-
ory.
186
Clearly, initial research will focus on the test
characteristics (sensitivity and specificity among aver-
age-risk patients as well as cost and safety). The dif-
fusion processes of new technologies into routine clin-
ical practice will reflect several attributes (see Fig. 1),
including complexity (the degree to which a new test is
perceived as difficult to integrate within the practice),
compatibility (consistency with existing values, needs
of patients and providers, and the ongoing structure of
the organization),
187
and their relative advantage (the
degree to which they are perceived as “better” than
others).
187,188
Review of the state of the science with respect to
emerging technologies is beyond the scope of this re-
port. Several new technologies are on the horizon for
breast cancer, cervical cancer, and CRC screening. These
include HPV DNA testing,
189
a vaccine that reduces the
incidence of HPV-16 infection,
190
full-field digital mam
-
mography that captures the X-ray image digitally, com-
puter-aided detection,
191
virtual colonoscopy,
192
and
stool-based molecular screening.
193,194
The attributes of
each test and forces within the health care system will
inform research priorities regarding these new methods.
Research Phase
Greenwald et al.
195
outlined important phases of the
research process, from basic biomedical research to
nationwide prevention and health services programs.
More recently, Hiatt and Rimer
196
emphasized the
need to conceptualize cancer control research as a
synthesis of fundamental research, intervention re-
search, surveillance research, and application of pro-
gram delivery, including cost-effectiveness. In moving
innovations successfully through research phases, one
of the greatest challenges is faced after efficacy has
been established, when studies in defined populations
are conducted to determine the potential benefits for
eventual application in large populations. Rigorous
studies, performed in real-world settings to establish
effectiveness, are enormously challenging. This phase
of research is pivotal to the ultimate adoption and
diffusion of successful preventive health services pro-
grams in practice for two reasons (see the article in
this issue by Glasgow et al.
172
on disseminating effec
-
tive cancer screening interventions). First, the studies
demonstrate that innovative strategies can be per-
formed under actual practice conditions, not just in
well controlled settings with highly trained research
staff. Second, the studies potentially illuminate the
processes of implementation (successful and unsuc-
cessful) that realistically can inform future adoption.
Important process dimension concerns are 1) why
variation may have occurred in dose or fidelity of
intervention implementation, 2) which components of
an intervention were or were not implemented, and 3)
which contextual factors aided or detracted from the
potential impact.
Studies of Health Services Delivery Trends and their
Correlation with Screening
The development and refinement of future cancer
screening interventions must consider the context of
1180 CANCER Supplement September 1, 2004 / Volume 101 / Number 5
Page 16
evolving trends in health care delivery. Important de-
velopments in U.S. health care delivery systems re-
quire vigilant attention to potential areas for research
and natural experiments. For example, concern re-
garding the cost of health insurance and entitlements
remains strong. Decreased funding for the under-
served (“a safety net with bigger holes”
197
) already is
evident. Employers’ concerns regarding health care
spending remain high.
198
Various proposals to address
an increasingly strained system continue to evolve.
For example, the fear already is being voiced that
trends toward increased cost-sharing by patients may
affect preventive services. Solanki et al.,
96
in 52 differ
-
ent health plans, modeled the effects of 2 forms of
cost-sharing (copayments and coinsurance/deduct-
ibles) on clinical preventive services, including Pap
smear and mammography utilization. Both forms of
cost-sharing had negative and significant, direct ef-
fects on screening utilization.
Some of these concerns may be moderated by
continued emphasis on requirements for benchmarks
and standards, such as those of HEDIS and the Na-
tional Committee on Quality Assurances; however,
this result remains to be seen. The costs of this mon-
itoring are not inconsequential. Clearly, insurance
products in the U.S. continue to reinvent themselves.
Changing typologies of health plans
199,200
present a
challenge to tracking the performance of plans’
screening benefits.
Methods and Measurement
Study designs must consider new threats that may
influence methodologic integrity and make compari-
sons across studies difficult (see the report by Vernon
et al.
173
in this issue on methodologic lessons learned
from cancer screening research). Examples of several
threats specific to the health care setting are presented
briefly below.
Changing typologies of health plans, as discussed
earlier, make it exceedingly difficult to assess the im-
pact over time of health plan and insurance changes
on screening behavior. Operational definitions of plan
categories and important plan characteristics will
need to be specified.
201,202
It is interesting to note that
changes in insurance coverage and increased financial
barriers may encourage deception by providers,
203
thus posing a threat to reliability and validity of per-
formance studies. For example, if screening becomes
subject to more copayments on the basis of a personal
risk profile, then physicians, in turn, may be subject to
more pressures from patients and may become more
willing to sanction deception regarding eligibility. So
long as screening benefits require judgments about
level-of-risk categories, clinicians will be challenged
by patients regarding tests the patients view as neces-
sary.
The recently implemented Health Insurance Port-
ability and Accountability Act regulations will have a
substantial impact on all research conducted on pa-
tient populations. These regulations dictate how sub-
ject recruitment is conducted and may affect both the
internal and external validity of studies significant-
ly.
204
In particular, recruiting patients to studies will
become an increasing challenge as access to contact
information for potentially eligible patients becomes
more difficult and as informed consent procedures
become more complex. The likely result will be re-
duced response rates, which should prompt research-
ers to pursue ways of overcoming this difficulty.
Because of the expanded focus on eliminating
health disparities, researchers need to be cognizant of
the limitations of data from organizations that serve
minority populations.
205
The variety of strategies used
to collect data concerning race and ethnicity across
registries, plans, and practice sites; misclassification;
and considerable missing data all contribute to unre-
liable data.
206,207
Complex, new classification ap
-
proaches to multiple-race assessment in the U.S. Cen-
sus will put further pressure on health services and
public health researchers to develop consistent and
useful approaches to classifications of race and eth-
nicity.
208
Increasing concern about the confounding of
race and ethnicity findings with respect to education
and income will require careful attention to the use of
standardized, valid measures of several sociodemo-
graphic variables.
209
CONCLUSIONS
The evidence concerning interventions within health
care settings is impressive and complex. The literature
has validated the importance of emphasizing the eco-
logic perspective and focusing on multiple factors re-
lated to target groups and levels of influence. Much
has been learned regarding the multiple levels of in-
fluence on provider and patient behavior—influences
that can either hinder or enable screening participa-
tion. Much also has been learned about the “model
principles” that drive successful interventions. Con-
tinued inquiry will enhance further the potential of
screening technology to reduce cancer morbidity and
mortality.
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  • Source
    • "The passive approach depends on public awareness the potential participant is made aware of (that screening is available) and approaches the screening center on their own volition or upon the recommendation of their physician; in this case, recruitment is enhanced by media coverage, as well as by advertisement [8]. Two active recruitment methods include mailing a letter of invitation to the subject or a phone call from a trained staff member [9,10]. It has been shown that the mailed invitation approach is less expensive than direct active recruitment (telephone call), however it may be less effective [11,12] and may not be cost-effective in terms of the actual number of subjects recruited successfully. "
    [Show abstract] [Hide abstract] ABSTRACT: The effectiveness of a genetics-based public health screening programs depend on the successful recruitment of subjects who qualify for intensified screening by virtue of a positive genetic test. Herein we compare the effectiveness of a mailed invitation and follow-up phone call for non-responding subjects and an initial invitation by telephone addressed to male BRCA1 mutation carriers for prostate screening. The final participation rate was 75% (42 of 56) for men who were initially contacted by mail (and follow-up phone call) and 81% (30 of 37) for men who were initially contacted by telephone. Among the men who were initially contacted by mail, it was necessary to telephone 54% of these patients (30 of 56). After a calculation of the cost-effectiveness related to these results, we conclude that if the costs of the phone call were to exceed the costs of the letter by 2.5 times or more, then savings would be arranged by initiating contact with a mailed invitation.
    Full-text · Article · Dec 2013 · Hereditary Cancer in Clinical Practice
  • Source
    • "In some countries, shared decision-making can take place in a primary care consultation before screening (Miles A. et al, 2004; Zapka and Lemon, 2004; Price et al, 2010; Zapka et al, 2011), but in the UK, which has an organised programme of cancer screening (NHS, 2012), information is mailed out with screening invitations, and the decision about whether to participate must be made by the individual. Although there is some variation between the breast, cervical and bowel screening programmes, and between the nations of the UK, in general the programmes encourage people to use the information provided to weigh up the pros and cons of screening. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals' own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening. Methods: In face-to-face interviews, a population-based sample of adults across Britain (n=1964; age 50–80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks. Results: Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation. Conclusion: Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An ‘expert' view may be an important part of autonomous health decision-making.
    Full-text · Article · Nov 2012 · British Journal of Cancer
  • Source
    • "Despite numerous patient and provider barriers to CRCS, the most influential factor determining adherence to the CRCS guidelines is provider recommendation [17] [18] [19] [20] [21] [22]. Yet, due to those barriers, providers often miss CRCS opportunities for their patients [23] [24]. Combining multiple provider-directed with officesystem-directed interventions in the primary care setting shows the most potential to increase CRCS rates [15] [25] [26] [27]. "
    Full-text · Article · Jan 2012 · Journal of Cancer Therapy
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