A Clinic-Based Mammography intervention Targeting Inner-City Women

A Clinic-Based Mammography intervention Targeting Inner-City Women Victoria Taylor, MD, MPH, Beti Thompson, PhD, Daniel Lessler, MD, MHA, Yutaka Yasui, PhD, Daniel Montano, PhD, Kay M. Johnson, MD, Janice Mahloch, RN, Mary Mullen, BA, Sue Li, PhD, Gloria Basseft, RN, Harold 1. Goldberg, MD

OBJECTIVE: The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.

DESIGN: A randomized controlled trial employing firm system methodology was conducted.

SETTING: The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.

PARTICIPANTS: Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).

LNTERVENTIONS: The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.

MEASUREMENTS AND MALN RESULTS: Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p <c .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5: 95% confidence interval 1.9. 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.

CONCLUSIONS: A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.

Received .from the Division of Public Health Sciences. Fred Hutchinson Cuncer Research Center, Seattle. Wash. (IT, BT, fl, JM. SL): Department of Healrh Services (IT. BT, DL). De- partment ojMedicine IDL. KMJ. M M , GB, HIG). and Department of’ Epidemiology (KMJ). University of Washington, Seattle, Wash.: and Balfelle Research Institute. Seattle, Wash. (DM).

Address correspondence and reprint requests to Dr. Taylor: Cancer Prevention Research Program. Fred Hutchinson Cancer Research Center (MP-702). 1 100 Fuirview Ave. N . Seattle, WA 98 1 09. 104

KEY WORDS: mammography: clinic-based intervention: inner- city women. J GEN INTERN MED 199914:104-111.

reast cancer is the most common form of malignancy B among women, and only lung cancer causes more deaths.’ In 1992 data showed that 12% of all American women will be diagnosed with breast cancer during their lifetime, and nearly 4% will die from the disease.2 Al- though there is no proven method for the primary prevention of breast cancer, it has been clearly demonstrated that mammographic screening reduces mortality among women aged 50 years and As a result the Na- tional Cancer Institute has issued cancer control objec- tives for the year 2000, which include the provision of regular mammography to at least 60% of older women3

Adherence to breast cancer screening guidelines has risen steadily over the last decade; however, low-income, minority, and inner-city women consistently demonstrate utilization rates that are well below those of the general population. ls8 Whitman et al. reported, for example, that only 14% of age-eligible women attending three inner-city Chicago clinics had been mammographically screened in the previous year.8 Similarly, Bastani et al. found that only 21% of women aged 50 years and older who received care at medical facilities operated by the Los Angeles Department of Health Services were receiving routine mammogram^.^

Among women who have not had a recent mammogram, the reasons most often cited are not knowing it is necessary and lack of physician recornmendati~n.~ At least 80% of older women, including those from hard-to- reach groups, however, regularly visit a physician.g.’O Therefore, the greatest potential for increasing mammography compliance may lie with interventions that take ad- vantage of contacts with the health care system to edu- cate and motivate patients. The National Coordinating Committee on Clinical Preventive Services has provided a framework for the successful implementation of screening maneuvers in primary care settings. This group proposed that a clinical environment that facilitates and supports screening activities requires use of patient tracking and provider reminder systems, the availability of health education materials to foster patient knowledge and interest, and formalization of nursing involvement . I ‘ We developed a multifaceted mammography intervention, based on these principles, and implemented the program in an inner-city primary care clinic. In this article we present the results of a randomized trial, using firm system methodology, to

105 Volume 14, February 1999 JGIM

evaluate the impact of our intervention program on mammography completion rates. 12.13

METHODS

Study Setting

Our study setting was Harborview Medical Center, a county-owned hospital delivering comprehensive medical services to residents of inner-city metropolitan Seattle. A low-income allowance is in effect at the hospital whereby patients without insurance coverage are charged for services on a sliding scale depending on their ability to pay; this allowance system is applied to charges for mammography. The hospital also accepts the Medicare assignment rate as payment in full. Washington State mandates coverage of mammographic screening by commercial insurers and extends mammography benefits to Medicaid recipi- ents. Harborview Medical Center's institutional guidelines for mammography specify that women in their fifties should be screened annually, and women aged 60 through 74 years should be screened every 2 years.

The intervention program was implemented and evaluated in the hospital's Adult Medicine Clinic, which pro- vides ambulatory care to patients aged 18 years and older. It is staffed by general internists, internal medicine residents, and mid-level practitioners (Table 1). The majority of visits are for routine medical management. Acutely ill patients are usually seen in a separate urgent care clinic or the hospital's emergency department. Because Harborview Medical Center operates other clinics specifically for immigrants and refugees, few of the Adult Medi- cine Clinic patients are non-English speakers.

All University of Washington hospitals, including Harborview Medical Center, participate in a distributed computer network with a central data repository. This da- tabase produces patient profile reports (which include ba- sic demographic information, principal diagnoses, and current medications) that are attached to medical charts

at the time of each patient visit. As part of this project, a prevention registry component of the report was opera- tionalized. Specifically, the date of each patient's last mammogram (or a statement indicating the hospital had no record of mammography completion) automatically ap- pears on the report. The hospital's computer system is also used to maintain and update clinic appointment schedules. Finally, it enables the hospital's radiology department to keep up-to-date records of patients' mammography status.

Study Design

Our study protocol was approved by the University of Washington Institutional Review Board. l4 An overview of the study design is provided in Figure 1. We conducted a randomized controlled trial using firm system methodology. This approach has been successfully applied to clinical, educational, and health services research in a variety of settings. 12.13.1517 Randomized trials based on the firm system utilize ongoing randomization of all new patients and providers to equivalent group practices or firms. Ran- domized trials can then be conducted by making an experimental change in some firms while maintaining usual care in other firms. The effect of any change is evaluated by comparison between intervention and control firm patients.13 A detailed description of firm system methods has previously been provided by Cebul.I2

Since 1987 the Adult Medicine Clinic at Harborview Medical Center has operated as three firms. Specifically, patients are randomized to one of three firms at the time of their first clinic visit. In addition, all providers are randomized to one of the firms before they start providing patient care in the Adult Medicine Clinic (blocking is used to ensure each f m has a similar number of interns, second- year residents, third-year residents, and attending physicians). Therefore, there should be no differences in the types of patients or types of care provided across firms.

Table 1. Provider Characteristics at Baseline*

Characteristic ~

Age (mean), years Male, n (%) Level of training, n (Yo)

Attending physician Resident Mid-level

(mean), n Weekly clinic sessions

Intervention Intervention Firm At Intervention Firm B* Firms A and B Control Firm5

(n = 19) (n = 15) Combined (n = 34) (n = 15)

33 33 33 34 8 (421 9 (60) 17 (50) 9 (601

15 (44) 17 (50) 1 (6)

1.4 1.0 1.2 1.1

*Racial characteristics of providers were not collected. No statistically signij??ant differences occurred acrosspnns. fAll interventionJim A providers completed the survey. *Two interventionJm B providers did not complete the survey. §One controlprm provider did not complete the survey.

106 Taylor et al.. Mamniography Intervention JGW

Index Clinic Vistr Appeared on weekl) iornputerired

Completed scheduled appointmenr' Computer indicated non-compliance a i t h in\tttutional xreening putdelines Not pre\tauslv entered into the crud>

appointment schedule

,

Eligibility Cnleria Previously assigned to ail h d u k Medicine Clinic firm' Aged 50-71 years

- Intervention Firm B

Outcome Asmrment Completion of manirnoprJph) uiihin uphi weeks of the indei clinic \ b s i i

' See text for a detailed description of the firm systeni ' Did not subsequently cancel t h r j r appointment and u r r e not "no shous" ' Women aged 50-59 should be mammaeraphicall) screenrd annually and women aged 60.74

should be screened every two >ears

FIGURE 1. Overview of study design.

Patients are routinely seen by a provider with the same firm assignment as themselves a t all clinic visits. In this study, two of the firms received our intervention and one firm served as control. (We chose to have two intervention firms to maximize the number of women who could poten- tially benefit from the mammography program.) The control firm was selected by lottery.

We compared the baseline characteristics of patients and providers assigned to the three firms. Computerized hospital records demonstrated that there were no significant differences between the intervention and control firms with respect to the previous mammography experience of age-eligible women who were active patients of the Adult Medicine Clinic (Harborview Medical Center defines patients as active if they have been seen in the previous 18 months). A baseline survey of health care providers (response rate 94%) showed that provider characteristics were similar (Table 1).

Women were enrolled in the study over a 15-month period (September 1995 through November 1996). To be eligible for the study, women had to be established patients of an Adult Medicine Clinic firm (i.e.. we did not en- ter women who were visiting the clinic for the first time), and between 50 and 74 years of age. Intervention and control firm women were entered into the trial at the time of their "index" clinic \;isit (defined as the first time their name appeared on the clinic appointment schedules that were computer-generated at the beginning of each week, they completed their scheduled appointment, and the computer system indicated that they were out of compliance with the hospital's screening mammography guidelines). Thus, eligibility for the trial was established in an identical manner for intervention and control firm pa-

tients. Intervention firm patients received the mammography program, and control firm patients received usual care. Consistent with an evaluation approach previously used by Burack et al., our outcome of interest was mammography completion within 8 weeks of an index clinic visit.'

Intervention firm women who met the study entry cri- teria were not offered the mammography program (at the time of their index clinic visit) if their self-reported last mammogram date indicated compliance with institutional screening guidelines, they already had a future scheduled mammogram appointment, they could not speak English (and no interpreter was available), or they had a medical problem that was life-threatening (e.g., chest pain) or terminal (e.g., end-stage lung cancer) (Fig. 2). These women, however, were included in our outcome evaluation analyses because equivalent data were not available for control firm patients (and, by definition, the control firm included such women). As this was an intent-to-treat analysis, then, we would not expect these exclusions from the program in the intervention arm to bias results. m

Intervention Program

Our intervention program included physician education as well as multiple clinic-based and patient follow-up components that have previously shown promise when evaluated individually. lS26 Prior to the implementation of interventions targeting women, we conducted an "aca- demic detailing" education program for intervention firm

NO NURSING PROVIDER PROMPT

k 2 3 2 I I I

j$i$nentsd

+ i; 1 Pamphlet Bus taken

Mlammograph! nppommcnt N=100 Reminder'

Yot indicated 14

4 Canceled appointment

Not mdicated I I

RCZt\""* I n complidnie Had appointment Language M C d l C d 6

No mammogrephy appointment

Did not cancel appointment N=77 I

' Indicate, the number of women who s a ~ thr video. wrrr glvcn a pamphlet. and were provided with a bus token. Indicates the number of women who were mligiblc for the metvention progiam because they self- reponed being in compliance with screening guidelines, already had B mammography appomtment scheduled, were non-Enghh bprakers. and had acute or terminal medical prohlrme at the time of their index visit.

' Indicates the number of women who did and did not i r ~ r i v r d telephone 01 postcard reminder as uell as the number for whom a reminder was not mdmted (becauae their mammography appointment was less ihan one week after their clin8c appomtmcni). Sixty-fire women received a telephone reminder: the remaining I 0 recelved a reminder postcard.

' Indicates the number of women who did and did nut r e c a v e a reschedulmg contact as well as the number for whom a cmtacl was not indicated (becaur they rescheduled at the ilme they canceled their initial mammography appointment)

FIGURE 2. Summary of process evaluation results.

JGIM Volume 14, February 1999 107

providers.lg A chief resident in internal medicine met individually with each physician and discussed the effectiveness of mammography, screening guidelines, breast cancer risk factors, and women’s barriers to screening. Women were offered the clinic-based intervention components before seeing their health care provider. The project employed a project nurse who worked in the clinic 20 hours per week. Clinic-based intervention activities were implemented by this research nurse when she was available, and by the regular clinic nursing personnel at other times. (The regular clinic nurses were trained by the project nurse prior to intervention implementation.) All follow-up intervention activities were implemented by the research nurse.

As described above, our intervention program included a computer-generated provider mammography prompt that routinely appeared on intervention firm patient profile reports (for those women never screened at the hospital or out of compliance with institutional guidelines for interval screening). A separate nursing prompt form (that included a brief series of process evaluation questions) was also attached to the front of patient charts. If patients agreed to a mammogram appointment, the nurse high- lighted the patient profile prompt and attached a completed radiology department mammography request form for physician signature. Whenever possible, mammogram appointments were scheduled before women left the clinic.

When discussing mammography, nurses invited women to watch a motivational video, provided an informational pamphlet, and offered transportation assistance (in the form of bus passes) to facilitate completion of scheduled screening appointments. Our video, which was developed for the project using qualitative data findings, follows a woman through her first mammogram and emphasizes role modeling.27 It uses a “talk show” format with three women panelists giving their reasons for not having mammography, and members of the audience providing testi- monials addressing each bamer; a female physician pan- elist also participates in a short discussion about breast cancer screening. Barriers addressed in the video include concerns about embarrassment and pain in association with mammography, perceptions that mammograms can cause cancer, beliefs about the necessity of mammography for women without a family history of breast cancer, and lack of physician recommendation for breast cancer screening. The pamphlet addresses key facts using a question-and-answer format (e.g., “Do I need a mammogram? Yes, research shows that all women over 50 clearly benefit from regular mammograms.”).

Those women who scheduled a mammogram appointment more than a week after their index clinic visit received a telephone or postcard reminder (depending on whether or not they could easily be reached by telephone). In addition, the radiology department computerized data- base was systematically accessed to check whether each woman attended her scheduled mammogram appointment and, if not, whether she had rescheduled the appointment herself. Those patients who had neither attended nor re-

scheduled mammography were contacted by the project nurse and encouraged to make another appointment.

Data Collection and Analysis

We ascertained each woman’s age, race, health insurance coverage, and prior history of mammography (yes vs no) at Harborview Medical Center through linkage with the hospital’s computer network. (Prior mammography at the hospital was our best estimate of whether women had or had not previously been screened.) Similarly, the computerized system was accessed to determine if women did or did not complete mammography within 8 weeks of their visit to the Adult Medicine Clinic.

We used the x2 test and, when necessary, Fisher’s Exact Test to compare the characteristics (i.e., age, race, insurance coverage, and previous mammography experience) of intervention and control firm patients as well as the proportions of intervention and control women who received mammography within 8 weeks of their index clinic visit.28 Unconditional logistic regression techniques were used to examine the intervention effect after adjust- ing for demographic covariates (i.e., main effects model). To assess any differential intervention effect among subgroups (e.g., by race), an interaction term for study arm (intervention vs control) and the relevant demographic co- variate was added to the main effects model and tested.29 We also compared the intervention effects among women who received the clinic-based interventions from the project nurse and those who received interventions from regular clinic nursing personnel.

During February 1996, a low-intensity, direct mail intervention (invitational letter) targeting intervention firm (but not control firm) women who were out of compliance with institutional screening mammography guidelines was initiated. Women were identified for the direct mail intervention at 6-month intervals, based on month of birth. Because the letters could have reinforced the clinic-based mammography program, we also examined the proportions of intervention and control women who completed mammography within 8 weeks of their index among the subgroups of intervention firm women who did and did not receive a direct mailing before, or within 8 weeks of their index clinic visit.

Finally, a process evaluation was conducted to assess the delivery of the intervention program components. This involved recording, for each intervention woman, whether the program was initiated as well as which intervention components were actually provided (e.g., provider education, pamphlet, bus pass, and appointment reminder).

RESULTS

Study Group Characteristics

During the 15-month study period, 314 women were entered into the randomized trial: 129 from intervention

Taylor et al., Mammography lnteruention JGIM ~~

108

firm A, 103 from intervention firm B, and 82 from the control firm (Table 2). Two thirds (66Vo) of the women were in their fifties (as would be expected because of the differential institutional screening mammography guidelines for the 50-59 and 60-74 age groups). The majority of study participants were either African American (3g0/o) or white (42%). The remainder were Asian. Native American, or of mixed race. Ninety percent of the study group had commercial insurance (24%). Medicaid (31%). or Medicare (35%) coverage. Less than one half (46%) of the study participants had previously been mammographically screened at the hospital. The age distributions as well as the mammography history of intervention and control firm women were similar. Some significant differences were de- tected, however, between the intervention and control firm women. Fewer African Americans and whites, but more Asians and Native Americans were in the intervention firms than the control firm. Twice the number of intervention firm compared to control firm women had commercial insurance. Fewer had Medicare or Medicaid.

Outcome Evaluation

As presented in Table 3, nearly one half of the intervention firm women (49%) completed mammography within eight weeks of their index clinic visit, compared with 22% of the control firm women (p < .001). A statistically significant intervention effect was observed for intervention firm A (55% completed mammography) versus the control firm (p < .001) as well as for intervention firm B (41% completed mammography) versus the control firm ( p < .O 1 ) . Bivariate comparisons of mammography completion

rates among subgroups of women indicated that our intervention effect was significant for the 50-59 and 60-74 age groups, African-American and white women, patients with Medicare coverage, and the uninsured (p < .05). In addition, the intervention program was effective for women with ( p < ,001) and without (p = .06) a history of mammographic screening at the hospital.

Multivariate analyses showed that after adjustment for age, race, insurance coverage, and previous mammography, intervention firm women had more than three times higher odds of participating in screening within 8 weeks of their index clinic visit than control firm women (odds ratio 3.5; 95% confidence interval 1.9, 6.5). Insur- ance coverage modified the intervention effect (p < . O l ) ; women with Medicare coverage or no insurance demonstrated greater effects than those with commercial insurance or Medicaid. Previous mammography at Harborview Medical Center also enhanced the intervention effect (p =

.07). Our logistic regression analyses showed no significant differential intervention effect by age group or race (i.e., interaction terms for those demographic variables were not significant).

Fifty-eight percent of the intervention firm women saw the project nurse (as opposed to one of the regular clinic nurses). The intervention effect was similar among women who received intervention program components from the project nurse (47% completed mammography within 8 weeks) and patients seen by a regular clinic nurse (5 1% completed mammography). Our results indicate that the direct mail intervention had no reinforcing effect. Specifically. 47% of the women who received a mailing prior to, or within 8 weeks of their index clinic

Table 2. Characteristics of Patients Entered into the Study

Intervention

Firm A Firm B Combined Intervention Intervention Firms A and B Control

Firm All Women (n = 129), (n = 103). (n = 232), ( n = 821, (n = 314),

Characteristic n (Yo) n (%) n (%) n (Yo) n (Yo)

Age 50-59 years 86 (67) 62 (GO) 148 (64) 60-74 years 43 (33) 41 (40) 84 (36)

African American 55 (43) 33 (32) 88 (38) White 49 (38) 44 (43) 93 (40) Oiher* 25 (19) 26 (25) 51 (22)

Commercial 36 (28) 28 (27) 64 (28) Medicaid 36 (28) 33 (:32) 69 (30) Medicare 44 (34) 35 (34) 79 (34) None 13 (10) 6 (6) 19 (8)

Yes 63 (49) 38 (37) 101 (44)

Race"

Insurance';

Previous mammography'

No 66 (51) 65 (63) 131 (56)

*Sign$cant diSferencejor interventionJim A and B combined versus controlJim (p < .05). 'Signijkant dtuerence.for interventionJim B versus controlfirm (p < ,135). *Asian or Natiue Americun.

58 (71) 206 (66) 24 (29) 108 (34)

35 (43) 123 (39) 40 (49) 133 (42)

7 (9) 58 (18)

10 (12) 74 (24) 29 (36) 98 (31) 32 (39) 111 (35) 11 (14) 30 (10)

44 (54) 145 (46) 38 (46) 169 (54)

JGIM Volume 14, February 1999 109

Table 3. Mammography Completion Rates by Patient Characteristics

ComDleted MammoaraDhv. (%)

Characteristic

Intervention Control Firms Firm

(n = 82) tn = 232) ~

Age 5G59 years* 6G74 years*

African American* White* Other

Insurance Commercial Medicaid Medicare* None*

Yes* Not

Race

Previous mammography

All women*

52 40

48 43 57

53 42 46 58

63 37 49

28 8

20 23 29

50 34 6 9

23 21 22

*Sign@ant dlfference for interventionm and contro lm @ < .05). ?D$erence for interuentionjm and controljnn [p < .lo).

visit completed mammography compared with 50% of the patients who did not receive a mailing.

Process Evaluation

Our process evaluation focused on monitoring delivery of the intervention components. All but 3 (91%) of the 35 intervention firm providers participated in our aca- demic detailing program. Figure 2 summarizes process evaluation results for the 232 intervention firm women who had a provider prompt generated on their patient profile. Nurses attempted to initiate the intervention program for 185 (80%) of these patients. (Women did not receive the intervention when the clinic was particularly busy, or when float nurses who were unfamiliar with the program staffed the clinic.) Because 36 of these women were found to be ineligible, nurses actually discussed mammography with 149 women: 49 of the women who received our intervention declined a mammography appointment. Fifteen (320/0) of the 47 women with a provider prompt on their patient profile, but no nursing intervention, completed screening. In comparison, 86 (58%) of the patients who received the nursing intervention had a mammogram within 8 weeks of their index clinic visit. I t is of note that only 1 of the 13 intervention firm women who received a rescheduling contact (after canceling their initial mammogram appointment) participated in screening.

DISCUSSION

Burack et al. reported results in 1994 from a randomized trial of a program to enhance mammography

participation in five clinics serving residents of inner-city DetroiL7 A “limited” intervention [physician breast cancer control education and elimination of out-of-pocket mammography expenses for patients) was compared with a “full” intervention that included all the elements of the limited intervention as well as computer-generated physician prompt sheets, patient reminders prior to scheduled mammography appointments (at two sites), and an appointment rescheduling system. Compared with the limited intervention, full intervention was associated with a significant absolute increase in mammography completion of 18% (compared with 27% in our study). The proportions of physician prompt forms returned with their process evaluation sections completed (indicating the provider reminder had been acted upon) varied from 39% to 78% by project site (compared with 80% of the process evaluation forms completed by nurses at our one study site). Between 10% and 25% of women initially declined mammography appointments (compared with 33% at our one study site). Finally, consistent with our findings, rescheduling efforts did not contribute to enhanced mammography participation.

A group of investigators in Wisconsin in 1995 evaluated a breast cancer screening intervention targeting so- cially disadvantaged women.30 Study participants were randomized to intervention or control status. The intervention consisted of a physician reminder letter followed by a telephone call from a health educator: telephone contacts included barrier-specific counseling as well a s assistance with appointment scheduling. Mammography completion rates were significantly higher among the intervention group after 6 months. However, it should be noted that the study population was uniformly non-Hispanic white and received care through a health maintenance program.

Interventions to improve delivery of screening maneuvers in the primary care setting have been variably successful. In general, physician reminders have been most consistently effective in improving breast cancer screening with reported increases in mammography utilization of between 5% and 20%.23 In this project mammography completion rates among intervention firm women were 32% in association with physician education and a provider prompt on patient profile reports (10% greater than for control firm women), but 49% when the nursing intervention was also provided. This suggests that the nursing components had an effect over and above that of the provider education and physician prompt.

Recently, increased attention has been given to the use of videotapes in health education, and video equipment is now commonplace in hospitals and medical clinics.21 This method of health education is also practical because after a modest initial investment the ongoing costs are relatively small.20 A relatively small proportion (17%) of the patients who received our nursing intervention watched the video. Qualitative information from the nurses involved with the project suggests that the video

Taylor et al.. Mammography Intervention JGIM ~~

110 .- ~ -~

component was disruptive to patient flow during busy clinic days (the video equipment was located in a waiting room cubicle), and women were concerned about “miss- ing” their physician appointment while they were watch- ing the video. However, the research nurse also perceived that the video saved time that might otherwise have been devoted to individual patient instruction. In some clinic settings it might be possible to build video viewing time into appointments and provide a separate room for health education activities.

Marcus et al. tested several clinic-based interventions, including transportation assistance, designed to improve adherence to screening follow-up among Los An- geles women with abnormal Pap smears: over one quarter (27%) of the women who were given bus passes reported using them, and this intervention significantly improved patient ~ompliance.~“ Few of the women in our study (4%) accepted bus passes. Reasons for the low usage may include concerns about the safety of public transportation among an older patient population (91% of women in the LQS Angeles study were less than 45 years old), and the availability of valet parking for patients seen at Harbor- view Medical Center. In addition. the research nurse reported that some women had their own monthly bus passes. It is possible that reimbursement for taxicab fares might be a more effective form of transportation assistance for women aged 50 years and over.

There is relatively little information on the variation in effectiveness of clinic-based mammography interventions across patient groups.23 We found our program to be effective for women in their fifties (23% absolute increase in mammography use) as well as older patients (32% increase in use). It also appeared to enhance mammography participation among women from diverse racial groups. However. the intervention program had a differential effect, depending on type of insurance coverage. The absolute screening increases were substantial among patients with Medicare (40%) and the uninsured (50%). but not for those with commercial insurance (30/0) and Medicaid (8%). It is possible that commercially insured women responded to the intervention program, but chose to be screened at another health care facility.

A detailed analysis of the costs and cost-effectiveness of our intervention program will be the subject of a future report. However, preliminary analyses suggest that the cost of delivering the program components was approximately $200 per patient and $700 per additional mammogram completed.”’ In comparison, Mandelblatt et al. recently reported the costs of a nursing intervention to provide breast cancer screening within the context of emergency department visits: the average cost per woman exceeded $1.800.32

Ongoing randomization of patients to firms does not guarantee that similar populations will result, especially when subgroups are targeted (e.g., one age group or gender). In addition. “randomization decay“ can occur from differential dropout rates that eventually lead to noncom-

parability of long-term patients.I2 In this study the num- bers of women entered into the study varied by firm. (The total number of Adult Medicine Clinic patients assigned to each firm reflects the pattern seen among women entered into our trial.) There also were significant differences between the intervention and control firms with respect to race and insurance coverage. Such differences should not theoretically occur in a firm system and suggest that randomization decay had occurred in the Adult Medicine Clinic. Therefore, our study design should be considered quasi-experimental.

In firm trials behavioral change can be affected by dominant physicians distributed asymmetrically across firms.12 We did not collect data on the providers seen at index clinic visits. However, there are approximately 50 providers in the Adult Medicine Clinic, and the majority of physicians spend only one half-day in the clinic each week. Also, a significant intervention effect was seen in both intervention firms. As a result, we cannot rule out the possibility that one or a few physicians from each of these firms may be responsible for the intervention effect reported.

In contrast to Burack et al., we only evaluated our intervention program in one clinic. In addition, our study design excluded new patients as well as women whose appointments did not appear on the clinic schedule at the beginning of each week. Therefore, patients who routinely schedule appointments at short notice were not included in the trial. Computerized hospital records indicate that about 500 women aged 50 to 74 years complete clinic visits in any 15-month period. Therefore, we estimate that about one third of the age-eligible women who visited the clinic during our intervention period were not entered into the study. Women who schedule their visits at short notice may be less likely to participate in mammography programs than those who do not.

Unlike previously reported clinic-based initiatives, our mammography program was based on recent recom- mendations from the National Coordinating Committee on Clinical Preventive Services. * 1 Therefore, our primary research objective was to assess the overall impact of an in- tegrated set of mammography interventions. A limitation of the study design was that it precluded an assessment of the individual and interactive effects of program components. Further, it is unclear to what extent our findings are generalizable to other health care facilities serving so- cially disadvantaged populations. However, our large intervention effect suggests that a clinic-based mammography intervention that emphasizes nursing involvement and incorporates physician education, provider prompts, health education materials, and patient appointment reminders can enhance adherence to breast cancer screening guidelines by inner-city women.

~~~~~~ ~ ~

This work was supported b y grant 62 119 from the National Cancer Institute

JGIM Volume 14, February 1999 1 1 1 ~

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14. Goldberg HI, McGough H. Testing the implementation of clinic guidelines. IRB Rev Hum Subj Res. 1991;13:1-7.

15. Aucott J N , Petecanos E, Dombrowski R, Fuehrer SM, Laich J, Aron DC. Implementation of local guidelines for cost-effective management of hypertension: a trial of the firm system. J Gen In- tern Med. 1996;11:139-46.

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A Clinic-Based Mammography intervention Targeting Inner-City Women

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