A clinic-based mammography intervention targeting inner-city women

A Clinic-Based Mammography Intervention Targeting Inner-City Women Victoria Taylor, MD, MPH, Befi 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 Bassett, RN, Harold I. Goldberg, MD

OBJECT/VE: The objective was to evaluate the effect of a cl inic-based intervent ion program on mammography use by inner-cl ty women .

DESIGN: A randomized controlled trial employing firm sys- tern methodology was conducted.

SETTING: The s tudy se t t ing was a general internal medic ine cl inic in the university-aff i l iated county hospital serving metropol i tan Seatt le .

PARTICIPANTS: Women aged 50 to 74 years wi th at least one routine cl inic appo intment (when t h e y were due for mare- mography) during the s tudy period were enrolled in the trial (n = 314).

INTERVENTIONS: The intervent ion program emphasized nursing invo lvement and included phys ic ian education, provider prompts, use of audiovisual and printed patient educat ion materials, transportation ass i s tance in the form of bus passes, preappointment te lephone or postcard reminders, and rescheduling ass is tance . Control firm women received usual care.

MEASLrREMENTS AND MA/N RESULTS: Mammography complet ion wi th in 8 w e e k s of cl inic v is i t s was s ignif icantly

higher among intervent ion (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potent ia l confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% conf idence interval 1.9, 6.5). The intervent ion effect was modif ied by type of insurance coverage as wel l as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screenln~ participation.

CONCLUSIONS: A cllnic-based program incorporating physician education, provider prompts, pat ient educat ion materials, and appointment reminders and emphas iz ing nursing involvement can facilitate adherence to breast cancer screening guidel ines among inner-city women.

Received from the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Wash. (VT, BT, YY, JM, SL); Department of Health Services (VT, BT, DL), De- partment o f Medicine (DL, KMJ, MM, GB, HIG), and Department of Epiderniology (KMJ), University of Washington, Seattle, Wash.; and Battelle Research Institute, Seattle, Wash. (DM).

Address correspondence and reprint requests to Dr. Taylor: Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center (MP-702), 1100 Fairview Ave. IV, Seattle, WA 98109.

104

K E Y WORDS: mammography; clinic-based intervention; inner- c i ty women. J GEN INTERN MED 1999;14:104-111 .

B reast cancer is the most common form of mal ignancy

among women, and only lung cancer causes more

deaths. ~ In 1992 data showed tha t 12% of all American

women will be diagnosed with breas t cancer dur ing their

lifetime, and nearly 4% will die from the disease, a Al-

though there is no proven method for the primary preven-

t ion of breas t cancer, it has been clearly demonstra ted

that mammographic screening reduces mortality among

women aged 50 years and older.~.2 As a resul t the Na- tional Cancer Inst i tute has issued cancer control objec-

tives for the year 2000, which include the provision of reg-

u la r mammography to at least 60% of older women. 3

Adherence to breas t cancer screening guidelines has r isen steadily over the last decade; however, low-income,

minority, and inner-city women consistent ly demonstra te

utilization rates that are well below those of the general

population. L3-8 Whi tman et al. reported, for example, that

only 14% of age-eligible women a t tending three inner-ci ty

Chicago clinics had been mammographical ly screened in the previous year. 8 Similarly, Bastard et al. found that only

21% of women aged 50 years a nd older who received

care a t medical facilities operated by the Los Angeles

Depar tment of Health Services were receiving rout ine lTlainiilogralTis. 5

Among women who have not had a recent mammo-

gram, the reasons most often cited are not knowing it is necessary and lack of physician recommendation. 7 At

least 80% of older women, including those from hard-to- reach groups, however, regularly visit a physician. 9.~~

Therefore, the greatest potenUal for increasing mammography compliance may lie with intervent ions that take ad-

vantage of contacts with the heal th care system to edu-

cate and motivate patients. The National Coordinating Committee on Clinical Preventive Services has provided a

framework for the successful implementaUon of screening

maneuvers in primary care settings. This group proposed

that a clinical envi ronment tha t facilitates and supports

screening activities requires use of pat ient t racking and

provider reminder systems, the availability of health edu-

cation materials to foster pat ient knowledge and interest,

and formalization of nu r s i ng involvement.Zz We developed

a multifaceted mammography intervention, based on these principles, and implemented the program in a n inner-ci ty

primary care clinic. In this article we present the results

of a randomized trial, us ing firm system methodology, to

JGIM Volume 14, February 1999 105

evaluate the impac t of our in tervent ion p rogram on mam-

mography complet ion rates.12.~3

METHODS

Study Sett ing

Our s tudy set t ing was Harborview Medical Center, a county-owned hospi ta l delivering comprehensive medical services to res idents of inner-c i ty metropol i tan Seattle. A low-income al lowance is in effect a t the hospi ta l whereby pat ients wi thout i n su rance coverage are charged for services on a sl iding scale depending on their abil i ty to pay; this al lowance sys tem is appl ied to charges for mammog-

raphy. The hospi ta l also accepts the Medicare a s s ignment rate as payment in full. Washington State manda te s coverage of mammographic screening by commercial insurers

and extends m a m m o g r a p h y benefi ts to Medicaid recipi- ents. Harborview Medical Center 's insti tutional guidelines

for m a m m o g r a p h y spec i fy tha t women in their fifties should be screened annual ly , and women aged 60 through 74 years should be screened every 2 years .

The intervent ion p rogram was implemented and evaluated in the hospi ta l ' s Adul t Medicine Clinic, which pro- r ides ambula to ry care to pa t ien ts aged 18 yea r s and older. It is staffed by genera l internis ts , in ternal medicine

residents, and mid-level prac t i t ioners (Table 1}. The majority of visits are for rout ine medical management . Acutely ill pa t ients are usua l ly seen in a sepa ra te u rgen t care clinic or the hospi ta l ' s emergency depar tment . Because Harborview Medical Center opera tes o ther clinics specifically for immigran ts and refugees, few of the Adul t Medi- cine Clinic pa t ien ts a re non-Engl i sh speakers .

All University of Wash ing ton hospi ta ls , inc luding Harborview Medical Center, par t ic ipate in a d i s t r ibu ted computer ne twork with a centra l da t a repository. This da-

tabase p roduces pa t i en t profile repor ts (which include ba- sic demographic information, pr incipal diagnoses, and current medicat ions) tha t are a t t ached to medical cha r t s

a t the t ime of each pa t ien t visit. As pa r t of th is project, a prevent ion registry component of the repor t was opera- tionalized. Specifically, the date of each pa t ien t ' s l a s t m a m m o g r a m (or a s t a t emen t indica t ing the hospi ta l had no record of m a m m o g r a p h y completion) au tomat ica l ly ap-

pea r s on the report . The hospi ta l ' s compute r sys tem is also used to ma in ta in and upda t e clinic appo in tmen t

schedules . Finally, i t enables the hospi ta l ' s radiology de- p a r t m e n t to keep up- to -da te records of pa t ien ts ' mammography s ta tus .

Study Des ign

Our s tudy protocol was approved by the Universi ty of Wash ing ton Ins t i tu t ional Review Board. ~4 An overview of

the s tudy design is provided in Figure 1. We conducted a randomized controlled tr ial us ing firm sys tem methodology. This approach has been successful ly appl ied to clini-

cal, educat ional , and hea l th services r e sea rch in a variety of sett ings. 12,1a,ls-17 Randomized tr ials b a s e d on the firm sys tem utilize ongoing randomiza t ion of all new pa t ien ts and providers to equivalent group prac t ices or firms. Ran- domized tr ials can then be conduc ted by mak ing an ex- per lmenta l change in some firms while ma in ta in ing u s u a l care in other firms. The effect of any change is evaluated

by compar ison between intervent ion and control firm pa- t ients, la A detai led descr ip t ion of firm sys tem methods has previously been provided by C e b u l ) 2

Since 1987 the Adul t Medicine Clinic a t Harborvtew Medical Center has opera ted as three firms. Specifically, pa t i en t s are randomized to one of three f irms at the t ime of thei r first clinic visit, In addit ion, all providers are randomized to one of the f irms before they s t a r t providing pa- t ient care in the Adult Medicine Clinic (blocking is u sed to ensure each firm has a s imilar n u m b e r of interns, second- yea r res idents , th i rd-year res idents , a n d a t t end ing physi - cians). Therefore, there should be no differences in the types of pa t ien ts or types of care provided across firms.

Table I. Provider Characteristics at Baseline*

Intervention Intervention Firm A~ Intervention Firm B~ Firms A and B

Characteristic (n = 19) (n = 15) Combined (n = 34) Control Firmw

(n = 15)

Age (mean), years 33 33 33 34 Male, n (%) 8 {42) 9 (60) 17 (50) 9 (60) Level of training, n (%)

Attending physician 8 (42) 7 (47) 15 (44) 6 (40) Resident 10 (53) 7 (47) 17 (50} 8 (53) Mid-level 1 (5) 1 {7) 1 (6) 1 (7)

Weekly clinic sessions (mean), n 1.4 1.0 1.2 1.1

*Racial characteristics of providers were not collected. No statistically signt.ficant differences occurred acrossfirms. tall intervention flrm A providers completed the survey. I~wo interventlon.firm B providers did not complete the survey. ~One control f irm provider did not complete the survey.

106 Taylor et at., Mammography Intervention JGIM

Elig~il i ty Criteria �9 Previously assigned to an Adult Medicine

Clinic firm" '~ Aged 50-74 years

Index Clinic Visit �9 A p p e a ~ on weekly computerized

a l ~ i n t m e a t schedule �9 Completed scheduled appointment b * Computer indicated non-compliance with

institutional screening guidelines * �9 Not previously entered into the study

Previously assigned to [ Intervention Firm A or

Intervent on Firm B

Previously assigned to ] Control Firm

r r

te entionpro rao i [ ]

Outcome Assessment �9 Completion of mammography within

eight weeks of the ndex clinic vie t

' See text for a detailed description of the firm system ) Did not subsequently cancel their appointment and were not "no shows" r Women aged 50-59 should be mammographically screened annually and women aged 60-74

should be screened every two years

FIGURE 1. Overview of study design.

Patients are routinely seen by a provider with the same

firm ass ignment 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

In-ms to maximize the n u m b e r of women who could poten-

tially benefit from the mammography program.) The con-

trol firm was selected by lottery.

We compared the basel ine characteristics of pat ients

and providers assigned to the three firms. Computerized

hospital records demonstra ted that there were no signifi-

cant differences between the intervent ion and control firms with respect to the previous mammography experi-

ence of age-eligible women who were active pat ients of the

Adult Medicine Clinic (Harborview Medical Center defines pat ients as active ff they have been seen in the previous

18 months). A basel ine survey of health care providers (response rate 94%) showed that provider characteristics

were similar (Table 1).

Women were enrolled in the s tudy over a 15-month

period (September 1995 through November 1996). To be

eligible for the study, women had to be established pa- t ients of an Adult Medicine Clinic firm (i.e., we did not en-

ter women who were visiting the clinic for the first tame),

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 visit (defined as the first t ime their

n a m e appeared on the clinic appoin tment schedules tha t

were computer-generated at the beginning of each week,

they completed their scheduled appointment , and the

computer system indicated that they were out of compli-

ance with the hospital 's screening mammography guide-

fines). Thus, eligibility for the trial was established in an

identical m a n n e r for intervent ion and control firm pa-

tients. Intervention firm patients received the mammography program, and control firm patients received usua l

care. Consistent with an evaluation approach previously used by Burack et al., our outcome of interest was m a m - mography complet ion within 8 weeks of an index clinic visit. 7

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

mamrnogram 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 ter-

minal (e.g., end-stage lung cancer} {Fig. 2}. These women,

however, were included in our outcome ~ evaluation analy-

ses 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 pro-

gram in the intervention arm to b ias results. 18

lnteNention Program

Our intervention program included physician educa-

tion as well as multiple clinic-based and patient follow-up

components that have previously shown promise when evaluated individually. 19-28 Prior to the implementat ion of

interventions targeting women, we conducted an "aca-

demic detailing" education program for intervention firm

PROVIDER PROMPT NO NURSING I GENERATED t, I=N 47RVENTION I I,N._=232

NURSING INTERVENTION N=149 Comnonents' n Video 26 Pamphlet 97 Bus token 6

Mammography appointment N=IO0

I Reminder" n

l Ye# 75 NO 11 Not indicated 14

Canceled appointment N=27 Rescbedulin~ * n IYes No Not indicated I 1

--.., Ineligible N=36 Reason ) R In compliance 19 Had appointment 9 Language 2 Medical 6

No i~ammography I appomtment N=49

Did not cancel appointment I N=73

' Indicates the number of women who saw the video, were given a pamphlet, and were provided with a bus token.

b Indicates the number of women who were ineligible for the intervention program because they self- being in compliance with screening guidelines, already had a mammogrephy appointment

uled, were non-English speakers, and had acute or terminal medical problems at the time of their index visit. Indicates the number of women who did and did not receive a telephone or postcard reminder as well as the number for whom a reminder was not indicated (because their mammography al[;pointment was less than one week after their clinic appointment). Sixty-five women received a telephone reminder; the remaining I0 received a reminder postcard.

�9 Indicates the number of women who did and did not receive a rescheduling contact as well as the anmbet for whom a contact was not indicated (because they rescheduled at the time they canceled their initial mammography appointment).

FIGURE 2. Summary of process evaluation results.

]GIM Volume14, Februanj1999 107

providers. 19 A chief resident in internal medicine met indi-

vidually 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 be-

fore 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 imple-

mented by this research nurse when she was available, and by the regular clinic nurs ing personnel at other times.

(The regular clinic nurses were trained by the project nurse

prior to intervention implementation.) All follow-up inter-

vention activities were implemented by the research nurse.

As described above, our intervention program included a computer-generated provider mamrnography prompt

that routinely appeared on intervent ion firm pat ient pro-

file reports (for those women never screened at the hospital or out of compliance with ins t i tu t ional guidelines for

interval screening). A separate nu r s ing prompt form (that

included a brief series of process evaluation questions)

was also at tached to the front of pat ient charts. If pat ients

agreed to a mammogram appointment , the nurse high- lighted the pat ient profile prompt and at tached a com-

pleted radiology depar tment mammography request form

for physician signature, Whenever possible, mammogram

appointments were scheduled before women left the clinic.

When discussing nmmmography, nurses invited women

to watch a motivational video, provided an informational

pamphlet, and offered t ranspor ta t ion ass is tance (in the

form of bus passes) to facilitate completion of scheduled

screening appointments . Our video, which was developed

for the project u s ing qualitative data Fmdings, follows a

woman through her first mammogram and emphasizes

role modeling. 27 It uses a "talk show" format with three

women panel is ts giving their reasons for not having mam-

mography, and members of the audience providing testi- monials addressing each barrier; a female physician pan- elist also participates in a short discussion about breast

cancer screening. Barriers addressed in the video include concerns about embar ra s smen t and pain in association

with mammography, perceptions tha t mammograms can

cause cancer, beliefs about the necessity of mammography for women without a family history of breas t cancer,

and lack of physician recommendat ion for breas t cancer

screening. The pamphle t addresses key facts us ing a

ques t ion-and-answer format (e.g., "Do I need a mammo-

gram? Yes, research shows tha t all women over 50 clearly benefit from regular mammograms.").

Those women who scheduled a mammogram appoint-

ment more t h a n a week after their index clinic visit re-

ceived a telephone or postcard reminder (depending on

whether or not they could easily be reached by telephone).

In addition, the radiology depar tment computerized data-

base was systematically accessed to check whether each

woman at tended her scheduled mammogram appoin tment

and, ff not, whether she had rescheduled the appointment

herself. Those pat ients who had neither at tended 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, heal th insur-

ance 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 bes t estimate of whether women had

or had not previously been screened.) Similarly, the com-

puterized system was accessed to determine ff women did or did not complete mammography within 8 weeks of their visit to the Adult Medicine Clinic.

We used the • test and, when necessary, Fisher 's

Exact Test to compare the characteristics (i.e., age, race,

insu rance coverage, and previous mammography experience) of intervention and control fLrm pat ients as weU as

the proportions of intervention and control women who

received marnmography within 8 weeks of their index

clinic visit. 2s Uncondit ional logistic regression techniques

were used to examine the intervent ion effect after adjust-

ing for demographic covariates (i.e., ma in effects model).

To assess any differential intervent ion effect among subgroups (e.g., by race), an interact ion term for s tudy a rm

(intervention vs control) and the relevant demographic co-

variate was added to the ma in effects model and tested. 29 We also compared the intervention effects among women

who received the clinic-based intervent ions from the

project nu r se and those who received intervent ions from

regular clinic nu r s i ng personnel .

During February 1996, a low-intensity, direct marl

~ te rven t ton (invitational letter) targeting intervent ion firm

(but no t control firm} women who were out of compliance

with insti tutional screening mammography guidelines was

initiated. Women were identified for the direct marl ihter- vention at 6-month intervals, based on month of birth. Because the letters could have reinforced the clinic-based

mammography program, we also examined the propor- t ions 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 marling before, or within 8 weeks of their index clinic visit.

Finally, a process evaluat ion was conducted to assess

the delivery of the intervent ion program components . This

involved recording, for each intervent ion woman, whether

the program was init iated as well as which intervention

components were actually provided (e.g., provider educa-

tion, pamphlet, bu s pass, and appoin tment reminder).

RESULTS

Study Group Characteristics

During the 15-month s tudy period, 314 women were

emered into the randomized trial: 129 from intervention

108 Taylor et al_, Manunography Intervention JGIM

f inn A, 103 from intervention firm B, and 82 from the con-

trol firm (Table 2). TWo thirds (66%) of the women were in their fkfLies (as would be expected because of the differential inst i tut ional screening mammography guidelines for

the 50-59 and 60-74 age groups). The majority of s tudy part icipants were either African American (39%) or white

{42%). The remainder were Asian, Native American, or of

mixed race. Ninety percent of the s tudy group had com-

mercial insu rance (24%), Medicaid (31%), or Medicare

(35%) coverage. Less t h a n one half (46%) of the s tudy

part icipants had previously been mammographically

screened at the hospital. The age distr ibutions 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, bu t more Asians and Native Americans were in the intervention

firms than the control funn. Twice the n u m b e r of interven-

tion firm compared to control firm women had commercial

insurance. Fewer had Medicare or Medicaid.

O u t c o m e E v a l u a t i o n

As presented in Table 3, nearly one half of the inter-

vention firm women (49%) completed mammography within

eight weeks of their index clinic visit, compared with 22%

of the control fn-m women (p < .00 I). A statistically signif-

icant 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 <

.01). Bivariate comparisons of mammography completion

rates among subgroups of women indicated that our in-

tervention effect was significant for the 50-59 and 60-74 age groups, African-American and white women, pat ients with Medicare coverage, and the u n i n s u r e d (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 ad jus tment for age, race, insurance coverage, and previous mammog-

raphy, intervention firm women had more t han three

t imes higher odds of part icipating in screening within 8

weeks of their index clinic visit t h a n control firm women

(odds ratio 3.5; 95% confidence interval 1.9, 6.5). Insur- ance coverage modified the intervent ion effect (p < .01);

women with Medicare coverage or no insurance demon-

strated greater effects t h a n those with commercial insur -

ance or Medicaid. Previous mammography at Harborview

Medical Center also enhanced the intervent ion effect (p =

.07). Our logistic regression analyses showed no signifi-

can t differential intervention effect by age group or race

(i.e., interact ion terms for those demographic variables

were not significant).

Fifty-eight percent of the intervent ion firm women

saw the project nu r se (as opposed to one of the regular

clinic nurses). The intervent ion effect was similar among

women who received intervent ion program components

from the project nu r se (47% completed mammography

within 8 weeks) and pat ients seen by a regular clinic

nurse (51% completed mammography). Our results indi-

cate that the direct mail intervent ion 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

Characteristic

Intervention Intervention Intervention Firms A and B Control

Firm A Firm B Combined Firm (n = 129), (n = I03), (n = 232), (n = 82),

n (%) n (%) n (%) n (%)

All Women (n = 314),

n (%)

Age 50-59 years 86 (67) 62 (60) 60-74 years 43 (33) 41 (40)

Race*t African American 55 (43) 33 (32) White 49 (38) 44 (43) Othert 25 (19) 26 (25)

Insurance*t Commercial 36 (28) 28 (27) Medicaid 36 (28) 33 {32) Medicare 44 (34) 35 (34) None 13 {10) 6 (6)

Previous mammography t Yes 63 (49) 38 (37) No 66 (51) 65 (63)

148 (64) 58 (71) 84 (36) 24 (29}

88 (38) 35 (43) 93 {40) 40 (49) 51 (22) 7 (9)

206 {66} 108 (34)

123 (39) 133 (42)

58 (18)

64 (28) 10 (12) 74 (24) 69 (30) 29 (36) 98 (31) 79 {34) 32 (39) i 11 (35) 19 (8) 11 (14) 30 (10)

101 (44) 44 (54) 131 (56) 38 (46)

145 (46) 169 (54)

*Significant difference for intervention f irms A and B combined versus control f irm (p ~ .05). tSignificant difference for intervention f irm B versus control f i rm (p < .05). ~Asian or Native American.

]GIM Volume 14, February1999 109

Table 3. Mammography Completion Rates by Patient Characteristics

Characteristic

Completed Mammography, (@/0) Intervention Control

Firms Firm (n = 232) (n = 82)

Age 50-59 years* 52 28 60-74 years* 40 8

Race African American* 48 20 White* 43 23 Other 57 29

Insurance Commercial 53 50 Medicaid 42 34 Medicare* 46 6 None* 58 9

Previous mammography Yes* 63 23 Noi 37 21

All women* 49 22

*[email protected]~t difference for intervention firms and control firm ~ < .05). Difference for intervention firms and control firm ~ <. I 0).

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 b u t 3 (91%) of the

35 intervention firm providers participated in our aca-

demic detailing program. Figure 2 summarizes process

evaluation resul ts for the 232 intervent ion firm women

who had a provider prompt generated on their pat ient profile. Nurses at tempted to initiate the intervent ion pro-

gram for 185 (80%) of these patients. (Women did not receive the intervent ion when the clinic was particularly

busy, or when float nu r se s who were unfamil iar with the program staffed the clinic.} Because 36 of these women were found to be ineligible, nu r se s actually discussed mammography with 149 women; 49 of the women who received our intervent ion declined a mammography ap-

pointment. Fifteen (32%) of the 47 women with a provider

prompt on their pat ient profile, b u t no nu r s ing interven-

tion, completed screening. In comparison, 86 (58%) of the

patients who received the nu r s ing intervention had a

mammogram within 8 weeks of their index clinic visit. It is

of note tha t only 1 of the 13 intervention firm women who

received a reschednling contact (after canceling their ini-

tial mammogram appointment) participated in screening.

DISCUSSION

Burack et al. reported resul ts in 1994 from a ran-

domized trial of a program to enhance mammography

participation in five clinics serving residents of inner-ci ty

Detroit7 A "limited" intervention (physician breas t cancer control educat ion and el imination of out-of-pocket mam-

mography expenses for patients) was compared with a

~full" intervention that included all the elements of the

limited intervent ion as well as computer-generated physi- c ian prompt sheets, pat ient reminders prior to scheduled

mammography appoin tments (at two sites), and a n appo in tment rescheduling system. Compared with the lim-

ited intervention, full intervention was associated with a

significant absolute increase in mammography comple-

t ion of 18% (compared with 27% in our study). The pro-

portions of physician prompt forms re turned with their

process evaluation sections completed (indicating the pro-

r ider reminder had been acted upon) varied from 39% to

78% by project site (compared with 80% of the process evaluation forms completed by nu r se s at our one s tudy

site). Between 10% and 25% of women initially declined

mammography appoin tments (compared with 33% at our

one s tudy site). Finally, consis tent with our findings, re-

scheduling efforts did not contr ibute to enhanced mam-

mography participation.

A group of investigators in Wisconsin in 1995 evalu-

ated a breas t cancer screening intervent ion targeting so-

cially disadvantaged women. 3~ Study part ic ipants were

randomized to intervent ion or control s tatus. The inter-

vent ion consisted of a physician reminder letter followed

by a telephone call from a health educator; telephone con-

tacts included barrier-specific counsel ing as well as as-

's istance with appoin tment scheduling. Mammography

completion rates were significantly higher among the inter-

vention group after 6 months. However, it should be noted that the s tudy populat ion was uniformly non-Hispanic

white and received care through a heal th main tenance

program.

Interventions to improve delivery of screening maneuvers in the primary care setting have been variably suc-

cessful. In general, physician reminders have been most consistently effective in improving breas t cancer screen-

ing with reported increases in mammography util ization of between 5% and 20%. 23 In this project mammography completion rates among intervent ion firm women were

32% in association with physician educat ion and a provider prompt on pat ient profile reports (10% greater t h a n

for control firm women), b u t 49% when the nu r s ing inter-

vent ion was also provided. This suggests tha t the nu r s ing

components had an effect over and above tha t of the pro-

vider educat ion and physician prompt.

Recently, increased a t tent ion has been given to the

use of videotapes in heal th education, and video equip-

men t is now commonplace in hospitals and medical clin-

ics. 2~ This method of heal th educat ion is also practical be-

cause after a modest initial inves tment the ongoing costs are relatively small. 2~ A relatively small proportion (17%}

of the pat ients who received our n u r s i n g intervent ion

watched the video. Qualitative information from the nu r ses involved with the project suggests tha t the video

l l 0 Taylor et al., M ~ r a p h y Intervention ]GIM

component was disruptive to pat ient flow during busy

clinic days (the video equipment was located in a waiting room cubicle), and women were concerned about "miss-

ing" their physician appo in tment 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 pat ient instruct ion. In some clinic

settings it might be possible to bui ld video viewing time

into appoin tments and provide a separate room for health

educat ion activities.

Marcus et al. tested several clinic-based interven-

tions, including t ranspor ta t ion assistance, designed to

improve adherence to screening follow-up among Los An-

geles women with abnormal Pap smears; over one quar ter

(27%) of the women who were given bus passes reported

us ing them, and this intervent ion signlficanfly improved

pat ient compliance. ~ Few of the women in our s tudy (4%)

accepted b u s passes. Reasons for the low usage may in-

clude concerns abou t the safety of public t ranspor ta t ion

among an older pa t ient populat ion (91% of women in the Los Angeles s tudy were less t h a n 45 years old), and the

availability of valet parking for pat ients seen at Harbor-

view Medical Center. In addition, the research nu r se re-

ported that some women had their own monthly bus

passes. It is possible tha t r e imbursement for taxicab fares

might be a more effective form of t ranspor ta t ion assis-

tance for women aged 50 years and over. There is relatively little information on the variation

in effectiveness of clinic-based mammography interven-

t ions across pat ient groups. 23 We found our program to

be effective for women in their fifties (23% absolute increase in mammography use) as well as older pat ients

(32% increase in use). It also appeared to enhance mam-

mography participation among women from diverse racial

groups. However, the intervent ion program had a differential effect, depending on type of insurance coverage.

The absolute screening increases were subs tant ia l among

pat ients with Medicare (40%) and the un in su red (50%), bu t not for those with commercial insurance (3~ and

Medicaid (8~ It is possible tha t commercially insured

women responded to the intervent ion program, bu t chose to be screened at another health care facility.

A detailed analysis of the costs and cost-effectiveness

of our intervent ion program will be the subject of a future report. However, prel iminary analyses suggest tha t the cost of delivering the program components was approxi-

mately $200 per pat ient and $700 per additional mammo-

gram completed, al In comparison, Mandelblatt et al. re-

cently reported the costs of a nu r s ing intervent ion to

provide breas t cancer screening within the context of

emergency depar tment visits; the average cost per woman exceeded $1,800. 32

Ongoing randomizat ion of pat ients to firms does not

guarantee tha t similar populat ions will result, especially

when subgroups are targeted (e.g., one age group or gen-

der). In addition, "randomization decay" can occur from differential dropout rates tha t eventually lead to noncom-

parability of long-term patients. 12 In this s tudy the n u m -

bers of women entered into the s tudy varied by firm. (The

total n u m b e r of Adult Medicine Clinic pat ients assigned to each firm reflects the pat tern seen among women entered

into our trial.) There also were significant differences be-

tween the intervention and control firms with respect to

race and insurance coverage. Such differences should not theoretically occur in a firm system and suggest tha t ran-

domization decay had occurred in the Adult Medicine

Clinic. Therefore, our s tudy design should be considered quasi-experimental.

In firm trials behavioral change can be affected by

dominan t physicians dis tr ibuted asymmetrically across

fu-msJ 2 We did not collect data on the providers seen a t

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 intervent ion 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 intervent ion effect

reported.

In contras t to Burack et al., we only evaluated our in-

tervention program in one clinic. In addition, our s tudy

design excluded new pat ients as well as women whose ap-

poin tments did no t appear on the clinic schedule at the

beginning of each week. Therefore, pat ients who routinely

schedule appoin tments at short notice were not included

in the trial. Computerized hospital records indicate that

about 500 women aged 50 to 74 years complete clinic vis-

its in any 15-month period. Therefore, we estimate that

about one third of the age-eligible women who visited the

clinic dur ing our intervention period were not entered into

the study. Women who schedule their visits at short no-

tice may be less likely to participate in mammography

programs t h a n those who do not.

Unlike previously reported clinic-based initiatives,

our mammography program was based on recent recommendat ions from the National Coordinating Committee on Clinical Preventive Services.t1 Therefore, our primary re-

search objective was to assess the overall impact of an in-

tegrated set of mammography interventions. A limitation of the s tudy design was tha t it precluded an assessment

of the individual and interactive effects of program components. Further, it is unc lea r to what extent our findings are generalizable to other heal th care facilities serving so-

cially disadvantaged populat ions. However, our large in-

tervention effect suggests tha t a clinic-based mammogra-

phy intervention that emphasizes nu r s ing involvement

and incorporates physician education, provider prompts,

health educat ion materials, and pa t ient appoin tment re-

minders can enhance adherence to breas t cancer screen-

ing guidelines by inner-ci ty women.

This work was supported by grant 62119 from the National Cancer Institute.

JGIM Volume 14, February 1999 111

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A clinic-based mammography intervention targeting inner-city women

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