The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Improving Comprehensive Medication Management (CMM) Completed Visit Rates in Newly Referred and No-Show Patient Cohorts

Background: Missed appointments are a common problem in health care. No-show rates and incomplete appointments for referred patients affect patient outcomes and clinician’s productivity, including comprehensive medication management (CMM) visits that pharmacists provide. This study aims to compare CMM completion rates between various intervention types in communicating with the patient. Methods: This was a prospective, multi-clinic study to examine newly implemented intervention effects on CMM completion rates. The primary outcomes were CMM completion rates among newly referred patients and CMM completion rates in any no-show patients, including both newly referred and returning patients. In the newly referred patient cohort, three intervention types (blocking time on the pharmacist’s schedule to speak to the patient, sending an electronic medical record or EMR-linked message, and sending a letter) were compared to a control group with no interventions. In the no-show cohort, a pharmacist call intervention was compared to a control group consisting of sending a letter. Results: Completed CMM appointment rate was six times likely with a pharmacist’s in-person reminder (odds ratio [OR] 6.0; 95% confidence interval [CI] 1.58-22.77) and with an EMR-linked message (OR 6.0; 95% CI 1.76 to 20.52) when compared to sending a letter. In no-show patients, completed CMM appointment rate was 2.36 times likely with a pharmacist’s call intervention versus sending a letter. Conclusion: Pharmacist’s direct reminder to the patient when in clinic and EMR-linked message improved CMM completion rate when compared to mailing a reminder letter. Pharmacist’s call to no-show patients for their CMM appointment was effective for the patients to reschedule and complete their CMM appointment compared to mailing a reminder letter. Article Type: Original Research

A targeted promotional DVD fails to improve Māori and Pacific participation rates in the New Zealand bowel screening pilot: results from a pseudo-randomised controlled trial

Background New Zealand’s Bowel Screening Pilot (BSP) used a mailed invitation to return a faecal immunochemical test. As a pilot it offered opportunities to test interventions for reducing ethnic inequities in colorectal cancer screening prior to nationwide programme introduction. Small media interventions (e.g. educational material and DVDs) have been used at both community and participant level to improve uptake. We tested whether a DVD originally produced to raise community awareness among the Māori population would have a positive impact on participation and reduce the proportion of incorrectly performed tests (spoiled kits) if mailed out with the usual reminder letter. Methods The study was a parallel groups pseudo-randomised controlled trial. Over 12 months, all Māori and Pacific ethnicity non-responders four weeks after being mailed the test kit were allocated on alternate weeks to be sent, or not, the DVD intervention with the usual reminder letter. The objective was to determine changes in participation and spoiled kit rates in each ethnic group, determined three months from the date the reminder letter was sent. Participants and those recording the outcomes (receipt of a spoiled or non-spoiled test kit) were blinded to group assignment. Results 2333 Māori and 2938 Pacific people participated (11 withdrew). Those who were sent the DVD (1029 Māori and 1359 Pacific) were less likely to participate in screening than those who were not (1304 Māori and 1579 Pacific). Screening participation was reduced by 12.3% (95% CI 9.1–15.5%) in Māori (13.6% versus 25.9%) and 8.3% (95% CI 5.8–10.8%) in Pacific (10.1% versus 18.4%). However, spoiled kit rates (first return) were significantly higher among those not sent the DVD (33.1% versus 12.4% in Māori and 42.1% versus 21.9% in Pacific). Conclusion The DVD sent with the reminder letter to BSP non-responders reduced screening participation to an extent that more than offset the lower rate of spoiled kits. Trial registration Australia and New Zealand Clinical Trials Registry ACTRN12612001259831. Registered 30 November 2013.

Organised Versus Opportunistic Cervical Cancer Screening in Urban and Rural Regions of Lithuania

Background and Objectives: In 2004, Lithuania started the Nationwide Cervical Cancer Screening Programme. However, screening is more opportunistic than population-wide and the programme’s coverage is insufficient. The aim of this study was to assess the effect of systematic personal invitation on coverage of cervical cancer (CC) screening in urban and rural regions of Lithuania. Materials and Methods: The study was conducted in an urban primary healthcare centre (PHCC) and in a rural PHCC, where prevailing CC screening practice was highly opportunistic. Over the first year, all women aged 25–60 who had not received a Pap smear test within the last three years in urban (n = 1591) and rural (n = 1843) PHCCs received a personal invitation letter to participate in the screening. Over the second year, the reminder letter was sent to the non-attendees (n = 1042 in urban and n = 929 in rural PHCCs). A random sample of women (n = 93), who did not attend for screening after two letters, was contacted by phone in order to identify the barriers of non-attendance. Results: Before the study, only 9.6% of the target population in urban and 14.7% in rural PHCCs participated in CC screening. After the first invitation letter, the participation in CC screening increased up to 24.6% in urban and 30.8% in rural areas (p < 0.001). After the reminder letter, the attendance was 16.4% in urban and 22.2% in rural PHCCs (p < 0.001). The most common barriers for the non-attendance were lack of time, long waiting time for family doctor’s appointment, worries that a Pap test might be unpleasant and preventive gynaecological examination outside of the screening program. Conclusions: A systematic personal invitation with one reminder letter significantly increased the coverage of CC screening and was more effective in rural regions than in urban regions. The assessed barriers for non-attendance can be used to improve the coverage of screening.

Breast Screening Reminder Letters and Phone Calls to Women in Their Language

Background: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation by all women in the target population. However, women from Arabic and Italian speaking backgrounds have lower breast screening participation compared with English-speaking women. A needs analysis involving consultation with Arabic and Italian speaking women found that invitation letters and calls are important enablers to breast screening, however language is a barrier. Women suggested sending reminder letters and making outbound reminder calls in their language. Aim: The aim of this study was to determine whether, and to what extent, reminder letters and phone calls in language resulted in increased screening rates in Arabic and Italian women. Methods: Two randomized control trials ran in 2017. TRIAL 1: Women due for a routine breast screen who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received a reminder letter in language (with the English version enclosed also), and women in the control arm received a reminder letter in English only. 1032 women were included in the study; comprising 322 Arabic and 710 Italian women. TRIAL 2: Lapsed women (had not had a breast screen within 27 months) who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received an outbound call in language inviting them to book an appointment; women in the control arm did not receive a call. 219 lapsed screeners were included; comprising 93 Arabic and 126 Italian women Results: TRIAL 1: • Women in the intervention arm more frequently booked (61.2%) compared with the control group (59.8%). However, this difference was not statistically significant. • For Italian women, 64.5% in the intervention group and 66.2% in the control group booked a screening appointment within 30 days of the mail out. Among Arabic women, the rates were 53.1% and 47.5% respectively. TRIAL 2: • Women in the intervention group were 10.7 times more likely to make a booking (42.9%) compared with the control group (4%). The effect was larger for Arabic than for Italian women. Conclusion: Sending reminder letters to Italian and Arabic women in their own language did not result in a statistically significant increase in bookings. Making reminder phone calls to Italian and Arabic women in their own language did result in a large, statistically significant increase in bookings and attendance.

Signed family physician reminder letters to women overdue for screening mammography: A randomized clinical trial

Objective To determine whether signed family physician reminder letters to women overdue for screening mammography prompts rescreening. Methods A randomized double-blind trial conducted in 2013 among women aged 51–73 and overdue for screening by 6–24 months. The study was carried out by the publicly funded British Columbia Cancer Agency Screening Mammography Program, which routinely sends standard reminder postcards to women who are due for mammography. Participating family physicians signed letters for the overdue women in their practices. The overdue women were mailed either the signed reminder letter and the standard reminder postcard, or the standard reminder postcard alone. The primary endpoint was the proportion of overdue women that attended a screening mammogram appointment within six months of mailing the study letters. The analysis was by intention to treat. Results In total, 822 family physicians participated and 5638 women were randomized. Mammography attendance by six months after mailing the reminders was 34.4% (947/2749) for women in the signed family physician letter arm, compared with 24.0% (660/2749) for women in the control arm (p < 0.0001). Adjusting for age, number of previous screening mammograms, and months overdue, women in the signed letter arm were significantly more likely to return for screening than women in the control arm (RR 1.41; 95% confidence interval: 1.30–1.54). Conclusion A signed family physician reminder letter improved mammography attendance for women who were overdue for screening mammography.

Surveillance colonoscopy in Austria: Are we following the guidelines?

Background and study aim The European guidelines for quality assurance in colorectal cancer screening and diagnosis contain postpolypectomy surveillance recommendations. They recommend follow-up intervals depending on the findings at index colonoscopy, and divide patients into a low-, intermediate- or high-risk group. The aim of this study was to assess the adherence of Austrian endoscopists to the European guidelines and to determine whether sending a reminder letter resulted in better adherence. Methods A single reminder letter containing the guidelines was sent to all endoscopists who participated in the Certificate of Quality for Screening Colonoscopy program in Austria. Adherence was assessed before and after the letter had been sent. Factors associated with adherence were investigated. Results We found poor baseline adherence to the guidelines. After the reminder letter, the adherence slightly improved in the low-risk group, but did not change in the intermediate-risk or high-risk groups. An adenoma detection rate of at least 20 % was associated with higher adherence rates. Generally, internists and hospitals showed better adherence compared with surgeons and private practices, respectively, both before and after the reminder letter. Conclusion A single reminder letter was not enough to improve the poor adherence to the European postpolypectomy surveillance guidelines. Thus, future studies are required to identify and eliminate all factors responsible for nonadherence to postpolypectomy guidelines in order to reach the goal of a safe, effective, and cost-effective colorectal cancer prevention tool in the near future.

Improving screening mammography return rates in overdue women: A randomized study of signed reminder letters from family physicians.

1 Background: For asymptomatic women aged 50 to 74 with an average risk for developing breast cancer, screening mammography (SM) is recommended every 2 years in British Columbia (BC). The Screening Mammography Program of BC (SMP) uses a schedule of multiple postcard reminders, which achieves an on-time (within 30 months) participation rate of 54% among those aged 50 to 69. The purpose of this study was to determine whether the SM return rate of overdue women could be improved by a reminder letter signed by their family physicians. Methods: Eligible women met the following criteria: prior normal SM, age 52 to 74, overdue by 30 to 48 months from their last SM and had agreed to being contacted for research by the SMP. All family physicians in BC were invited to participate. Consenting physicians signed the study letters, which encouraged SM, for all of the overdue women in their practice. Women were randomized to receive a postcard reminder or a postcard reminder and the signed family physician reminder letter. Six months after the mailing, the SMP database was queried to determine the SM return rate. Results: In BC, 822 physicians participated in the study and 5,385 women with signed letters were randomized. SMP sent a postcard to 2,689 women and a postcard and letter to 2,696 women. The age, number of prior SMs and time overdue were not statistically different between the arms. Within 6 months, 600 women (22.3%) in the postcard arm returned, while 894 women (33.2%) in the postcard and letter arm returned (odds ratio 1.7, p < 0.0001). The maximum difference between the SM return rates was observed at 4 months. On multivariable analysis, women who had >1 previous SM were more likely to return compared to those who only had 1 previous SM (odds ratio 2.2, p < 0.0001). Women who were 30 to 36 months overdue were more likely to return compared to those who were 42 to 48 months overdue (odds ratio 2.4, p < 0.0001). Conclusions: A signed family physician reminder letter is a simple and effective intervention to improve screening mammography return rates in overdue women.