Increasing Annual Recall in State Early Detection Programs

Institution: CHG Foundation
Investigator(s): Nicole Howard,  -
Award Cycle: 1997 (Cycle III) Grant #: 3AB-1800 Award: $58,530
Award Type: CRC Pilot Award
Research Priorities
Detection, Prognosis and Treatment>Imaging, Biomarkers, and Molecular Pathology: improving detection and diagnosis

Initial Award Abstract (1997)
This project seeks to increase compliance with annual recall for breast cancer screening (mammography and clinical breast examination) among low income, uninsured women ages 50 and above, participating in the Breast Cancer Early Detection Program (BCEDP) and the Breast and Cervical Cancer Control Program (BCCCP). The purpose of this research is to test the effectiveness of behavioral strategies designed to increase annual recall rates for BCEDP/BCCCP clients in San Diego and Imperial Counties, who were found to be asymptomatic for breast cancer during their initial or previous screening cycle.

The BCEDP/BCCCP provides free breast cancer screening services to program eligible women on an annual basis. Research has demonstrated that mortality can be reduced up to 30% among women 50 years of age and older through the use of annual screening mammography and clinical breast examination. Currently, more than 5,000 women are being served each month by the state-funded programs, with approximately 450-550 women screened per month in the San Diego-Imperial county region. The BCEDP/BCCCP has been extremely successful in providing initial screening services. However, evidence suggests that the programís underserved target population may not adhere to recommended annual screening over time. With 80,000 women screened statewide since 1991, the BCCCP has only been able to achieve an 18% mammography rescreening rate. The BCEDP/BCCCP is typical of efforts to increase breast cancer screening, "Overall mammography rates have increased substantially in the past decade, but rates of repeat and annual screenings remain low for women in the target age group" (Mayer, 1994). Only with annual screening is breast cancer mortality impacted, by enabling women to benefit from early detection.

This project seeks to: (l) conduct a literature review of cost effective strategies that show promise for increasing annual recall compliance among the target population; (2) through a physician survey and medical record review, identify existing annual recall strategies currently utilized by San Diego-Imperial County primary care providers and determine if new strategies can be incorporated into clinical practice; (3) through discussion groups with women over 50 years of age, ensure that new strategies are culturally sensitive and appropriate; (4) community collaborators will select up to three strategies to be put into place at BCEDP/BCCCP clinics; (5) community partners together with researchers and project staff will evaluate the effectiveness of the three strategies in a small study during Cycle III and in a full scale study in Cycle IV and; (6) send study results to approximately 1,000 BCEDP/BCCCP providers in California in an attempt to retain women in the statewide program over time so that older, low income women at highest risk are diagnosed earlier, possibly leading to better prognosis and a lowering of the number of deaths due to breast cancer.

Final Report (1998)
Research has demonstrated that mortality can be reduced by up to 30% with regular mammography and clinical breast examination (CBE) for women age 50 and older. California's Breast Cancer Early Detection Program (BCEDP) and the Breast and Cervical Cancer Control Program (BCCCP) provide free breast cancer screening to low-income under or uninsured women. These programs have been extremely successful in providing initial screening exams. However, evidence suggests that the target population is not adhering to recommended guidelines for annual CBE and mammography every 1-2 years.

The identification of interventions that show potential for increasing compliance for annual rescreening was the primary research question to be answered. In an attempt to learn more about rescreening practices, we carried out the following activities: (1) Reviewed the existing literature to identify interventions that show promise for increasing compliance with annual rescreening; (2) surveyed providers to determine the types of tracking systems that facilities use in order to recall patients for annual screening; (3) reviewed 33 l medical records of BCEDP/BCCCP consumers to determine the percentage of clients who were reminded by clinic staff to make an appointment for rescreening; (4) calculated baseline rescreening rates and; (5) interviewed consumers to determine factors that influenced their decision whether or not to be rescreened.

Among women in our study sample, we calculated a 32% compliance rate with annual rescreening. Of the l 06 women who had been seen for a rescreening CBE in l997, 68.9% received a reminder from the primary care provider. Of the 225 women who had not been seen for a rescreening CBE in l 997, only 38.7% received a reminder. This data suggests that reminders may play an important role in getting women to return for rescreening. However, compliance rates may still remain low with standard anniversary date reminders, since it is likely that many consumers will be lost to follow-up after a period of 12 months. 27.2% of consumers initially selected for inclusion in the study could not be contacted (e.g. disconnected telephone, interviewers reached a wrong number, etc.). An additional 25.7% of women could not be reached after repeated calls, suggesting that they too may be difficult to reach with standard rescreening reminders. Women who we were able to be contacted were more than twice as likely to have been compliant with annual CBE rescreening as compared to those who could not be contacted. In order to maximize compliance we believe that interventions delivered during the l 2 month interval between initial and repeat screening may be more effective than standard anniversary date reminders.

Our survey data show that consumers may not be established patients of the BCEDP/BCCCP providers. 20.9% of consumers reported a sick visit to the provider during the preceding l 2 months and only 7.0% reported visiting the provider for other preventive services. Interventions designed to strengthen the patient-provider relationship may improve compliance with annual rescreening as it has been well documented that physician referral is a strong predictor of adherence to regular screening.