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Effectiveness of healthcare system outreach for breast cancer screening

PI Name: Buist D, Romaire M
Title: Effectiveness of healthcare system outreach for breast cancer screening


Background: Mammography is the best available screening technique for detecting breast cancer early. The full potential of mortality reduction from mammography may be limited by decreased adherence to screening. Many cancer screening programs rely on reminder letters to maintain screening adherence, which have been shown to be effective in populations. At Group Health Cooperative, we have a unique opportunity to study a change in the type and timing of breast cancer screening reminders and their effects on mammography adherence. In 1985, Group Health started a breast cancer screening program that involved sending mammogram reminders to age-appropriate women to encourage breast cancer screening. As part of the program, the healthcare system provided reminder letters 4 months before a woman was due for her next mammogram. Mammography letters were specifically customized for each woman based on her risk of breast cancer. In 2007, Group Health redesigned outreach letters to a person-centered care approach, which places the person at the center of a clinical interaction and explicitly views the whole person, not as a diagnosis or someone with a specific clinical need. As part of this redesign, the reminders letters include recommended preventive service such as cancer screening, diabetes care, cholesterol screening and immunizations. These letters are also customized for every person based on whether they are due for these preventive services in the upcoming year and are sent just before individuals’ birthdays.

Objective/hypothesis: The objective of this study is to compare the effects of two types of reminder letters on screening mammography adherence – mammography-specific and person-centered letters. We will evaluate mammogram screening adherence by patient characteristics such as race, socioeconomic status, and education; and health system characteristics to determine whether either type of letter is more or less effective in certain subpopulations. Specific aims: 1) To compare the effectiveness of person-centered birthday reminder letters to mammogram-specific reminder letters on adherence to screening recommendations for breast cancer screening among an insured population of women, ages 40-74; and 2) to examine the effect of the time between receipt of the reminder letter and due date for breast screening on adherence to screening recommendations among an insured population of women, ages 40-74.

Study design: This is a longitudinal cohort study that will include women ages 40-74 enrolled in Group Health Cooperative between 2005-2009. We anticipate our study will include approximately 55,000 women per year who will be due for a mammogram and will receive a reminder letter; roughly 275,000 due mammograms during the study. We will use logistic regression to evaluate the association between reminder letter type and screening mammography adherence within six months of receipt of the reminder letter (Aim 1). We will also use logistic regression to evaluate the effect of the number of days between the birthday letter and mammogram due date on receipt of a screening mammogram (Aim 2). Both analyses will account for repeated measures and potential confounding factors and effect modification by race, education, mammography copayment, and insurance market segment.

Cancer relevance: Breast cancer is the most frequently diagnosed cancer in women, and the second most common cause of cancer mortality. Mammography reminders increase breast cancer screening adherence, which is the best way to detect cancer at an early, treatable stage. However, reminder letters focused on overall preventive services that are anchored by a memorable date (such as a birthday) may provide an opportunity to efficiently remind women of multiple needed preventive services. At Group Health Cooperative, we have a unique opportunity to compare the effect of mammogram-specific reminders to patient-centered reminders on mammogram screening adherence.