Research article
Promoting mammography: Results of a randomized trial of telephone counseling and a medical practice intervention

https://doi.org/10.1016/S0749-3797(00)00150-1Get rights and content

Abstract

Background: Despite widespread promotion of mammography screening, a distinct minority of women have remained underusers of this effective preventive measure. We sought to measure the effects of barrier-specific telephone counseling (BSTC) and a physician-based educational intervention (MD-ED) on mammography utilization among underusers of mammography screening.

Design: This was a randomized controlled trial. Women meeting criteria for mammography underuse at baseline (grouped by practice affiliation) were randomized to a reminder control condition (RC group received annual mailed reminders), BSTC or MD-ED interventions and followed for 3 years. Underuse was defined by failure to get two annual or biannual mammograms over a 2- to 4-year period prior to a baseline survey.

Participants and Setting: The study included 1655 female underusers of mammography aged 50–80 years who were members of two health maintenance organizations (HMO) in central Massachusetts.

Interventions: BSTC consisted of periodic brief, scripted calls from trained counselors to women who had not had a mammogram in the preceding 15 months. Women could receive up to three annual calls during the study. MD-ED consisted of physician and office staff trainings aimed at improving counseling skills and office reminder systems.

Main Outcome Measure: Self-report of mammography use during the study period was the main outcome measure. Regular use was defined as ≥1 mammogram every 24 months.

Results: Forty-four percent in each intervention group became regular users compared to 42% in the RC group. Among subjects who had prior but not recent mammograms at baseline, BSTC was effective (OR=1.48; 95% CI=1.04; 2.10), and MD-ED marginally effective (OR=1.28; 95% CI=0.88, 1.85). Most recent users at baseline and few never users became regular users (61% and 17%, respectively) regardless of intervention status.

Conclusions: Among mammography underusers BSTC modestly increases utilization for former users at a reasonable cost ($726 per additional regular user).

Section snippets

Study population and eligibility criteria

The UMMS study population comprised women, aged 50–80 years, who were members of two independent physician association (IPA) model HMOs serving central and southeastern Massachusetts and whose primary care physicians (PCP) were eligible for the study. Eligible PCPs were family, internal, or general practitioners who: (1) were either solo practitioners or members of a group of 10 or fewer physicians, (2) had a minimum of 16 women who were HMO enrollees between the ages of 50 and 80 years, and

Results

There was no difference in response rate to the final survey by intervention assignment. Response to the final survey was significantly associated with prior mammogram utilization, marital status, income, educational level, provider recommendation to have a mammogram, and attitude toward mammography, but not associated with age, perceived vulnerability, or intervention group.

Table 1 shows the baseline characteristics of the study subjects who completed the final survey by intervention arm.Only

Discussion

This study demonstrates that BSTC is modestly effective in encouraging women whose utilization has lapsed by ≥24 months (i.e., former users) to become regular users. For women who were recent but not regular users at the start of the study, both interventions were associated with substantial increases in utilization, but the increases were no greater than the increase associated with mailed reminders alone (the control condition). For women who had never had a mammogram at baseline, only a

Conclusion

This study demonstrates the importance of prior screening behavior in predicting subsequent behavior, an association that has been demonstrated by other investigators.13, 55 Our results indicate that even in a late period of screening adoption, BSTC has a place in the strategies of HMOs and PCPs in encouraging lapsed screeners to become regular users. For the small group of women who remain non-users of this technology in the later stages of adoption, more intensive interventions should be

Acknowledgements

This study was funded by the NIH grant R01 CA60130 and reviewed and approved by the Committee for the Protection of Human Subjects in Research at the University of Massachusetts Medical School, Worcester, Massachusetts.

The authors are grateful to Harvard Pilgrim Health Care and CIGNA Health Care of Massachusetts, Inc., for their support of the project and ongoing cooperation and assistance throughout the study.

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