1. Irena Pesis-Katz Ying Xian Norman Lindenmuth Kathy Riegel
Role of educational materials in increasing cervical cancer screening adherence rates – Evidence from randomized controlled trial in NYS insured women
Irena Pesis-Katz
Ying Xian
Norman Lindenmuth
Kathy Riegel
APHA Annual Meeting
November 05, 2007

2. Background
In 2000:
128,000 new cases
4,600 deaths
Cervical cancer screening test goal (Healthy people 2010)
97% of women 18 and older
Reality: 50% of newly diagnosed women have never been screened

3. Background Previous interventions
Adherence rates for follow-up among women with abnormal test results (Mitchell and Medley, 1989; Melnikow et al., 1999; Segnan et al., 1998; Marcus et al., 1992)
Not consistent results (Kaplan et al., 2000)
No insurance status

4. Objective
To evaluate the impact of member reminders and educational mailings as well as physician reminders on cervical cancer screening test rates among the non-compliant population.

5. Hypotheses
Sending reminder letters and educational materials to members increases compliance
Sending physicians a list of their non-compliant patients increase compliance
A comprehensive approach of sending both reminder letters and educational materials to members and a patient registry to their physicians will improve compliance rates

6. Methods – study population
All women enrolled in BCBS plan in CNY region:
Did not have a cervical cancer screening test in the last 3 years (HEDIS)
Age range: 21 – 64
Commercial HMO and Medicaid
Rural and urban setting
Sample size: 2,307 women

7. Methods - intervention
Two interventions tested:
Sending reminder letters and educational materials to members
Sending physicians a list of their non-compliant patients
Time frame:
Letter sent on November 2005
First follow up – after 4 months (March 2006)
Second follow up – after 6 months (May 2006)

8. Methods – randomization process
Phase I – physicians’ randomization
Specialty
Number of non-compliant patients
Age distribution of non-compliant patients
Phase II – patients’ randomization
Age
Urban/rural location
Insurance status

9. Methods – randomization process
Study
participants
Group A:
Physician
intervention
Group B:
No physician
intervention A1 A2 B1 B2
Letter to Member
Letter to Member

10. Methods – intervention groups
Group A1: physician intervention only
Group A2: both a physician and a member intervention
Group B1: member intervention only
Group B2: control group – ‘do nothing’

11. Findings – descriptive statistics
A1 A2 B1 B2
Individual
Characteristics
(12.3) (12.4) (11.9) (12.3)
85% 84% 87% 88%
15% 16% 13% 12%
83% 83% 78% 79%
17% 17% 22% 21% N
Age
(SD)
Insurance Status
% Commercial
% Medicaid
Location
% Rural
% Urban

12. Findings – post intervention
Was screening test done?
Group
Total
No (%) Yes (%) A1
Physician Only A2
Physician+member B1
Member only B2
Control
Total
536 (93)
537 (94)
549 (95)
546 (94)
42 (7)
34 (6)
31 (5)
32 (6)
578
571
580
2,168 (94)
139 (6)
2,307
Χ2 = 2.4, not significant at the p<0.1 level

13. Power issues? Base on sample size and rates, at 80% power
Detectable difference in non-compliant population: 7%
Translated to less than 1% difference in overall cervical cancer screening score

14. Conclusions
Hypothesis 1 - “Sending reminder letters and educational materials to members increases compliance”
Not supported by the trial
Hypothesis 2 – “Sending physicians a list of their non-compliant patients increase compliance”
Hypothesis 3 – “A comprehensive approach of sending both reminder letters and educational materials to members and a patient registry to their physicians will improve compliance rates”

15. Policy implications
Effectiveness of educational interventions to non compliant members
Costs of interventions
Things to consider:
Multifaceted approach
Pay for performance