Reminder Program Boosts Mammography Rates

By Laurie Barclay, MD
Medscape Medical News

July 14, 2009 — A multimodal reminder system can be both effectively implemented and maintained in a large health system and increase mammography rates, according to the results of a study reported online July 14 in the American Journal of Preventive Medicine.

"We know mammograms are effective, but too many women put them off, even when they have health insurance," lead author Adrianne C. Feldstein, MD, from Kaiser Permanente's Center for Health Research in Portland, Oregon, said in a news release. "This study is the first to show that these reminder programs can be effective in such a large group of women. If we could improve the country's mammography rate by the same amount, we could detect as many as 25,000 additional cases of breast cancer each year."

Using electronic medical record data, the investigators compared compliance with mammography during a prereminder phase (2004), a postreminder implementation phase (2006), and a postreminder maintenance phase (January 1 – July 1, 2007). The study sample consisted of 35,104 women aged 42 years or older who were 20 months past their last mammogram (index date) and who were members of the Kaiser Permanente Northwest health maintenance organization.

The intervention, which targeted women aged 50 to 69 years, consisted of a "mammogram due soon" postcard mailed 20 months after the last mammogram, followed by up to 2 automated phone calls and 1 live call for nonresponders. The primary comparison group was women aged 42 to 49 years, for whom clinical guidelines also recommend mammography, who did not receive the reminder system intervention. The main study endpoint was the time until participants underwent mammography during the 10 months after the index date.

In the prereminder phase, 63.4% of targeted women underwent mammography, compared with 75.4% in the postreminder implementation phase and 80.6% in the maintenance phases. During the same time, screening rates in the comparison group did not improve.

In the postreminder implementation phase, women who received the intervention were 1.51 times more likely to undergo mammography than those in the comparison group (95% confidence interval [CI],1.40 – 1.62), after controlling for demographics and clinic visits. This effect was maintained in the postreminder maintenance phase (hazard ratio, 1.81; 95% CI, 1.65 – 1.99).

"Our study shows that a reminder program can spark a big improvement in a short amount of time," said study coauthor Nancy Perrin, PhD, senior investigator at Kaiser Permanente's Center for Health Research. "Automated reminder programs make it more convenient for people to focus on staying healthy by getting the screenings they need."

Limitations of this study include lack of randomization, age difference between women in the intervention and comparison groups, lack of generalizability beyond the single health maintenance organization studied, and possible unmeasured confounders.

"The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system," the study authors conclude. "If widely implemented, this intervention could substantially improve community mammography screening.... Future studies should address practice-based factors that assist patients in completing mammograms within the context of a reminder program, as well as other factors that affect the reach and cost effectiveness of delivering the intervention to diverse patient groups in multiple settings."

The National Cancer Institute supported this study. The authors have disclosed no relevant financial relationships.

Am J Prevent Med. Published online July 14, 2009.