Effect of a multimodal reminder program on repeat mammogram screening

Abstract

Background: Patient mammogram reminders are effective but have not been fully implemented in practice to improve routine screening. The effectiveness of implementation and maintenance phases of a multimodal reminder program that incorporated automated calls capable of efficiently reaching large numbers of women was evaluated to improve repeat mammography screening.

Design: A quasi-experimental study was conducted in 2008 using electronic medical record data during three time periods: pre-reminder phase (2004), post-reminder implementation phase (2006), and post-reminder maintenance phase (January 1-July 1, 2007).

Setting/participants: Participants were female Kaiser Permanente Northwest HMO members aged 42 years or more who were 20 months past their last mammogram (index date) (N=35,104). The intervention program targeted women aged 50-69 years. Women aged 42-49 years (for whom clinical guidelines also recommend mammography) not targeted by the program constituted the primary comparison group (CG1).

Intervention: A "mammogram due soon" postcard was mailed to participants 20 months after their last mammogram, followed by up to two automated phone calls and one live call for nonresponders.

Main outcome measures: The outcome measure was the time until participants received a mammogram in the 10 months following the index date.

Results: Pre-reminder, 63.4% of targeted women completed a mammogram; this number increased to 75.4% in the post-reminder implementation phase; 80.6% completed a mammogram in the maintenance phases. After controlling for demographics and clinic visits, intervention women were 1.51 times more likely to complete a mammogram (CI=1.40, 1.62) post-reminder implementation, compared to CG1. The effect was maintained in 2007 (hazard ratio 1.81, CI=1.65, 1.99).

Conclusions: The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system. If widely implemented, this intervention could substantially improve community mammography screening.

Figure 1

Study population flow for three cohorts: pre-reminder, post-reminder implementation, and post-reminder maintenance. Target Group: mammogram recommended by USPSTF and patients targeted with reminders (age 50–69) Comparison Group 1: mammogram recommended by USPSTF but patients not targeted (age 42–49) Comparison Group 2: mammogram conditionally recommended by USPSTF (if life expectancy not compromised) but patients not targeted (age ≥70)

Figure 2

Mammogram reminder program to encourage routine mammograms

Figure 3

Proportion of women who have had a mammogram during 10 months of follow-up period Figure 3: Proportion of women who have had a mammogram during 10 months of follow-up. Target Group: mammogram recommended by USPSTF and patients targeted with reminders (age 50–69) Comparison Group 1: mammogram recommended by USPSTF but patients not targeted (age 42–49) Comparison Group 2: mammogram conditionally recommended by USPSTF (if life expectancy not compromised) but patients not targeted (age ≥70)