Telephone Care Management To Improve Cancer Screening among Low-Income Women

Context Minority and low-income women have low screening rates for cancer. Contribution In this trial from 11 community and migrant health centers in New York City, 1413 women overdue for cancer screening were randomly assigned to receive a telephone-based intervention (delivered by 8 prevention care managers) or usual care. The intervention included information about breast, cervical, and colorectal cancer and motivational and logistical support for obtaining screening. Within 18 months, the screening rates for all 3 forms of cancer increased more with telephone support than through usual care. Implications Telephone support delivered by trained personnel can improve cancer screening rates among some minority, low-income women. The Editors Higher screening rates for breast, cervical, and colorectal cancer could reduce cancer mortality rates substantially (1-4). Current cancer screening rates are particularly disappointing among ethnic minorities and individuals with low socioeconomic status (5, 6) who often present with late-stage diagnoses (7) and have high mortality rates (8, 9). Interventions to increase cancer screening have shown limited sustainability and effect on health care disparities. A previous study showed that an office systems approach, which used a medical record flowsheet and practice teamwork, increased screening rates by 20% to 33% in small rural community practices (10); however, a similar intervention was less effective in larger urban practices (11). An office intervention in low-income settings in Florida increased mammography use and home fecal occult blood testing at 12 months (12), but rates decreased substantially after research support ended (13). Use of the telephone to support cancer screening is well documented (14-18), but interventions have typically addressed a single form of cancer screening. In some settings, telephone infrastructures to support childhood immunization (19) and patients with chronic illnesses (20-23) already exist. These infrastructures could add screening support for patients who are already enrolled, or they could expand services to others while making minimal additional demands on primary care practices (24). This paper reports the results of a randomized, controlled trial that tested the effect of centralized telephone care management on cancer screening rates among women 50 to 69 years of age who obtained care at community and migrant health centers in New York City. Methods Settings Federally qualified community and migrant health centers provide comprehensive community-oriented primary care to over 12 million patients nationally (25) and are uniquely positioned to deliver cancer screenings to underserved and minority populations. We sought participation from 15 of the 21 community and migrant health centers in New York City because of their anticipated ability to provide sufficient patients for the study and their affiliations with tertiary care facilities that conduct mammography and colorectal screening and provide follow-up services for abnormal test results. Of these 15 sites, 2 were involved in competing research projects, 2 had few patients who were likely to be eligible and therefore served as pilot sites, and the remaining 11 participated. Clinical Directors Network, a practice-based research network in New York City, was responsible for recruiting clinicians, practices, and women and for implementing the intervention and evaluation. The project was approved by the Committee for the Protection of Human Subjects at Dartmouth College, by the institutional review board at Clinical Directors Network, and by all relevant bodies responsible for reviewing research at participating community and migrant health centers. Patients Recruitment Women were approached by research assistants during routine visits to the centers or were referred by a clinician. Research assistants explained the study and obtained written informed consent from women who agreed to participate. Women were compensated $15 for participating in an interview whether or not they met eligibility criteria. Eligibility Eligible women were 50 to 69 years of age, were overdue for at least 1 cancer screening according to their medical records, were patients of the center for at least 6 months, and had no plans to move or change health centers within 15 months. We excluded women whose primary language was not English, Spanish, or Haitian Creole and those who were acutely ill or currently receiving cancer treatment. After we obtained consent, a research assistant reviewed patient medical records to confirm eligibility. Mammography and Papanicolaou tests that were performed within the past year were seen as evidence of breast and cervical cancer screening, respectively, whereas reports of home fecal occult blood testing within the past year, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years were seen as evidence of colorectal cancer screening. Women whose charts indicated that they were up to date on all 3 cancer screenings were excluded. We also excluded women with unresolved abnormal screening results (for example, positive results on home fecal occult blood testing; mammography results that were categorized as American College of Radiology level 0, 4, or 5; and certain Papanicolaou test results) and notified their physicians of these findings. Design Eligible, consenting women were grouped by center, duration of enrollment at their center (12 months or >12 months), and the number of cancer screenings that they had received at recommended intervals (0 or 1 screening or 2 screenings). The New Yorkbased research assistant assigned women in each group to receive the intervention or usual care by using sealed randomization forms that were produced by Dartmouth College staff with a computer-based random-number generator. Patients were informed of their group assignment individually by telephone. At time of consent, all women received the publication titled Put Prevention into Practice Personal Health Guide (26), which contained information regarding recommended preventive services. Women who were assigned to the usual care group received a single telephone call during which trial staff answered questions about preventive care, informed women of their usual care status, advised them to obtain needed preventive care from their primary care clinician, and thanked them for their participation. Women who were assigned to the intervention group received a series of telephone support calls from a trained prevention care manager who was monitored to ensure quality and consistency. In much the same way that patient navigators guide women through the health care system during cancer treatment (27), prevention care managers facilitated the screening process for each woman by addressing barriers that prevent or delay receipt of cancer screenings. Prevention care managers received 7 hours of training, including an overview of the U.S. Preventive Services Task Force guidelines (28-30); a review of barriers to breast, cervical, and colorectal cancer screenings; and detailed explanations of the targeted screenings. Additional training included role-playing telephone calls during which the managers used the intervention scripts. Thereafter, logs were reviewed in monthly meetings to ensure fidelity to the intervention. The 8 prevention care managers were women, and most were college graduates. Their assignments were determined by patient language needs. Each care manager focused most of her work on patients from 1 or 2 sites while supporting smaller numbers of patients from other sites; contact with clinicians was limited. During the first call with a patient in the intervention group, the prevention care manager answered questions about the health guide and confirmed or updated screening dates found in the woman's medical record. She next determined how ready the woman was to act on each screening (31) and worked with the woman to prioritize overdue screenings. The prevention care manager then provided motivational support, responding to each participant's specific barriers to screening by using a structured script that was developed through an earlier series of interviews with women (32). Some participants had been advised during office visits with their clinicians to undergo screening; those who had not received such recommendations were sent a written recommendation from their clinician. Women who reported that they had difficulty communicating with their physician were sent brightly colored patient activation cards that listed overdue screenings, which they could share with their clinician at their next appointment. Care managers also scheduled appointments, provided accurate information about screenings over the telephone and by mail, prompted women with appointment reminder calls and letters, provided directions to screening facilities, and helped women to find a means of transportation to appointments. During subsequent calls, which continued for 18 months or until the patient was up to date for all screenings, the prevention care manager asked about future appointments and screenings the patient had received since the last call. The manager then responded to new and ongoing barriers for remaining overdue screenings. Only clinicians, not care managers, were responsible for ordering screenings at all but 2 centers, which permitted care managers to mail home fecal occult blood test kits directly to women who were willing to perform this test. Evaluation Descriptive data on the centers were gathered from surveys that were completed by clinicians and clinical directors. Outcome data were based on reviews of patient medical records, which were conducted at least 3 months after the intervention period to allow for the time lag between receipt of a service and the availability of documentation. Data included patient demographic characteristics, screening dates and results, chronic il