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

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

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

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.

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

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

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)

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

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

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’

Findings – descriptive statistics A1 A2 B1 B2 Individual Characteristics 578 571 580 578 45.8 45.6 45.9 45.8 (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

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

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

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”

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