Can postal prompts from general practitioners improve the uptake of breast screening? A randomised controlled trial in one east London general practice

Abstract

Objective-To determine the eVect on the uptake of breast screening of a personalised letter from the general practitioner recommending mammography, sent to coincide with an invitation from the NHS breast screening programme. Design-Randomised control trial with stratification of prognostic variables. Setting-A group practice in Hackney, east London. Subjects-473 women invited for breast screening by the City and East London Breast Screening Service. Outcome measure-Attendance for mammography. Results-All women in the randomised trial were followed up; 134 of 236 (57%) randomly allocated to receive the prompting letter attended for mammography compared with 120 of 234 (51%) controls. This diVerence was not significant ( 2 =1.43, p=0.23) Conclusion-Personal recommendation by a letter prompting attendance for mammography from the general practitioner known best to women due to be screened did not improve uptake of breast screening in this east London practice. Other strategies are needed to increase uptake of mammography in inner cities. (J Med Screen 1998;5:49-52) Keywords: breast cancer; general practitioners; patient compliance One in 12 women will develop breast cancer at some stage in their life.1 In an eVort to tackle this major public health problem, the National Health Service breast screening programme (NHSBSP) invites all women aged 50 to 64 for a mammogram every three years. Seventy per cent of women need to accept their invitations if the Health of the Nation target of a 25% reduction in breast cancer mortality by the year 2000 is to be achieved.2 3 Although nationally 71% of eligible women were screened in 1991-92, 4 a more recent review reports uptake rates of 77% in 1995.5 Uptake in inner cities has been low and uptake in City and East London Health Authority (Hackney, Tower Hamlets, and Newham) was 45% between 1989 and 1992.6 A more recent report gives uptake rates as low as 38% in this area. 7A systematic review of computer generated reminders for doctors and patients suggested that they probably increase the uptake for cancer screening services.8 However, few of the studies cited were randomised, and most were based in America, in "academic" rather than community settings. A small retrospective analysis in a Scottish general practice showed that personal knowledge of the general practitioner was positively related to attendance. 9 Defining simple interventions that can be used by inner city primary health care teams to increase mammography uptake may be crucial to the success of the NHSBSP. We used a randomised controlled trial to test the eVect on breast screening uptake rates of a personal letter prompting attendance for mammography from the general practitioner best known to each woman. MethodThe trial took place in an inner city training general practice in Hackney, east London, comprising seven principals with a list size of 11 194. The area has one of the highest levels of deprivation in the United Kingdom, and a large Turkish population. 10 In March 1996 the NHSBSP was conducting...

Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening

“…The increase in attendance for the letter (66% versus 60%; adjusted OR 1.3) is consistent with a previous small trial involving a (systematic) postal intervention. 6 Likewise, the increase in attendance for women whose notes were flagged (67% versus 60%; adjusted OR 1.4) is similar to other studies, although slightly smaller than the pooled OR of 1.6 (95% CI 1.2 to 2.2) from a previous meta-analysis. 7 Although regression to the mean and the Hawthorne eVects may in part explain the general increase in rates of uptake from round two (table 3) to round three (table 4) even among control practices, the mean rates of uptake are now well above 60% for all three active intervention groups.…”

“…A meta-analysis of 10 randomised controlled trials found that the uptake of cervical screening could be increased by a personalised letter, 5 but only one British trial has examined such an intervention in breast screening. 6 Women in the intervention group were more likely than controls to attend for breast screening (57% v 51%), but the sample size was small and significance was not reached (relative risk (RR) 1.11, 95% confidence interval (95% CI) 0.96 to 1.30).…”

“…A meta-analysis of 10 randomised controlled trials found that the uptake of cervical screening could be increased by a personalised letter, 5 but only one British trial has examined such an intervention in breast screening. 6 Women in the intervention group were more likely than controls to attend for breast screening (57% v 51%), but the sample size was small and significance was not reached (relative risk (RR) 1.11, 95% confidence interval (95% CI) 0.96 to 1.30).Other interventions may be opportunistic, such as a flag placed in the medical records to prompt health professionals to discuss breast screening during a consultation. Although meta-analyses of trials suggest benefits from manual as well as computerised flags, 7 previous evaluations of reminders to family doctors to recommend screening have largely been observational or set outside the United Kingdom.…”

Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis

“…For instance, in relation to attendance for breast screening, some UK interventions have involved letters of endorsement or telephone calls from the woman's local GP practice in addition to standard screening invitations and leaflets, but the reported impact on uptake has been disappointing. 124,125 Explanations and implications for reminders Several potential mechanisms might explain variations in levels of attendance by source of original appointment. First, the identity of the person/department/service that initiates the making of an appointment (invites the patient to the appointment) may influence patient perceptions that attendance at the appointment will positively contribute to well-being and/or that non-attendance will result in negative consequences.…”

Interventions to increase breast screening uptake: do they make any difference?

“…The study of O'Connor et al was based at a single inner city practice and the eVects of material deprivation cannot be disentangled. 11 On the other hand, the study of Taplin et al (USA) comprised subjects who had above national average incomes and educational levels. 12 One descriptive study did show increased attendance, from 16% to 75%, using a GP letter as an invitation.…”