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

Abstract

Objectives-To examine the eVectiveness and cost-eVectiveness of two interventions based in primary care aimed at increasing uptake of breast screening. Setting-24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round. Methods-Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-eVectiveness of the interventions. Results-6133 Women were included: 1721 control; 1818 letter; 1232 flag; 1362 both interventions. Attendance data were obtained for 5732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more eVective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were £26 (letter) and £41 (flag). Conclusions-Although both interventions increased attendance for breast screening, the letter was the more costeVective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (£41) costs are judged worthwhile in terms of the gains in breast screening uptake. (J Med Screen 2001;8:91-98) Keywords: cluster randomised controlled trial; breast screening; uptake; primary careBreast cancer is the most common female cancer in the United Kingdom, with an estimated 33 000 newly diagnosed cases and 15 000 deaths occurring each year.1 In 1986, the Forrest Report 2 recommended the provision of a national breast screening programme in the United Kingdom for women aged 50-64 years.The National Health Service breast screening programme (NHSBSP) provides mammographic screening in specialised breast screening units which call women for screening every 3 years through their general practice using "prior notification lists" generated by health authorities. Forrest estimated that if 70% of eligible women attended for screening, a 25% reduction in mortality from breast cancer could be achieved in the United Kingdom. 2The programme as a whole is reaching current targets: in England, 75% of invited women attended for screening in 1996-7.3 However, these national figures hide considerable geographical diversity-at the time of the study, 18 out of 100 health authorities had an uptake rate less than 60%. Health promotion interventions aiming to improve uptake of breast screening often involve the primary healthcare team.4 Such interventions can be systematic, for example, a letter encouraging attendance sent from the general practitioner to all elig...

Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care

“…Despite a diVerence in attendance rates of nearly 3% (11.2% v 8.3%; table 3) and an adjusted OR (95% CI) of 1.4 (0.9 to 2.1) the flag was not as clearly eVective as the letter. Also, the interaction between the flag and screening history found in the parallel trial 15 was not found here; hence that observation may well have been a chance finding. Flags have not previously been subjected to rigorous evaluation among non-attenders, 13 14 and therefore positive findings based on descriptive accounts 12 should be interpreted with caution.…”

“…For both interventions and particularly the flag, the extra costs to the health service per additional attendance were higher among recent non-attenders than for women before their routine invitation. 15 This is perhaps not surprising as non-attenders might be expected to be less amenable to interventions in primary care (at least in terms of absolute diVerences). This proposition is supported by the statistics about consultations and screening history (table 2).…”

“…Also, among women invited for screening in a previous round with known history, in the present trial only about one third had attended compared with three quarters in the parallel trial. 15 Given the much smaller numbers of women per practice, the total costs per general practice of interventions targeted at non-attenders were considerably lower than for all invited women. 15 Issues for future research include design of the letter both generally and with respect to languages and translation sheets, particularly bearing in mind the increasing emphasis on informed choice.…”

“…Practices were excluded if they were fully or mostly computerised and therefore not reliant on paper records, if they had fewer than 100 women aged 50-64 years or if they were included in the parallel trial involving all eligible women. 15 Fringe practices (where practices were responsible to two diVerent health authorities) were also excluded. …”

A cross-sectional population-based study of breast cancer screening among women with HIV in Ontario, Canada

“…Strategies such as colocation of preventive services, 10 patient letters, reminder phone calls and educational materials have been shown in studies of women without HIV to improve screening uptake, and they warrant evaluation in women with HIV. 26,29,30 Reminder letters for breast cancer screening are sent to patients in Ontario, and it is unclear why there is differential uptake among women with and without HIV. Physiciandirected interventions may be required, as physicians may emphasize the provision of HIV-specific primary care services to the detriment of routine, non-HIV-specific health screening, such as mammography.…”