A clinic-based mammography intervention targeting inner-city women Increasing screening mammography in asymptomatic women: evaluation of a second-generation, theory-based program. Delayed Feedback of Physician Performance Versus Immediate Reminders to Perform Preventive Care: Effects on Physician Compliance A randomized trial of the impact of risk assessment and feedback on participation in mammography screening. Prospective randomised controlled trial of methods of call and recall for cervical cytology screening. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. Improving Breast Screening Uptake: Persuading Initial Non-Attenders to Attend Reducing financial barriers enhances the return rate of stool Hemoccult packets. Update of the Swedish two-county program of mammographic screening for breast cancer. A two-step intervention of increase mammography among women aged 65 and older. Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders Cervical screening in general practice. Increasing the pneumococcal vaccination rate of elderly patients in a general internal medicine clinic. Improving compliance with breast cancer screening in older women. Results of a randomized controlled trial. Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Computerized reminders to encourage cervical screening in family practice. A comparison of methods for increasing compliance within a general practitioner based screening project for colorectal cancer and the effect on practitioner workload. Comparison of three methods of recalling patients for influenza vaccination. Increased utilization of influenza and pneumococcal vaccines in an elderly hospitalized population. Behavioral Interventions to Increase Adherence in Colorectal Cancer Screening Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial. Impact of Medicare reimbursement on influenza vaccination rates in the elderly. Breast screening: a randomised controlled trial in UK general practice of three interventions designed to increase uptake. Improving the utilization of screening mammography in primary care practices. Evaluation of three methods for improving mammography rates in a managed care plan. Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods. A randomised intervention study to examine the effect on immunisation coverage of making influenza vaccine available at no cost. Maximizing Compliance With Hemoccult Screening for Colon Cancer in Clinical Practice Using physician correspondence and postcard reminders to promote mammography use. Improving compliance with immunization in the older adult: results of a randomized cohort study. Effect of a cancer screening intervention conducted by lay health workers among inner-city women. Nurse-Initiated Health Promotion Prompting System in an Internal Medicine Residents' Clinic Patient compliance with colorectal cancer screening in general practice. Can health education increase uptake of cervical smear testing among Asian women? Cancer screening utilization: is there a role for social work in cancer prevention? Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries. Prescribe for health. Improving cancer screening in physician practices serving low-income and minority populations. CONTROLLED TRIAL OF FAECAL OCCULT BLOOD TESTING IN THE DETECTION OF COLORECTAL CANCER Modeling adherence to colorectal cancer screening. Do postcard reminders improve influenza compliance? A prospective trial of different postcard "cues". Strategies to Increase Mammography Utilization Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized controlled trial in general practice. Improving the effectiveness of screening for colorectal cancer by involving nurse clinicians. Implementing preventive services. Success and failure in an outpatient trial. Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. Randomised trial of compliance with screening for colorectal cancer. Medicare Reimbursement for Preventive Care: Changes in Performance of Services, Quality of Life, and Health Care Costs Randomized controlled study of customized preventive medicine reminder letters in a community practice.
Objective The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women . Design A r and omized controlled trial employing firm system methodology was conducted . Setting The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle . Participants Women aged 50 to 74 years with at least one routine clinic appointment ( when they were due for mammography ) during the study period were enrolled in the trial ( n=314 ) . Interventions The intervention program emphasized nursing involvement and included physician education , provider prompts , use of audiovisual an printed patient education material s , transportation assistance in the form of bus passes , preppointment telephone or postcard reminders , and rescheduling assistance . Control firm women received usual care . Measurement and Main Results Mammography completion within 8 weeks of clinic visits was significantly higher among intervention ( 49 % ) than control ( 22 % ) firm women ( p<.001 ) . These effects persisted after adjustment for potential confounding by age , race , medical insurance coverage , and previous mammography experience at the hospital ( odds ratio 3.5 ; 95 % confidence interval 1.9 , 6.5 ) . The intervention effect was modified by type of insurance coverage as well as prior mammography history . Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation . Conclusions A clinic-based program incorporating physician education , provider prompts , patient education material s , and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women Two theory-based programs to increase mammography screening rates among asymptomatic women were implemented and evaluated in the community . One program ( E ) was based on the Health Belief Model ( HBM ) ; the second program ( EP ) added exercises adapted from the social psychology of compliance . Program impact on screening among 295 primarily Caucasian , middle-class women was evaluated against untreated controls ( C ) over a 6-month period . Both programs led to increases in HBM components ( Perceived Susceptibility , and Perceived Benefits ) and Intentions to obtain a mammogram . Screening rates 2 to 3 times higher were observed in the EP and E over C conditions ; EP and E did not differ . A mediational model of compliance illustrated the interplay of HBM components in the compliance process In an academic general medicine clinic , we performed a r and omized , controlled trial to compare ( 1 ) the effects of supplying monthly feedback reports of compliance with preventive care protocol s by 135 internal medicine house staff with ( 2 ) the effects of specific reminders given to them at the time of patient visits . The protocol s were r and omly divided into two groups , A and B , and half the house staff were given feedback for Group A and half for Group B. Thus , each group served as a control for the other . Each feedback group was also r and omly assigned to receive reminders for either Group A or B protocol s. House staff receiving feedback more often complied with fecal occult blood testing , mammography , pneumococcal vaccination , use of metronidazole , and combined Group A and B protocol s than did controls ( P < 0.01 ) . There was also significantly more compliance with the same protocol s by house staff receiving reminders , but the increase for fecal occult blood testing , pneumococcal vaccination , and combined Group A protocol s was twice that seen in physicians given feedback alone . In addition , reminders alone increased compliance with oral calcium supplementation . Overall compliance with the preventive care protocol s was low : 10 - 15 % in physicians receiving neither feedback nor reminders , increasing to 15 - 30 % in those receiving reminders . Physician compliance with suggested preventive care protocol s can be increased by both delayed feedback and immediate reminders , but reminders have a greater effect BACKGROUND Although rates of mammography screening among women in the general population have been increasing they still fall short of national goals . This study evaluated the effects on rates of participation in mammography screening of obtaining risk factor information and providing general or personalized risk information through direct mailed correspondence . METHODS Women enrollees in a health maintenance organization ( N = 2,076 ) , age 50 and above , were r and omized to one of the following four groups : ( a ) no risk factor question naire + generic invitation , ( b ) no risk factor question naire + general risk invitation , ( c ) risk factor question naire + general risk invitation , and ( d ) risk factor question naire + personal risk invitation . Computerized visit records were monitored for 12 months following a mailed invitation to assess whether a mammogram had been obtained . RESULTS Overall participation was 37.5 % and the rate of participation did not differ significantly across groups ( P = 0.26 ) . Participation was related to age ( P < 0.02 ) , with rates highest for women ages 60 - 69 years ( 42.7 % ) compared with those for women ages 50 - 59 ( 35.5 % ) and those age 70 + ( 33.7 % ) . Among women with a family history of breast cancer , the personalized risk invitation was associated with significantly higher participation compared with general risk invitation ( 66.7 versus 42.9 % , respectively ; P < 0.003 ) . CONCLUSIONS Women with a family history of breast cancer are more likely to obtain a mammogram if that fact is reinforced as a risk factor . Research on environmental barriers to mammography screening may suggest alternative strategies for increasing participation OBJECTIVE --To discover whether systematic methods of call and recall are more effective than a non- systematic method and to see which of the two systematic methods was more effective . DESIGN -- Prospect i ve r and omised controlled trial over a year . SETTING --One group general practice . PATIENTS --416 Women over 35 eligible for a smear test who had never had a cervical smear test or in whom a smear test was overdue ( previous test more than five years before ) . INTERVENTIONS --One group received written invitations to have a smear taken . The second group had their notes tagged so that the doctor would remind them ( when they attended for another reason ) to have a smear test . No special intervention was made in the third group . MAIN OUTCOME MEASURE -- Performance of a cervical smear test during the year of the study . RESULTS --32 % ( 45/140 ) of the screened group , 27 % ( 39/142 ) of the tagged group , and 15 % ( 20/134 ) of the control group had a smear test during the year . The percentage of women having a smear test in the screened group was not significantly different from that in the tagged group , but the percentages in the two groups were significantly different from that in the control group . Whether a woman had had a previous smear test significantly affected the uptake of the invitation to have a smear test independently of the method of invitation . CONCLUSIONS --The systematic methods of call and recall were more effective than a non- systematic method . There was no significant difference between the two systematic methods ( sending letters or tagging the notes ) at one year BACKGROUND Although tests for occult blood in the feces are widely used to screen for colorectal cancers , there is no conclusive evidence that they reduce mortality from this cause . We evaluated a fecal occult-blood test  in a r and omized trial and documented its effectiveness . METHODS We r and omly assigned 46,551 participants 50 to 80 years of age to screening for colorectal cancer once a year , to  screening every two years , or to a control group .  Participants who were screened su bmi tted six guaiac-impregnated paper slides with two smears from each of three consecutive stools . About 83 percent of the slides were rehydrated . Participants who tested positive underwent a diagnostic evaluation that included colonoscopy .  Vital status was ascertained for all study participants during 13 years of follow-up . A committee determined causes of death . A single pathologist determined the stage of each tissue specimen . Differences in mortality from colorectal cancer , the primary study end point , were monitored with the sequential log-rank statistic . RESULTS The 13-year cumulative mortality per 1000 from colorectal cancer was 5.88 in the annually screened group ( 95 percent confidence interval , 4.61 to 7.15 ) , 8.33 in the biennially screened group ( 95 percent confidence interval , 6.82 to 9.84 ) , and 8.83 in the control group ( 95 percent confidence interval , 7.26 to 10.40 ) . The rate in the annually screened group , but not in the biennially screened group , was significantly lower than that in the control group . Reduced mortality in the annually screened group was accompanied by improved survival in those with colorectal cancer and a shift to detection at an earlier stage of cancer . CONCLUSIONS Annual fecal occult-blood testing with rehydration of the sample s decreased the 13-year cumulative mortality from colorectal cancer by 33 percent Objectives – Firstly , to determine whether the acceptance rate of the second invitation for breast screening ( sent to women who have failed to attend after the first invitation ) might be increased by an accompanying letter from a general practitioner ( GP letter ) . Secondly , to identify the additional costs of sending such a letter . Methods – 465 women registered with four practice s in a single health centre were recruited into a r and omised controlled trial in which the intervention was the inclusion of a st and ard , photocopied letter signed by the non-attender 's doctor with the second invitation to attend for breast screening . The control group received only the st and ard invitation from the breast screening centre . The costs associated with the intervention were assessed from data supplied by the breast screening centre , supplemented by direct observation of the preparation of second invitations and semistructured interviews with the staff taking part . Results - The attendance rate of the test group one month after the second invitation for screening was significantly higher than that of the control group ( 21 % v 10 % , P<0.01 ) . The average cost of a GP letter included with the invitation was 1.1 pence and the marginal cost for each extra attender was 9.6 pence . No non-monetary costs were identified . Conclusions – The inclusion of a GP letter appeared to be effective and feasible in increasing the attendance rate to the second invitation . This intervention should be tested in other screening groups to confirm the effectiveness of a GP letter and its cost effectiveness Patient compliance in returning fecal-hemoccult card packets has been studied in recent years but no specific interventions have been shown consistently to improve the return rate . It was wondered whether removing a small financial barrier for indigent patients would positively affect compliance . Therefore , the effect of prepaid postage on the rate of return was studied . Pre-prepared packets containing hemoccult cards with return envelopes were distributed in a r and omized fashion to indigent and private insurance patients in outpatient clinics . On half of the return envelopes return postage was applied . The main outcome measure was the rate of return of stamped and unstamped packets  stratified between indigent and private insurance patients . The overall rates of return were 117 of 159 ( 74 % ) for the stamped packets and 102 of 166 ( 61 % ) for unstamped packets ( p < 0.02 ) . After stratification , in the indigent patients ( n = 177 ) , 73 of 95 ( 77 % ) stamped packets were returned compared to 46 of 82 ( 56 % ) unstamped packets ( p < 0.006 ) . In the private insurance patients ( N = 148 ) , 44 of 64 stamped packets ( 69 % ) and 52 of 84 unstamped packets ( 62 % ) were returned ( p > 0.10 ) . Removing even small financial barriers ( eg , providing a postage stamp ) can enhance compliance for indigent patients The results of the Swedish two-county trial of mammographic screening for breast cancer are presented , up date d to December 31 , 1990 , which is an average of 10.8 years follow-up per person . The main result of the trial in terms of breast cancer mortality remained the same : compared with the control group , the group invited to screening had a relative breast cancer mortality of 0.70 ( P = 0.0002 ) with 95 % confidence interval ( 0.58 , 0.85 ) . Analysis of survival showed that relative to the control group , the cancers detected at prevalence screen , incidence screens , and in the interval between screens had a good prognosis , whereas cancers detected in those who had refused screening had a very poor prognosis . When adjusted for tumor size , lymph node status , and tumor grade ( differentiation ) , the better survival associated with incidence screen and interval detection was largely accounted for , indicating that the benefit of incidence screening is largely achieved through the effect of screening on the three prognostic variables , notably size of the tumor . Results indicate that to achieve a substantial mortality reduction , 50 % of screen-detected invasive cancers should be less than 15 mm in diameter , at least 30 % of screen-detected grade 3 tumors should be less than 15 mm , and at least 70 % of screen-detected tumors should not have lymph node metastases . The percentage of grade 3 tumors of a given size should be the same in screen-detected cancers as in clinical ly detected , and breast cancer prevalence at first screen should be at least three times the expected incidence rate in the absence of screening . This should be achieved without the recall rate for further examination exceeding 9 % , and procedures including further imaging techniques and fine needle aspiration or core biopsy should be used before resorting to surgical biopsy . These aims can be achieved in specialist screening centers if particular attention is paid to re sources for screening and diagnostic evaluation , specialist training of clinical and technologic screening staff , and ongoing monitoring of mammographic quality , recall rates , and the attributes of the tumors detected OBJECTIVES This study evaluated a two-step intervention for mammography screening among older women . METHODS Four hundred and sixty women , identified from physician practice s , were r and omized to a control or a two-step intervention ( physician letter and peer counseling call ) group . Women in the intervention group who obtained a mammogram received a grocery coupon . RESULTS Over the 12 months of the study , more women in the intervention group than in the control group obtained mammograms ( 38 % vs 16 % ) . The most dramatic difference was in the higher odds that women in the intervention group would obtain a mammogram within 2 months ( odds ratio = 10.5 ) . CONCLUSIONS The intervention significantly increased screening mammography . Future efforts must be multifaceted and incorporate the unique concerns of older women Abstract Objectives : To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening , and whether women from different ethnic groups benefited equally . Design : Controlled trial , r and omised by general practice . Setting : Inner London borough of Newham . Subjects : 2064 women aged 50–64 years who had failed to attend for breast screening . Women came from 26 of 37 eligible practice s. 31 % were white , 17 % were Indian , 10 % Pakistani , 14 % black , 6 % Bangladeshi , 1 % Chinese , 4 % were from other ethnic groups , and in 16 % the ethnic group was not reported . Main outcome measures : Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation . Results : Attendance in the intervention group was significantly better than in the control group ( 9 % v 4 % ) . The response was best in Indian women — it was 19 % in the intervention group and 5 % in the control group . Conclusions : This simple , low cost intervention improved breast screening rates modestly . Improvement was greatest in Indian women — probably because many practice staff shared their cultural and linguistic background . This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates . Key messages The uptake of breast screening is inadequate and inequitable in some deprived areas —often those with large minority ethnic population s Training general practice receptionists to contact women who had not responded to an initial invitation for breast screening made a small but important improvement in attendance Improvement was most pronounced among Indian women — perhaps because most practice s employed staff who spoke an Indian language Re sources of local general practice s could be used as part of multifaceted programmes to increase screening rates in areas of low uptake This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice :  tagging the medical record to remind the doctor to offer a Pap smear , sending an invitation to make an appointment for a Pap smear , and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women . The study took place in a university general practice at Lockridge , near Perth . A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive . Of these , 757 were eligible for inclusion in the study and were allocated r and omly to one of three intervention groups or a control group . In total , 177 women had a Pap smear during the study . Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group ( odds ratio ( OR ) 2.13 , 95 % confidence interval ( CI ) 1.34 to 3.57 , and OR 1.67 , CI 1.01 to 2.77 respectively ) , but there was no significant difference between the tagged-notes and the control groups . Women who attended the screening clinic rated the experience positively . Attendance , however , was inadequate for the clinic 's viability in a private practice To improve the  pneumococcal vaccination status of an elderly patients group , those older than 64 years of age were identified from a computer file of all continuing care patients in a general internal medicine clinic . In a r and omly chosen study group ( N = 163 ) , 91 elderly patients ( 56 per cent ) had received the pneumococcal vaccine .  Factors associated with a higher rate of pneumococcal vaccination  included receiving the previous year 's influenza vaccine , a medical problem list attached to the patient 's chart , active clinic status ( i.e. , seen in the year before the study began ) , and more than two problems listed in the computer record . Letters encouraging pneumococcal vaccination were then sent to patients who had not been vaccinated . Twenty of 72 patients ( 28 per cent ) who received the letter were vaccinated during the next year ; 8 per cent of control patients ( three of 39 ) who did not receive the letter were vaccinated . The 95 per cent confidence limit for the relative difference between the study and control group is 6 to 53 per cent . The relative difference was also significant for influenza vaccination  between the intervention group and the portion of the control group that had not been vaccinated at the first chart review . Factors associated with pneumococcal vaccination rate following the mailing of the reminder letter were active clinic status and being up to date for either influenza or tetanus vaccination . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND To compare three approaches for improving compliance with breast cancer screening in older women . METHODS R and omized controlled trial using three parallel group practice s at a public hospital . Subjects included women aged 65 years and older ( n = 803 ) who were seen by residents ( n = 66 ) attending the ambulatory clinic from October 1 , 1989 , through March 31 , 1990 . All provider groups received intensive education in breast cancer screening . The control group received no further intervention . Staff in the second group offered education to patients at their visit . In addition , flowsheets were used in the " Prevention Team " group and staff had their tasks redefined to facilitate compliance . RESULTS Medical records were review ed to determine documented offering/receipt of  clinical breast examination and mammography .  A subgroup of women without previous clinical breast examination ( n = 540 ) and without previous mammography ( n = 471 ) were analyzed to determine the effect of the intervention . During the intervention period , women without a previous clinical breast examination were offered an examination significantly more often in the Prevention Team group than in the control group , adjusting for age , race , and comorbidity and for physicians ' gender and training level . The patients in the Prevention Team group were offered  clinical breast examination  ( 31.5 % ) more frequently than those in the patient education or control groups , but this was not significant after adjusting for the above covariates . Likewise ,  mammography  was offered more frequently to patients in the Prevention Team and in the patient education group than to patients in the control group , after adjusting for the factors above using logistic regression . CONCLUSIONS The results provide support for patient education and organizational changes that involve nonphysician personnel to enhance breast cancer screening among older women , particularly those without previous screening A r and omized trial was conducted to evaluate the combined impact of a physician reminder letter and a telephone contact on the use of Pap tests and mammograms in a low-income managed care program . Women 40 to 79 years of age who were past due for cancer screening were r and omly assigned to an intervention or control group . Medical cl aims were review ed after 6 months to determine intervention effectiveness . The odds of receiving all needed cancer screening tests during follow-up were four times higher in the intervention group . Women who reported having to take time off from work to see a doctor had lower odds of getting screened In a r and omized trial three ways of increasing rates of cervical screening  were compared for women attending a family medicine center . Working from computerized medical records , 1,587 women aged 18 to 35 years who were overdue for a screening test were included in the study . In a control group , no formal method was used to encourage patients to attend for screening , and 13.7 percent obtained a test within the trial year . In one intervention group the physician was issued a message identifying those women visiting the center for a routine appointment who were due for screening ; 16.1 percent were screened . Sending a letter to patients in a second group yielded a 25.9 percent compliance rate . In a third group the practice nurse called patients on the telephone to advise them to obtain the test , and 20.0 percent complied . Reminders issued to the physician provide a low-cost , opportunistic approach to reach women who happen to visit the practice , but this approach should be supplemented by telephoning or sending a letter to those women who do not attend regularly Screening for colorectal cancer by testing for faecal occult blood ( FOBT ) is effective for early diagnosis , but the success of a screening programme also depends on compliance . The aims of this study were to assess the effect of health education on compliance and to assess any addition to general practitioner workload that result ed . Altogether 3860 patients were recruited and r and omly allocated to test or control group . The test group was further divided into subgroups , some of which received health education .  Compliance with FOBT was 54.7 % ( 210/384 ) in the subgroup receiving only the doctor 's letter , which fell to 48.1 % ( 743/1544 ) in the group receiving health education .  General practitioner consultation rates were similar in test and control groups Despite recommendations supporting annual influenza vaccination for people aged 65 years or older , vaccination rates remain low . Several studies have evaluated the effect of sending mailed reminders , but few have compared alternative ways of reminding patients to receive the vaccine . In a r and omized trial of 939 patients aged 65 years or older in four family practice s carried out between Oct. 23 and Dec. 31 , 1984 , we compared three ways of reminding elderly patients to receive the vaccine : personal reminder by the physician , telephone reminder by the nurse and reminder by letter . The vaccination rates for the three groups were 22.9 % , 37 % and 35.1 % respectively . No reminder was issued to a control group , and the rate was 9.8 % . Some patients could not be reached by telephone , and some did not see the physician during the specified time . Among the patients whom the nurse actually contacted , the vaccination rate was 43.5 % ; the rate for patients whom the doctor actually saw was 45.1 % . Overall , a telephone reminder by the nurse was the most effective method , and at an hourly salary of $ 16 or less this method would also be the most cost-effective . The reminders used in this study were automatically generated from a computerized medical record system . The study shows how a computerized system can be used to identify patients for whom preventive procedures are due This study compared three interventions design ed to increase acceptance of influenza and pneumococcal vaccines among elderly hospitalized patients . All individuals 65 and older able to give informed consent ( 73 patients ) who were admitted to one medical floor of an acute care hospital were r and omized to one of three groups . All groups received informational pamphlets explaining influenza and pneumococcal disease , their respective vaccines , and indications for their use . The first group received pamphlets only , the second received nursing follow-up , and the third received trained volunteer follow-up .  Patients on another medical floor served as controls . The results showed a significant improvement in vaccine acceptance in all three study groups compared to controls for both influenza ( 78 % vs 0 % ) and pneumococcal ( 75 % vs 0 % ) vaccines . The differences among the three groups were not significant . No significant differences were found among patients accepting or refusing vaccination with regard to diagnosis , age , length of stay , sex , or having a private physician . We conclude that a simple educational program followed by offering vaccination before hospital discharge can be easily implemented , and dramatically increase immunization rates in this high risk group This investigation was a r and omized controlled trial to determine the impact of health education interventions on the return of mailed fecal occult blood ( FOB ) tests ( FOBT adherence ) in a colorectal cancer screening program . The study sample included 2,201 men and women aged 50 to 74 years who were members of an Independent Practice Association (IPA)-type health maintenance organization ( HMO ) . Subjects were r and omly assigned to a “ usual care ” Control Group ( advance letter , screening kit , reminder letter ) , and Treatment Groups 1 ( usual care + reminder call ) , 2 ( usual care + self-held screening booklet + reminder call ) , or 3 ( usual care + self-held screening booklet + instruction call + reminder call ) . Bivariate analysis revealed significant differences in adherence ( P<.001 ) across study groups : Control Group ( 27 % ) , Group 1 ( 37 % ) , Group 2 ( 37 % ) , Group 3 ( 48 % ) . In addition , a significant positive association between age and adherence ( P<.001 ) was found . Logistic regression analysis revealed an interaction between sex and treatment . Adherence among men in all treatment groups increased significantly ( P<.0001 ) in relation to Control Group males . Men in Group 3 also were more likely to adhere than those in Group 2 ( P<.01 ) or Group 1 ( P<.01 ) . Among women , adherence was significantly higher in Group 3 than in Group 2 ( P<.03 ) , Group 1 ( P<.025 ) , or the Control Group ( P=.0008 ) . The primary reason cited for nonadherence was perceived inconvenience of the FOB testing procedure OBJECTIVE --To assess whether an organised programme of prevention including the use of a health promotion nurse noticeably improved recording and follow up of cardiovascular risk factors and cervical smears in a general practice that had access to computerised cell and recall . DESIGN --R and omised controlled trial . SETTING --General practice in inner London . PATIENTS --All 3206 men and women aged 30 - 64 registered with the practice . INTERVENTION -- The intervention group had their risk factors ascertained and followed up by the health promotion nurse and the general practitioner , whereas those in the control group were managed by the general practitioner alone . END POINT -- Recording and follow up of blood pressure and cervical smears after three years . Recording of smoking , family history of ischaemic heart disease , and serum cholesterol concentrations were also examined . MEASUREMENTS and MAIN RESULTS --When the trial was stopped after two years the measurements of blood pressure in the preceding five years were 93 % ( 1511/1620 ) v 73 % ( 1160/1586 ) ( 95 % confidence interval for difference 17.5 to 22.7 % ) for intervention and control groups respectively . For patients with hypertension the figures were 97 % ( 104/107 ) v 69 % ( 80/116 ) ( 18.2 to 38.2 % ) . For women the proportion who had had a cervical smear in the preceding three years were 76 % ( 606/799 ) v 49 % ( 392/806 ) ( 22.5 to 31.9 % ) . Recording of smoking , family history of ischaemic heart disease , and serum cholesterol concentrations was also higher in the intervention group compared with the control group . CONCLUSION --An organised programme , which includes a nurse with specific responsibility for adult prevention , is likely to make an important contribution to recording of risk factors and follow up of those patients with known risks BACKGROUND Influenza is responsible for significant morbidity , mortality , and medical costs , but immunization rates in the elderly remain low . METHODS As part of a demonstration project in rural Pennsylvania , 1,989 community-dwelling Medicare beneficiaries , 65 - 79 years old , completed a health risk appraisal including questions about flu shots . Participants were r and omized to two experimental ( hospital or physician ) or control groups . Experimental groups were offered free flu shots for the 1990 - 91 flu season . Follow-up interviews to determine vaccination rates were completed about 1 year later . RESULTS Baseline immunization rates were almost identical for the hospital-based ( 41.2 % ) , physician-based ( 41.3 % ) , and control group not offered free immunizations ( 40.6 % ) . Follow-up rates for the groups offered immunizations rose significantly to 63.6 and 69.1 % for hospital and physician groups , respectively , while the control group also increased significantly to 54.1 % . Individuals who were more educated , were older , and had greater chronic diseases history ( myocardial infa rct ion , hypertension , and pulmonary disease ) were more likely to be immunized . Male and married elderly were more likely to be immunized as a result of the demonstration . CONCLUSIONS Increasing community education and providing immunizations free through Medicare will increase immunization rates among elderly . The elderly are more likely to receive flu shots provided through physicians ' offices than through hospital-based clinics STUDY OBJECTIVES : To determine the relative effectiveness of three interventions design ed to increase the uptake of breast screening . DESIGN : R and omised controlled trial of a nurse visit with health education ( group A ) , nurse visit without health education ( group B ) , and GP letter ( group C ) . SETTING : The area of south east London served by the Butterfly Walk Breast Screening Unit in Camberwell . PARTICIPANTS : Women aged between 50 and 64 years who were registered with 27 GPs in the Lambeth , Southwark and Lewisham family health services authority and who had not attended for first round screening . MAIN RESULTS : Altogether 799 women were r and omly allocated to the three groups . In general , delivering the nurse based interventions proved difficult . In group A , 11.4 % ( 95 % CI 7.9 , 14.9 % ) of women subsequently attended for screening compared with 7.8 % ( 95 % CI 5.1 , 11.4 % ) in group B and 13.1 % ( 95 % CI 7.9 , 18.4 % ) in group C. The differences between the groups ( 95 % CIs ) were not statistically significant : A versus C , -1.7 % ( -8.0 , + 4.6 % ) ; B versus C , -5.3 % ( -11.3 , + 0.7 % ) ; A versus B , + 3.6 % ( -1.0 , + 8.2 % ) . CONCLUSIONS : A personal letter from the GP seems to be at least as effective at increasing the uptake of breast screening in non-attenders as a nurse making a home visit to discuss the issue of breast screening , and is not noticeably less effective than a visit at which a health education intervention is delivered . It is possible that the GP letter is considerably more effective than either of the two interview-based interventions . With regard to implementing strategies which will increase breast screening uptake and are cost effective , further trials of similar minimal interventions in primary care are required Screening mammography is underutilized in many primary care practice s. We design ed a prospect i ve , controlled trial to evaluate two strategies for improving the utilization of mammography in an academic general medicine clinic . We assigned teams of house officers to ( 1 ) physician audit with periodic feedback , ( 2 ) a visit-based strategy directed at both patient and physician , or ( 3 ) a no intervention concurrent control arm . After 6 months , the percentage of 50- to 74-year-old women meeting the st and ard of an annual mammogram  was 36 % for patients in the control arm , 62 % for patients of feedback residents , and 54 % for patients of the arm receiving the visit-based strategy . Patients of female providers were slightly more likely to meet the st and ard , but no effects were detected for patient race , new as opposed to follow-up patient , or higher frequency of clinic visits . We conclude that audit with feedback and a new visit-based strategy of a patient cue associated with a simplification of the ordering process each greatly improved the rate of utilization of screening mammography . Practitioners could reasonably choose the strategy most suited to their own situation INTRODUCTION Mammography has been shown to reduce breast cancer mortality among women 50 and older . Although mammography rates are increasing nationally , this effective screening tool remains underused . This study was conducted among 395 women who were members of a network model health maintenance organization ( HMO ) in Philadelphia in order to determine which of three methods was most effective in increasing mammography rates : ( 1 ) a birthday card reminder only ( the st and ard method ) ; ( 2 ) a personalized letter from the medical director and material s promoting mammography ; and ( 3 ) a multicomponent phone call incorporating a reminder , counseling , and scheduling of appointments . An additional goal was to determine whether the interventions were more or less effective depending on a woman 's readiness to get a mammogram , as measured by stage of change . METHODS Eligible women were r and omized into one of three treatment groups described earlier . Mammography rates were calculated on the basis of a cl aims review and follow-up phone interviews after a period of six months . RESULTS Women who received the telephone intervention were most likely to obtain a mammogram ( 28 % ) ; followed by the group that received the birthday card only ( 15 % ) , and those who received the mailed intervention ( 9 % ) . CONCLUSIONS These results indicate that a multicomponent phone intervention is significantly effective in promoting mammography in managed health care plan members . An analysis by women 's stage of change found a difference in the effectiveness of the three interventions among contemplators only During the 1984 - 1985 influenza season two study groups were used to compare telephone and letter reminder methods with a control group that received no reminder to determine which was the most effective strategy to increase influenza vaccination rates among the high-risk patient population of a university-based family practice . Seven hundred eighty-seven high-risk patients were r and omly assigned to one of the three study groups : a mailed-reminder group , a telephone-reminder group , and a control group .  Vaccination rates for both reminder methods were significantly higher than for the control group ( P less than .02 ) , and if successfully contacted , the telephone-reminder group had a significantly better vaccination rate than the mailed-reminder group ( P less than .05 ) . If successful telephone contact can be made , this reminder method is more effective than a letter reminder to increase influenza vaccination rates among high-risk patients AIMS This study aims to assess the effects of two interventions on influenza vaccination coverage : a simple organisational strategy , and making the vaccine available free . METHODS Sixteen general practitioners in the Auckl and region were r and omly selected to participate . Patients over 65 years of these general practitioners were r and omly allocated to control , letter of invitation for a flu vaccine , or offer of a free flu vaccine . Administration of a flu vaccine for each person in the study was documented in each general practitioner surgery . Vaccine coverage for each of the three groups was measured . RESULTS Results were available for 15 of the 16 participating general practitioners , a total of 2791 subjects .  Immunisation coverage rates for control , letter of invitation and vaccine at no cost , were 17 % , 27 % and 45 % respectively . Statistical analysis , allowing for the cluster method used to obtain subjects , showed risk ratios of 1.55 and 2.65 for the two interventions , with p values of < 0.00001 . CONCLUSIONS A potential source of bias in this study is underreporting of administration of vaccine to people in group 1 . Notwithst and ing this potential bias , both interventions were highly effective at increasing the uptake of influenza vaccine in the elderly population . General practitioners should be recommended to routinely invite patients over 65 years to have a flu vaccine . Given the commitment of the Ministry of Health to the vaccination against influenza of people over 65 , this study would suggest that serious consideration should be given to making the vaccine available at no cost to this age group A factorial design r and omized controlled trial to test several clinical ly feasible strategies primary -care practitioners may use in routine practice to increase  patient participation in occult blood testing for colorectal cancer is reported . Three compliance-enhancing intervention strategies ( physician/nurse talk , and /or reminder postcard , and /or reminder phone call ) were introduced . Patient health beliefs were examined as compliance predictors . High compliance levels were seen in all intervention groups , with a mean of 89 % compared with 68 % in controls . An interactive talk by the physician or nurse increased compliance by 12 - 13 % . The reminder postcard was the most effective single intervention . It increased compliance by 24 - 25 % , achieving 92.7 % overall compliance , and appeared to be cost-effective . Patient health beliefs were of minimal value in predicting compliance in this study OBJECTIVES In a health maintenance organization that mails letters to women recommending that they schedule mammograms , we conducted a r and omized trial to evaluate simple methods of increasing the use of screening mammography . METHODS Using a 2 x 2 factorial design , we tested the effects of ( 1 ) mailing the recommendation letter from each woman 's primary care physician rather than from the program director and ( 2 ) sending a subsequent reminder postcard . RESULTS Sending a reminder postcard nearly doubled the odds that women would get mammograms within 1 year ( participate ) . The letter from the woman 's personal physician had no effect . Attending a clinic more than 45 minutes from the screening center , being a current smoker , or being in fair or poor health were negatively associated with subsequently obtaining a mammogram . The odds of participation doubled if women had had previous mammograms . CONCLUSIONS When preceded by written recommendations to schedule mammograms , reminder postcards effectively increased participation . Future r and omized trials to promote use of screening mammography should compare interventions with a reminder condition OBJECTIVE To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients . DESIGN R and omized controlled trial using three parallel group practice s at a public urban teaching hospital . SETTING Public teaching hospital . SUBJECTS All patients 65 years of age and older ( n = 1202 ) seen by resident physicians ( n = 66 ) attending three ambulatory medical practice s from October 1 , 1989 to March 31 , 1990 . INTERVENTIONS All three provider groups received intensive education in immunization st and ards . The control group received no further intervention . Staff in the second group offered education to patients at their visits . In the third group , the prevention team , a flowsheet was used , patient education offered , and staff had their tasks redefined to facilitate compliance ; for vaccinations , eg , nurses could vaccinate independent of MD initiative . MEASUREMENTS AND MAIN RESULTS Medical records were review ed for the 1202 patients seen , including 756 patients seen during both the 1988 - 89 and 1989 - 90 influenza seasons , to determine documented offering and receipt of vaccinations . During the intervention period ( 1989 - 90 ) ,  influenza vaccinations  were offered significantly more frequently to prevention team patients ( 68.3 % ) than to patients in either the patient education ( 50.4 % ) or control ( 47.6 % ) groups ( P = 0.006 ) , even after adjusting for the patients ' prior vaccination status , age , gender , race , and high-risk co-morbidity and for physicians ' level of training . Likewise , pneumococcal vaccinations  were offered more frequently to previously unvaccinated prevention team patients ( 28.3 % ) than to patient education ( 6.5 % ) or control ( 5.4 % ) group patients ( P = 0.001 ) , even after adjusting for the factors using multivariate analysis . Compliance rates did not differ between patient education and control subjects for either vaccine . Pre-intervention physician surveys documented higher perceived than actual compliance for both vaccines , with 89.0 % and 52.8 % of physicians believing that they complied with influenza and pneumococcal vaccination guidelines , respectively . CONCLUSIONS The results of this trial provide strong support for organizational changes that involve non-physician personnel to enhance vaccination rates among older adults INTRODUCTION We conducted a r and omized controlled trial to determine if an in-home educational intervention conducted by lay health workers ( LHWs ) could increase adherence among low-income , inner-city , African-American women to breast and cervical cancer screening schedules . METHODS We recruited 321 African-American women from diverse inner-city sources . After baseline interviews , they were r and omly assigned to either the intervention ( n = 163 ) or the control ( n = 158 ) group . Those in the intervention group were visited in their homes up to three times by LHWs who provided a culturally sensitive educational program that emphasized the need for screening . RESULTS Ninety-three ( 93 ) women in the intervention group and 102 in the control group completed the postintervention interview . For Pap smears , the increase in screening was similar in both groups . For clinical breast exams ( CBEs ) , however , there was a modest increase in the intervention group . The improvement was greatest for mammography , for which there was a 10 % to 12 % increase . Among women who were not on recommended schedules at baseline , the improvement was substantial and greater in the intervention group . CONCLUSIONS LHWs ' intervention appeared to improve the rate at which inner-city women obtained CBEs and mammograms , but had no effect on Pap smears . A high attrition rate weakened our ability to make conclusive statements about the exact impact of the intervention Although cure of many diseases depends on early detection , screening schemes have been difficult to implement in busy clinic environments . We describe the testing of a nurse-initiated prompting system for six health promotion and disease prevention procedures in an internal medicine residents ' clinic at a university-affiliated community program . Maneuvers investigated were breast examination , pelvic examination and Pap smear , rectal examination in men , mammogram , stool guaiac test , and blood glucose determination . A nurse review ed the charts and used a list in the front of each chart to prompt residents in the experimental group . Residents in the control group were not prompted . A significant improvement ( P < .05 ) in performance was seen in the prompted group . Performance of rectal examination and mammograms improved most , increasing from 41 % to 93 % and 18 % to 64 % , respectively . There were no significant changes in the control group . This simple nurse-initiated prompting system improved the performance of health promotion and disease prevention maneuvers A r and omized controlled trial to test patient compliance with screening for colorectal cancer in association with general practice health checks was carried out in six practice s ( three urban and three rural ) . A total of 1588 patients aged 45 - 64 years were r and omized to one of four intervention groups . In the first group patients were posted a Haemoccult test ( Kline Beckman ) kit . This group was not invited for a health check . In the second group patients were posted the Haemoccult test kit , together with an invitation to attend for a health check . In the third group patients were posted an invitation for a health check , which explained that the patient would be offered the Haemoccult test kit by the nurse at the health check . In the fourth group patients were just invited for a health check . It was found that combining faecal occult blood testing with the health check did not reduce attendance at the health check--43.5 % of patients attended when the Haemoccult test kit was offered by the nurse at the health check , 43.6 % attended when a test kit was included with the invitation to attend the health check and 42.9 % attended when the health check invitation was posted on its own . Overall , compliance with Haemoccult testing was not significantly increased by associating it with a health check ( 26.2 % versus 25.5 % ) but compliance was higher when the faecal occult blood testing kit was enclosed with the health check invitation than when it was offered at the health check ( 31.7 % versus 20.6 % , P less than 0.001 ) . It is easier and cheaper to combine various screening procedures . Although the overall use of the Haemoccult test in the study population was low , there is no reason why the relatively higher compliance rate obtained on posting the test kit with a health check invitation can not be achieved in previously unscreened population s with higher expected compliance rates . However , faecal occult blood screening for colorectal cancer should not be undertaken on a population basis until its effectiveness in reducing mortality has been proven by r and omized trial OBJECTIVES --To determine the effects of three different methods of providing health education on the uptake of cervical smear testing among Asian women , and to evaluate the acceptability of different health education material s. DESIGN -- Prospect i ve cohort study over one year of effects of written material s by post , personal visit to give written material s , and personal visit to show a video on the  uptake of smear testing . Techniques included a personally administered question naire . SETTING --Leicester , a city with a large Asian population . SUBJECTS--737 r and omly selected Asian women aged 18 to 52 who were not recorded on the central cytology laboratory 's computer as ever having had a cervical smear test . 159 declined to participate or were not contactable . INTERVENTIONS --Women were r and omised into four groups : visited and shown a video ( 263 ) , visited and shown a leaflet and fact sheet ( 219 ) , posted a leaflet and fact sheet ( 131 ) , not contacted at all ( 124 ) . MAIN OUTCOME MEASURES --Cervical smear test recorded on computer within four months after intervention . RESULTS --57 ( 37 % , 26 % of group ) of the women visited and given leaflets and 80 ( 47 % , 30 % of group ) shown the video attended for cervical smears . Only six ( 5 % ) of those who were not contacted and 14 ( 11 % ) of those sent leaflets had a smear test during the study . CONCLUSION --Health education interventions increased the uptake of cervical cytology  among Asian women in Leicester who had never been tested . Personal visits were most effective irrespective of the health education material s used , but there was some evidence that home viewed videos may be particularly effective in one of the most hard to reach groups : Urdu speaking , Pakistani Moslems . Written translated material s sent by post were ineffective Colorectal cancer is a life threatening , yet treatable , disease . Although early detection can improve health outcomes and preserve quality of life , many people are not screened . A post-test experimental design was used to test an intervention to increase screening behavior  among eighty-one family practice patients , aged 50 - 70 . Subjects were given a brief talk and a packet of educational material s. The physician recommended that each person complete a screening test at home . The experimental group was given a free screening test . The utilization rate in the experimental group was 51 % compared to 0 % in the control group . Findings suggest free kits  encourage more use ; yet further exploration is needed to explain non-use , even when free kits are provided . Recommendations for future social work practice and research are discussed BACKGROUND We review ed published and unpublished studies of mass mailings design ed to increase utilization of  influenza vaccine  among Medicare beneficiaries . METHODS Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project data base for unpublished studies . Study selection criteria were : use of a controlled trial design and use of mass mailings direct  to Medicare beneficiaries to increase receipt of influenza vaccinations .  Study selection and data extraction were performed in duplicate by physician review ers with consensus resolution . RESULTS Six controlled trials of mass mailings were identified . One study , published in the Morbidity and Mortality Weekly Report ( MMWR ) , reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not . This study was cited as justification for mail interventions performed in five subsequent studies , none of which reported clinical ly meaningful results . None of these five studies was published . CONCLUSIONS Mass mailings have at best had clinical ly trivial effects on increasing influenza vaccination among Medicare beneficiaries . Publication bias has contributed to continued use of a relatively ineffective intervention OBJECTIVE To evaluate a health maintenance organization (HMO)-sponsored intervention to improve cancer screening in private physician practice s serving low-income , minority population s. DESIGN A r and omized controlled trial with preintervention and postintervention measurements . Measurements were obtained by abstract ing information from independent r and om sample s of medical charts ( N = 2316 at preintervention and 2238 at postintervention ) . SETTING Forty-seven primary care physician practice s located in low-income and minority urban neighborhoods in Chicago , Ill. INTERVENTION Practice s were encouraged to adopt an office chart reminder system and to use a patient health maintenance card . Activities to facilitate the adoption of these items and for compliance with cancer screening guidelines included on-site training and start-up assistance visits , a physician continuing medical education seminar , and quality assurance visits with feedback to physicians . MAIN OUTCOME MEASURES The proportions of patients with a chart-documented mammogram , clinical breast examination , Papanicolaou smear , or fecal occult blood slide test in the 2 years before preintervention and postintervention chart abstract ions . RESULTS Between baseline and postintervention , there was a net increase in the proportion of HMO members in the intervention , compared with the control practice s , who received in the preceding 2 years a Papanicolaou smear ( 11.9 % ) and a fecal occult blood slide test ( 14.1 % ) . There was a net increase in the proportion of non-HMO patients in the intervention compared with the control practice s who received a clinical breast examination ( 15.3 % ) and a fecal occult blood slide test ( 20.2 % ) . CONCLUSIONS Implementation of an HMO-mediated , multicomponent intervention to improve cancer screening was feasible and effective for the Papanicolaou smear , fecal occult blood slide test , and the clinical breast examination , but not for mammography 20 525 patients from general practitioners ' lists were r and omly allocated into test and control groups . The 10 253 test subjects were invited to perform haemoccult faecal occult blood testing over 3 days . 3613 ( 36 . 8 % ) of the 9807 who received their invitations completed the test . Compliance was improved by direct invitation from the general practitioner and by prior health education by letter or interview .  77 people ( 2 . 1 % ) had a positive test result , and 50 % of these on investigation had neoplastic disease--12 had invasive carcinomas ( 9 Dukes ' stage A , 2 stage B , 1 stage C ) and 27 had 40 adenomas ( 12 over 2 cm , 2 of which contained areas of severe dysplasia ) . In the year following the screening test 1 carcinoma ( stage C ) has presented in the group which accepted the test , and 10 carcinomas ( 4 stage B , 4 stage C , 2 stage D ) have presented in the control group . This respresents a 3 . 6 times greater detection rate per 1000 persons in the test group than in the control group . Only 8 adenomas have presented in the control and non-responding groups . Fibreoptic sigmoidoscopy identified the 10 carcinomas within its range and 39 of the 40 adenomas . Double-contrast barium enema identified only 9 of the 12 carcinomas and 24 ( 62 % ) of the 40 adenomas . All 3 carcinomas not identified by barium enema were polypoid Dukes ' stage-A lesions BACKGROUND An explanatory framework referred to as the Preventive Health Model was used to identify factors associated with prospect i ve adherence to colorectal cancer screening . METHODS Data on sociodemographic , psychosocial , social influence , and program factors were collected via telephone survey  for 501 older adult members of an independent practice association-type health maintenance organization . Subjects were later mailed fecal occult blood tests for completion and return . Adherence was defined as the return of the tests within 90 days . RESULTS Structural analysis shows that for men ( N = 145 ) , perceived self-efficacy ( OR = 1.4 ) , salience and coherence of testing ( OR = 2.3 for a 5-point increment on a 30-point scale ) , and exposure to  health education interventions ( OR = 6.8 ) were significant independent predictors of intention to adhere and of adherence . Among women ( N = 185 ) , predictors were age ( OR = 1.8 ) and salience and coherence of testing ( OR = 1.8 for a 5-point increment on a 30-point scale ) . CONCLUSIONS These findings indicate that for both men and women , adherence is influenced strongly by the extent to which the behavior is judged to make sense in everyday life . It also appears that additional education and encouragement may persuade men and younger women to participate in screening A r and omized trial of various postcard reminder " cues " was performed to improve underst and ing of health-related behavior and to find better strategies for improving influenza vaccination compliance . Data were gathered on 283 high-risk patients ( 92 per cent response rate ) who received : 1 ) a " neutral " cue simply announcing the availability of vaccine ;  2 ) a " Health-Belief-Model " card written to take advantage of the association between certain health beliefs and vaccination behavior ; 3 )  a " personal " card signed by the patient 's physician ; or 4 )  no postcard . The highest rate of vaccination occurred among recipients of the Health-Belief-Model postcard ( 51.5 per cent vs. 20.2 per cent for control , p less than 0.001 ) . Linear logistic regression analysis found that age , prior vaccination history and experimental group had a significant effect on likelihood of being vaccinated . After adjusting for age and prior vaccination experience , the vaccination rate was found to be significantly higher for persons receiving the Health-Belief-Model postcard compared with persons receiving no postcard or a neutral postcard . We conclude that reminder postcards emphasizing elements of the health belief model may help increase vaccination rates This study compared the effects of theoretically driven interventions on compliance with mammography utilization . A 2 × 2 factorial design yielded groups : a control group , a belief intervention group , an informational intervention group , and a belief/informational intervention group .  A probability sample of 301 women , age 35 and older , without a history of breast cancer were r and omly assigned to groups . Subjects in the intervention groups received individually tailored messages to alter beliefs or provider information related mammography screening . Belief messages were developed from Health Belief Model constructs . Belief interventions significantly influenced all belief variables except perceived susceptibility in the desired direction . Women in belief/informational intervention group were almost four times more likely than those in the control group to comply with mammography recommendations in the year following intervention ( odds ratio=3.75 ) . In addition , belief variables and intervention significantly predicted mammography compliance 1 year postintervention OBJECTIVE To examine the impact of postal invitations and user fee on influenza vaccination rates . DESIGN A controlled r and omized trial in 13 general practice s. One third of the participating patients received postal invitations to influenza vaccination free of charge . Another third received postal invitations to influenza vaccination on paying the usual fee ( US$ 40 - 60 ) . The last third served as a control group , being vaccinated at their own request and paying the usual fee . SETTING General practice in the Counties of Funen and Vejle , Denmark . PATIENTS Five hundred and eighty-five patients aged 65 years or older , recognized by their general practitioner ( GP ) as being in the risk group for whom influenza vaccination is recommended . MAIN OUTCOME MEASURES Influenza vaccination rates . RESULTS In the control group 25 % ( 19 - 31 % , 95 % confidence interval ) of the patients were vaccinated , compared with 49 % ( 42 - 56 % ) in the group who received a postal reminder and paid the usual fee , and 72 % ( 65 - 78 % ) in the group invited to be vaccinated free of charge . CONCLUSION It is suggested that GPs send postal invitations to their elderly patients in the risk groups urgently recommending influenza vaccination . Attention should also be given to offering free influenza vaccination to elderly patients who have recognized indications for vaccination Despite repeated publications of the American Cancer Society guidelines , 2 little screening is performed . Although controversy continues concerning the utility and cost-effectiveness of this guideline , 3 findings from a previous study of residents demonstrated that 97 % favored yearly fecal occult blood testing ( FOBT ) for patients age 50 and older . Less than six percent of eligible patients seen by these residents received this Physicians endorse prevention but provide only low levels of screening , health counseling , and immunization . Between 1981 and 1986 , a r and omized controlled trial was conducted at the Seattle ( Wash ) Veterans Affairs Medical Center to assess the effectiveness of the following three methods of delivery of preventive services : ( 1 ) a physician-oriented model that includes education and motivation , a chart flowsheet listing recommended activities , and periodic feedback about performance ; ( 2 ) a patient education model in which patients were mailed an informative brochure advising them to ask physicians for preventive services as depicted in a patient-held pocket guide ; and ( 3 ) a health promotion clinic that patients were invited to attend . A control group received their usual care .  A total of 1224 male out patients were enrolled in the trial .  Baseline prevention rates for 12 age-specific prevention activities were below 25 % . Neither the control group rates during the 5-year trial nor the rates for the two educational models , either singly or as a combined intervention , changed . Only the health promotion clinic model was effective , tripling prevention rates in its first year and sustaining these levels for all 5 years . It is difficult to change the clinic roles of experienced physicians and their long-term patients in a specialized multiclinic setting . Providing a separate health promotion clinic option is popular with patients , bypasses gatekeeper barriers , is reasonable in cost , and warrants wider application BACKGROUND A dissemination intervention to facilitate adoption of a preventive practice guideline ( influenza vaccination for older adults ) in group practice s was developed and evaluated . The intervention , small-group consensus process , started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment ( ie , " buy in " ) to adopt the guideline . METHODS Thirteen group practice s and their primary care physicians ( mean size , 5 ) were assigned r and omly to intervention or control arms . In each group practice , physicians in the intervention arm met for 1 hour . Control physicians participated in an unrelated discussion ( non-steroidal drug use ) . Guideline adoption was determined by changes in physicians ' vaccination rates that were obtained through prechart and postchart review s of 51 physicians . Pre question naires and post question naires measured influenza knowledge and prevention attitudes . RESULTS Using analysis of covariance , the small-group consensus process was found to increase physician vaccination rates by 34 % compared with the control arm ( F ( 1,48 ) = 19.49 ) . All intervention arm physicians increased vaccination rates from before to after compared with 54 % of control arm physicians . Attitudes and knowledge did not change and were unrelated to increased vaccination rates . CONCLUSIONS A case is made for the small-group consensus process as an effective utilization-focused dissemination method . Interventions based on group dynamics and sensitive to local practice context s can be useful in facilitating adoption of guidelines by physicians in group practice OBJECTIVE To compare the impact of group outpatient visits to traditional " physician-patient dyad " care among older chronically ill HMO members on health services utilization and cost , self-reported health status , and patient and physician satisfaction . DESIGN A 1-year r and omized trial . SETTING A group model HMO in the Denver Metropolitan area . PARTICIPANTS Three hundred twenty-one members aged 65 and older , r and omized to a group visit intervention ( n = 160 ) or to usual care ( n = 161 ) . INTERVENTION Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse . Visits included health education , prevention measures , opportunities for socialization , mutual support , and for one-to-one consultations with their physician , where necessary . MEASUREMENTS Health services utilization and associated cost , health status , and patient and physician satisfaction . RESULTS Outcome measures obtained after a 1-year follow-up period showed that group participants had fewer emergency room visits ( P = .009 ) , visits to subspecialists ( P = .028 ) , and repeat hospital admissions per patient ( P = .051 ) . Group participants made more visits ( P = .021 ) and calls ( P = .038 ) to nurses than control group patients and fewer calls to physicians ( P = .019 ) . In addition , a greater percentage of group participants received influenza and pneumonia vaccinations ( P < .001 ) . Group participants had greater overall satisfaction with care ( P = .019 ) , and participating physicians reported higher levels of satisfaction with the groups than with individual care . No differences were observed between groups on self-reported health and functional status . Cost of care per member per month was $ 14.79 less for the group participants . CONCLUSIONS Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use , reduce cost of care , deliver certain preventive services more effectively , and increase patient and physician satisfaction A r and omised trial of compliance with screening for colorectal cancer by means of the haemoccult test was conducted in Farnborough and Basingstoke districts . In each of the 14 participating practice s ( 41 general practitioners ) 25 852 men and women aged between 40 and 70 years were r and omly allocated by household to one of six groups . The group determined the method of invitation to screening : a letter and the test were sent to the patient , or a letter with an appointment to attend the surgery was sent , or during a routine consultation the general practitioner invited patients to participate , and some patients received an educational booklet about bowel disorders and screening . Of the 17 824 people who were offered screening  , 7545 ( 42 % ) complied . Compliance was significantly affected by the method of invitation , but not by whether an educational booklet was received , and was highest ( 57 % ) in the group that was offered the haemoccult test during a routine consultation ( the " opportunistic " approach ) . In this group the compliance rate achieved by individual general practitioners ranged from 26 % to 82 % . Compliance was significantly higher in Farnborough , in the older ( 55 - 70 ) age group , in women , and in households in which two or more people were offered screening . The higher compliance in Farnborough may be explained by the higher proportion of older people and by the higher proportion of people living in households of two or more in the population that was offered screening . The fact that the screening programme in Farnborough was offered to the whole community and that the research er may have acted as a facilitator were probably also important . One per cent of the patients screened had a positive test , and 24 ( 38 % ) of the 63 patients who were positive and were investigated in hospital had neoplastic disease . The yield was 1.2 cancers and 1.2 benign adenomas ( 1 cm or larger in size ) per 1000 people screened . This low yield is likely to be a consequence of the relatively young age group screened A r and omized , controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians ' offices for patients aged 65 years or older . A total of 1,914 patients from 10 primary -care medical practice s in central North Carolina were r and omized within practice s to an intervention and a usual-care control group . The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages ( thus making these services free for patients ) , regular prompting of physicians to routinely schedule preventive care visits , a new office system in which nurses carried out many preventive procedures , and a form for charting preventive care . The performance of screening tests dramatically increased in the intervention group relative to control ( P < 0.001 ) , but there was evidence of lack of follow-up of abnormal findings by physicians . At the 2-year follow-up , there were minimal differences between intervention and control groups in health-related quality -of-life indicators . Relative to the $ 294 per patient 3-year cost to Medicare for waivered services , the intervention was reimbursed-cost neutral or slightly cost reducing ( $ 190 over 3 years ) for Medicare . It is concluded that adding reimbursement for preventive services to Medicare — even with the office systems changes made in this study —will not by itself lead to effective implementation of preventive services in community medical practice s. To enhance patient benefit from preventive services , greater attention needs to be focused on an organized approach to patient follow-up OBJECTIVE To test the effectiveness of customized , family-oriented reminder letters in activating patients to seek appropriate preventive services . DESIGN R and omized clinical trial . One group received computer-generated , customized letters explaining recommended preventive procedures for each family member . A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups . A third group ( control group ) received no letters .  SETTING A private medical centre , without university affiliation , in rural Quebec . PARTICIPANTS From 8770 patients who met study criteria , 719 families were r and omly selected . Data were available for 1971 of 1998 patients in these families . MAIN OUTCOME MEASURES The Family Received Index is the proportion of all procedures for which a family was overdue that they received . The Family End-of- study Up-to- date Index is the proportion of procedures for which the family was eligible and for which they were up-to- date at the end of the study . RESULTS The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters ( Kruskal-Wallis P = .0139 ) . Comparison of the Family End-of- study Up-to- date indices also demonstrated that families of patients sent customized letters were more likely to be up-to- date than families not sent letters ( Kruskal-Wallis P = .0054 ) . No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group . CONCLUSIONS This study demonstrates a clinical ly small but statistically significant value to customizing reminder letters
Context Knowing which strategies are the most effective for promoting preventive care might improve the low rates of utilization of many proven prevention practice s. Various approaches for promoting preventive care have been tried , but which ones work best ?
The Editors Despite the strong commitment to improved prevention reflected in reports from national task forces and performance measures of health care organizations , performance rates remain below national and international targets ( 1 - 5 ) .
These five services are covered by most insurance plans , including Medicare .
High visual appeal and clarity : Most interventions include visual material s of some kind .
Some types of graphic design flaws , such as high contrast or small font size for geriatric population s , make intervention material s almost unusable .