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Cancer Screening: Provider Reminder and Recall Systems – Cervical Cancer

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 25 studies (search period 1986 - November 2004). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.

The effectiveness of provider-directed interventions was determined by considering evidence across all three cancer screening sites combined, as long as there were not differences in effectiveness by screening test. This was done because provider behavior was thought to be less influenced than client behavior by the nature of screening tests.

Summary of Results

Detailed results from the systematic review are available in the CPSTF finding pdf icon [PDF - 126 KB].

Twenty-six studies qualified for the review of provider reminders to increase breast, cervical, or colorectal cancer screening.

  • Completed screenings increased by a median of 7.2% (interquartile interval [IQI]: 2.4% to 19.7%; 34 study arms).
  • Recommended or ordered screenings increased by a median of 7.9% (IQI: 6% to 12%; 14 study arms).
  • Effect estimates did not vary substantially by method of generating the reminder (electronic versus manual), delivery, content, format (client-specific vs generic), or by training status of provider.
  • For all screening modalities, the absolute effect of provider reminders on completed screenings appeared to diminish over time.

Intervention effects on cervical cancer screening:

  • Completed Pap tests increased by a median of 4.6% (IQI: 2.4% to 9.2%; 14 study arms).
  • Recommended or ordered screening by PAP ranged from 3% to 23% (5 studies).

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF finding pdf icon [PDF - 126 KB].

Five studies qualified for the economic review of provider reminder systems. Three of these studies focused on cervical cancer screening. The remaining two studies estimated cost effectiveness of provider reminders to increase breast cancer screening.

  • Three studies produced the following cost-effectiveness estimates for provider reminders to increase cervical cancer screening:
    • $17.33 for a computer-printed messages
    • $19.62 for tagged group files
    • $10.78 for a chart notation
    • $72.95 for a memorandum to the provider

Applicability

These findings apply across a broad range of clinical settings and provider and client populations, including clients rarely or never screened.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for reviews of provider reminder and recall systems to increase breast, cervical, and colorectal cancer screening.

Effectiveness

Effectiveness of provider reminders for increasing cancer screening by mammography, Pap tests, FOBT, and flexible sigmoidoscopy is established. Additional studies will be necessary to determine whether provider reminders are also effective in promoting screening colonoscopy. It is also not known whether benefits and cost savings can be achieved by provider reminder systems when used to promote multiple preventive services simultaneously.

Applicability

  • What contextual or population prevalence factors help to explain the reduced impact of reminders on mammography in more recent studies compared to older studies?

Other positive and negative effects

  • How can provider reminder systems that encourage use of cancer screening services be adapted for other preventive healthcare services?

Economic evaluations

  • How are the costs and cost-effectiveness of these interventions related to the structural characteristics of the settings of interventions?
  • In particular, can HMOs address logistical problems (e.g., contacting providers and reducing administrative time) more efficiently than fee-for-service practices, thereby lowering costs and improving cost-effectiveness?

Study Characteristics

  • Studies evaluated provider reminders delivered as printed or electronic chart notations or flags based on client screening history; preventive care checklists (not specific to client screening history); or memoranda listing clients who were overdue for screening or had never been screened.
  • Provider reminder systems were automated (computer generated or assisted) or required manual record reviews.
  • While most study populations consisted entirely of fully trained physicians, some consisted entirely or mostly of resident trainees.
  • Provider reminder systems were implemented in a variety of healthcare settings, including university and non-university clinics and offices and in urban, rural, and mixed urban and rural areas.
  • Race and ethnicity of client populations were generally not reported, although some studies specified that these populations included white or African-American clients or both.
  • Some studies specified that client populations included people who had never been screened or who were several years overdue for screening.
  • Studies were conducted in the U.S., the United Kingdom, Italy, Canada, Australia, Israel.

Publications

Baron RC, Melillo S, Rimer BK, et al. Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: a systematic review of provider reminders. American Journal of Preventive Medicine. 2010;38(1):110-7.
Baron RC, Rimer BK, Coates RJ, et al. Methods for conducting systematic reviews of evidence on effectiveness and economic efficiency of interventions to increase screening for breast, cervical, and colorectal cancers. American Journal of Preventive Medicine. 2008;35(1S):26-33.
Breslow RA, Rimer BK, Baron RC, et al. Introducing the Community Guide's reviews of evidence on interventions to increase screening for breast, cervical, and colorectal cancers. American Journal of Preventive Medicine. 2008;35(1S):14-20.

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