Follow-up Letter Research Articles

Tu1151 QUALITY OF RECOMMENDATIONS AFTER SURVEILLANCE COLONOSCOPY IN OLDER ADULTS

Current guidelines for surveillance colonoscopy in adults age ≥75 recommend that decisions be individualized, which may lead to wide variation in practice patterns. We evaluated the content and clarity of endoscopist-written recommendations after surveillance colonoscopy in older adults. We performed a single center, retrospective, chart review of adults age ≥75 who underwent surveillance colonoscopy. We developed a data collection tool to facilitate data abstraction and minimize inter-observer variability. Kappa scores for recommendation assessments showed substantial agreement. Patient age and gender, endoscopist recommendations for follow-up, and follow-up letters after review of pathology were collected. Recommendations for follow-up were categorized based on content (continue vs. stop surveillance), definitiveness of the recommendation (definitive [e.g., “should,” “recommend”] vs. not definitive [e.g., “could,” “consider”]), and if/what rationale was provided (e.g. “because of your age…”). Differences in recommendations were evaluated using Fisher’s exact test at the 0.05 level of significance. Between 2012-2019, 4453 colonoscopies were performed in adults age ≥75, of which 1324 were for surveillance. We evaluated a subset of these (n=165) using stratified sampling to get a range of patient ages and findings for each endoscopist (n=11). 21.8% of reports contained no recommendation, ranging from 0% to 60.0% by endoscopist. There was a significant difference in the proportion of “stop” versus “continue” recommendation given across all endoscopists (p = 0.001) (Figure 1). There were no discrepancies between colonoscopy reports and post-pathology follow-up letters (Table 1). Among reports that included a recommendation, 69.0% were to continue surveillance, 69.0% were definitive, and 72.1% provided a rationale. There was no significant difference in the definitiveness of the recommendation based on stopping or continuing (p = 0.89). Exams that recommended stopping included a rationale 65.0% of the time, citing: age (57.5%), the current exam being normal (12.5%), overall health (7.5%), and the patient’s history of polyps (7.5%). Exams that recommended continuing included a rationale 76.4% of the time, citing the malignant potential of polyps (34.8%), the patient’s history of polyps (32.6%), and overall health (10.1%). There is considerable variation in the content and clarity of endoscopist recommendations after surveillance colonoscopy in older adults. Over a fifth lacked any recommendation. This study highlights opportunities for quality improvement targeted at standardizing endoscopist written post-colonoscopy recommendations. Next steps include understanding patient and referring provider interpretation of written recommendations and how variation in recommendations affects follow-up and clinical outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Keep cheering

Soon after I started my first pharmacist position as a PRN (as needed) pharmacist at a community health center pharmacy, I took a special interest in smoking cessation counseling and follow-up. Every time I noticed a patient picking up a prescription for smoking cessation, I would provide unsolicited counseling. I would also ask if they were okay with me giving them a follow-up call to check in to see how they were doing on their journey to being tobacco-free. Since I worked as a PRN pharmacist, there were only a few patients that I could keep track of. When I made follow-up calls, if a patient informed me that they were struggling or had a relapse, I would encourage them by providing helpful tips and mentioning that I was cheering them on. I would also have smoking cessation resources mailed to them along with a pharmacist follow-up letter. All the patients seemed to appreciate having a personal “cheerleader.” Marico Dove, PharmD, PRN Pharmacist, Advance Community Health, Raleigh, NC

Sleep Validity of a Non-Contact Bedside Movement and Respiration-Sensing Device.

To assess the sleep detection and staging validity of a non-contact, commercially available bedside bio-motion sensing device (S+, ResMed) and evaluate the impact of algorithm updates. Polysomnography data from 27 healthy adult participants was compared epoch-by-epoch to synchronized data that were recorded and staged by actigraphy and S+. An update to the S+ algorithm (common in the rapidly evolving commercial sleep tracker industry) permitted comparison of the original (S+V1) and updated (S+V2) versions. Sleep detection accuracy by S+V1 (93.3%), S+V2 (93.8%), and actigraphy (96.0%) was high; wake detection accuracy by each (69.6%, 73.1%, and 47.9%, respectively) was low. Higher overall S+ specificity, compared to actigraphy, was driven by higher accuracy in detecting wake before sleep onset (WBSO), which differed between S+V2 (90.4%) and actigraphy (46.5%). Stage detection accuracy by the S+ did not exceed 67.6% (for stage N2 sleep, by S+V2) for any stage. Performance is compared to previously established variance in polysomnography scored by humans: a performance standard which commercial devices should ideally strive to reach. Similar limitations in detecting wake after sleep onset (WASO) were found for the S+ as have been previously reported for actigraphy and other commercial sleep tracking devices. S+ WBSO detection was higher than actigraphy, and S+V2 algorithm further improved WASO accuracy. Researchers and clinicians should remain aware of the potential for algorithm updates to impact validity. A commentary on this article appears in this issue on page 935.

Continuous intraoperative nerve monitoring in thyroidectomy using automatic periodic stimulation in 256 at-risk nerves.

Automatic periodic stimulation of the vagal nerve during thyroidectomy provides real-time feedback of recurrent laryngeal nerve function intraoperatively. To assess the validity of this device, the ability of monitoring to predict recurrent laryngeal nerve palsy was determined and the incidence of recurrent laryngeal nerve palsy recorded. All thyroidectomies using APS® (Automatic Periodic Stimulation, Medtronic) nerve monitoring were reviewed over a 27-month period. Changes in signal amplitude and latency during thyroidectomy were recorded from saved data. Postoperative fibreoptic laryngoscopy determined the incidence of vocal cord immobility and recovery of nerve function was assessed from follow-up letters. A total of 256 at-risk nerves were examined (132 hemi- and 62 total thyroidectomies) in cases involving benign and malignant disease. Permanent recurrent laryngeal nerve palsy occurred in six (2.3%) lobectomies and transient recurrent laryngeal nerve palsy occurred in two lobectomies (< 1%). Sensitivity for detecting postoperative vocal cord immobility was 100% and specificity 85% if the end amplitude was 50% below baseline. The positive predictive value when amplitude was 50% below baseline was 18%. The negative predictive value when amplitude was 50% above or equal to baseline was 100%. Intraoperatively, the amplitude was 50% below baseline more frequently in the vocal cord immobility group (t-test, P < 0.015). No vagal nerve complications occurred. Whilst the incidence of recurrent laryngeal nerve palsy is comparable to rates in the literature, the incidence of transient palsy is lower than published averages. APS is able to reliably predict recurrent laryngeal nerve palsy based on end amplitude.

Thriving During the 10-Year Accreditation Site Visit: Practical Tips From a Program's Perspective.

Thriving During the 10-Year Accreditation Site Visit: Practical Tips From a Program's Perspective.

Screening in the Prenatal Period for Intimate Partner Violence and History of Abuse: A Survey of Edmonton Obstetrician/Gynaecologists.

This study sought to understand how obstetrician gynaecologists (OB/GYNs) in Edmonton, Alberta screen prenatal patients for intimate partner violence (IPV). It also aimed to explore attitudes, beliefs, and perceptions regarding IPV and identify barriers to screening for IPV. Institutional protocols, resources, and support available to clinicians and patients were also reviewed. All Royal College of Physicians and Surgeons of Canada-certified OB/GYNs practicing general obstetrics in Edmonton were identified and were mailed letters and electronic questionnaires with two follow-up letters or emails at 2-week intervals. Personal and clinical practice demographic information was collected. Physicians' perceptions, screening practices, and barriers to screening were identified. Responses were collected, stored, and analyzed using a secure online database, Research Electronic Data Capture Database; all responses were completely anonymous. Of 58 physicians surveyed, 49 completed questionnaires (84% response rate). A total of 33% of respondents either never or rarely screened women for IPV during prenatal visits, 69% either never or rarely screened for childhood abuse, 94% did not have a screening protocol, and 77% did not have written materials to provide to patients. Multiple barriers were identified. A total of 94% of OB/GYNs believed that they were inadequately screening for IPV. Screening of pregnant women for IPV and a history of abuse is suboptimal. There are multiple barriers (cultural, societal, economic, and institutional) that prevent women from being screened for IPV and receiving appropriate support services.

Effectiveness and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in Washington State.

It has been demonstrated that fecal immunochemical test (FIT) mailing programs are effective for increasing colorectal cancer (CRC) screening. The objectives of the current study were to assess the magnitude of uptake that could be achieved with a mailed FIT program in a federally qualified health center and whether such a program can be implemented at a reasonable cost to support sustainability. The Washington State Department of Health's partner HealthPoint implemented a direct-mail FIT program at 9 medical clinics, along with a follow-up reminder letter and automated telephone calls to those not up-to-date with recommended screening. Supplemental outreach events at selected medical clinics and a 50th birthday card screening reminder program also were implemented. The authors collected and analyzed process, effectiveness, and cost measures and conducted a systematic assessment of the short-term cost effectiveness of the interventions. Overall, 5178 FIT kits were mailed with 4009 follow-up reminder letters, and 8454 automated reminder telephone calls were made over 12 months. In total, 1607 FIT kits were returned within 3 months of the end of the implementation period: an overall return rate of 31% for the mailed FIT program. The average total intervention cost per FIT kit returned was $39.81, and the intervention implementation cost per kit returned was $18.76. The mailed FIT intervention improved CRC screening uptake among HealthPoint's patient population. This intervention was implemented for less than $40 per individual successfully screened. The findings and lessons learned can assist other clinics that serve disadvantaged populations to increase their CRC screening adherence.

An integrated electronic health record-based workflow to improve management of colonoscopy-generated pathology results.

PurposeManaging and communicating colonoscopy-generated pathology results and appropriate follow-up recommendations can be challenging. To improve this process, we developed and implemented a standardized electronic health record-based intervention with built-in decision support.MethodsFourteen attending endoscopists performed enough colonoscopies to qualify for the study. For each, we randomly sampled and abstracted data from 35 colonoscopies that met prespecified inclusion criteria during both the pre-intervention and also post-intervention periods. Follow-up recommendations were compared to guidelines. We used the Wilcoxon Signed Rank Test to assess the change in the proportion of cases with guideline-concordant results, the proportion with a documented follow-up result letter, and the median time to letter completion. A brief survey assessed endoscopists’ satisfaction with the intervention.ResultsIn total, 1,947 colonoscopies were extracted, of which 968 met inclusion criteria. The proportion of follow-up recommendations that were guideline concordant increased from a median of 82.9% pre-intervention to 85.7% post-intervention (P=0.72). The proportion of observations with a documented follow-up result letter increased from a median of 88.9% pre-intervention to 97.1% post-intervention (P=0.07). The number of calendar days between the date of the colonoscopy and the date the letter was sent decreased from a median of 7.7 days pre-intervention to 6.8 days post-intervention (P=0.79). Eighty-six percentage of endoscopists were either “very satisfied” or “satisfied” with the overall process.ConclusionThe intervention was not associated with a statistically significant increase in guideline-concordant recommendations or efficiency measures, perhaps due to high baseline performance. The intervention was well received by endoscopists and captured data necessary for important downstream processes.

Dutch Law Approves Opt-out System.

Dutch Law Approves Opt-out System.

Behavioral insights on business taxation: Evidence from two natural field experiments

This paper presents the findings of two natural field experiments that were conducted in collaboration with the Australian Taxation Office (ATO). The first experiment tests the effect of changes to letters on businesses paying the correct amount of tax. The second experiment consists of two parts. The first part aims to raise awareness of the relevance of tax debt payment by changing internal guidelines used by field auditors. The second part focuses on studying the effect of changing the phone script used by desk auditors to facilitate payment arrangements and simplifying a follow-up letter. While the first experiment had no effects on any of the outcome measures considered, the results of the second experiment indicate that changing the phone script of desk auditors and simplifying the letter reduced the proportion of default assessments raised by the ATO by 69 percent, suggesting that businesses are responsive to certain types of nudges.

Expanding Population of Elders With HIV May Catch Nursing Homes Off Guard

Expanding Population of Elders With HIV May Catch Nursing Homes Off Guard

Behavioural Insights and Business Taxation: Evidence from Two Randomized Controlled Trials

This paper presents the findings of two Randomized Controlled Trials (RCTs) that were conducted in collaboration with the Australian Taxation Office (ATO). The first trial tests the effect of changes to letters (timing, social norms, color, and provision of information about charitable donations) on response rates of businesses, the timing of payments and the amount of tax debt payments. The second trial consists of two parts. The first part aims to raise awareness of the relevance of tax debt payment by changing internal guidelines used by field auditors. The second part focuses on studying the effect of changing the phone script used by desk auditors to offer assistance with payment arrangements and simplifying a follow-up letter. The findings of the first trial indicate that none of the treatments had a significant effect on any of the outcome measures considered. In contrast, the results of the second trial indicate that changing the phone script of desk auditors and simplifying the follow-up letter reduced the proportion of default assessments raised by the ATO significantly, suggesting that businesses are responsive to certain types of nudges.

Expanding Population of Elders With HIV May Catch Nursing Homes Off Guard

Expanding Population of Elders With HIV May Catch Nursing Homes Off Guard

Abstract C88: Novel use of electronic health records (EHRs) to facilitate free community prostate screening events

Abstract Introduction Free screening events, while a valuable means to educate and provide cancer screening for individuals in socioeconomically disadvantaged communities, suffer from a number of limitations including: limited scope, poor patient follow up, and lack of long term tracking of individuals with high risk screening outcomes. The Center for Medicare and Medicaid Services advocates for electronic health records (EHRs) to flag opportunities for “reduction of disparities, research, or outreach.” EHRs represent a potentially powerful tool to assimilate and track individual screening outcomes. However, implementation of electronic health records a to facilitate free screening events such as for prostate cancer has not been reported. Among the barriers to EHR use for free screenings is the requirement to create billable encounters for each patient for whom personal health information is to be entered. Therefore, we reconfigured our EHR to create HIPAA compliant, non-billable encounters for the purposes of entering demographic information, tracking screening results, and generating follow-up letters to participants and their primary care physicians (PCPs) after a free community screening event in an at risk community. Materials &amp; Methods Between 2013 and 2015 our group hosted three annual free prostate cancer community-screening events in the city of New Haven, CT. To facilitate tabulation of demographic information and screening results we prevailed upon our EHR administrators to design workflows to allow for patient registration and patient data capture unique to our screening events that would not be associated with a billable encounter. Providers counseled patients on prostate specific antigen (PSA) testing, ordered testing if appropriate, and performed a digital rectal examination (DRE) for each encounter. Demographic information and DRE results were manually entered into the EHR by a registered nurse for all patients and PSA testing performed by our own hospital-based ancillary service with direct resulting of PSA tests into the EHR. Automatic electronic alerts were generated for all PSA results and were preconfigured to be routed to the MD directing the event and two nurse managers. Results In the most recent screening year, 93 men were screened of whom 27 (29%) were flagged for follow-up: 21 (23%) for abnormal screening results and six for benign urologic issues who requested follow-up with our physicians. Using demographic information entered at the time of registration, 26 of the 27 (96%) participants flagged for follow-up were successfully contacted and only one participant could not be reached for follow-up. Letters to PCPs were successfully transmitted for all participants who had provided PCP information during the intake process. Of 21 participants with abnormal screening, 3 were known to have a preexisting diagnosis of prostate cancer and were actively under the care of a urologist and/or oncologist, 3 had established relationships with urologists and indicated their intent to follow-up with their regular urologist, 9 underwent repeat PSA testing and were offered follow-up with one of our urologists at no cost, 3 were scheduled for MRI of the prostate for further stratification of risk, and 3 were scheduled for prostate biopsy with one of our physicians. All tracking of results, coordination of care, and external communication to participants and their PCPs was executed through the EHR Conclusion The electronic health record when reconfigured to serve as a platform for a community screening event, allows for a novel, secure and multidimensional tool to enhance screening, provide appropriate follow-up, and establish vital long-term relationships with participants. Citation Format: Charles Walker, Meghan Curran, Jay Patel, Beth A. Jones. Novel use of electronic health records (EHRs) to facilitate free community prostate screening events. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C88.

Design-of-Experiments Approach to Improving Inferior Vena Cava Filter Retrieval Rates

PurposeThe association of retrievable inferior vena cava filters (IVCFs) with adverse events has led to increased interest in prompt retrieval, particularly in younger patients given the progressive nature of these complications over time. This study takes a design-of-experiments (DOE) approach to investigate methods to best improve filter retrieval rates, with a particular focus on younger (<60 years) patients. MethodsA DOE approach was executed in which combinations of variables were tested to best improve retrieval rates. The impact of a virtual IVCF clinic, primary care physician (PCP) letters, and discharge instructions was investigated. The decision for filter retrieval in group 1 was determined solely by the referring physician. Group 2 included those patients prospectively followed in an IVCF virtual clinic in which filter retrieval was coordinated by the interventional radiologist when clinically appropriate. In group 3, in addition to being followed through the IVCF clinic, each patient’s PCP was faxed a follow-up letter, and information regarding IVCF retrieval was added to the patient’s discharge instructions. ResultsA total of 10 IVCFs (8.4%) were retrieved among 119 retrievable IVCFs placed in group 1. Implementation of the IVCF clinic in group 2 significantly improved the retrieval rate to 25.3% (23 of 91 retrievable IVCFs placed, P < .05). The addition of discharge instructions and PCP letters to the virtual clinic (group 3) resulted in a retrieval rate of 33.3% (17 of 51). The retrieval rates demonstrated more pronounced improvement when examining only younger patients, with retrieval rates of 11.3% (7 of 62), 29.5% (13 of 44, P < .05), and 45.2% (14 of 31) for groups 1, 2, and 3, respectively. ConclusionsDOE methodology is not routinely executed in health care, but it is an effective approach to evaluating clinical practice behavior and patient quality measures. In this study, implementation of the combination of a virtual clinic, PCP letters, and discharge instructions improved retrieval rates compared with a virtual clinic alone. Quality improvement strategies such as these that augment patient and referring physician knowledge on interventional radiologic procedures may ultimately improve patient safety and personalized care.

Masked Man Challenged Psychiatrists’ Views on Homosexuality

Back to table of contents Previous article Next article Association NewsFull AccessMasked Man Challenged Psychiatrists’ Views on HomosexualityAaron LevinAaron LevinSearch for more papers by this authorPublished Online:28 Apr 2016https://doi.org/10.1176/appi.pn.2016.5a22AbstractA psychiatrist stigmatized because of his sexual orientation could protest only anonymously at APA’s 1972 Annual Meeting.“Any attempt to formulate a succinct, comprehensive overview of what happened in Washington last month at APA’s Annual Meeting is doomed,” began Psychiatric News’ June 2, 1971, coverage of what became one of APA’s most significant turning points.The report was brief: “Only a single disruption occurred ... when members of the Gay Liberation and the Radical Caucus seized the microphone. ...” during an otherwise uneventful business meeting.Among those who grabbed the mic was Franklin Kameny, Ph.D., an astronomer who had been fired from a federal government job after his homosexuality became known. Kameny took the occasion to attack APA and psychiatry in general for its “oppression of homosexuals.” At the time, homosexuality was defined as an illness in DSM, influenced both by psychoanalytic theory and general social prejudice.Gay advocates Barbara Gittings and Franklin Kameny, Ph.D., sit beside the masked “H. Anonymous, M.D.”, who years later revealed himself as John Fryer, M.D. Maryland psychiatrist Kent Robinson, M.D., speaks at the podium.Kay Tobin/The New York Public LibraryThis interruption was not well reported in the general press because at the same time some 7,500 anti-Vietnam War protesters were being arrested across town.Kameny expanded his views on psychiatry’s position on homosexuality in a long letter to the editor of Psychiatric News published in the July 7, 1971, issue.“Basically, we object to the negative attitudes of psychiatry toward homosexuality,” he wrote. “More specifically, we object to the sickness theory of homosexuality tenaciously held with utter disregard for the disastrous consequences of this theory to the homosexual, based as it is on poor science.”A more dramatic challenge to the status quo came a year later when the 1972 APA Annual Meeting in Dallas hosted a panel with gay advocates titled “Psychiatry: Friend or Foe of Homosexuals—A Dialogue.” There, a man wearing a rubber Halloween mask and a bushy wig slipped into the room and was introduced as “H. Anonymous, M.D.”“I am a homosexual,” he said. “I am a psychiatrist.”John Fryer, M.D., is honored by APA through presenting an annual award to an individual who has contributed to improving the mental health of sexual minorities. “The masked psychiatrist spoke of his difficulties in keeping his sexual orientation secret because of the bias and rejection he would encounter,” reported Psychiatric News. “‘My greatest loss,’ he said, ‘is my honest humanity. How incredible that we homosexual psychiatrists cannot be honest in a profession that calls itself compassionate and helping.’”Another panel member, APA Vice President (and later APA President) Judd Marmor, M.D., agreed with other speakers that psychiatry was biased against homosexuality.“I must concede that psychiatry is prejudiced as has been charged,” he said. “Psychiatric mores reflect the predominant social mores of the culture.”In a follow-up letter to the editor of Psychiatric News, Marmor argued by comparison that no one would suggest that strongly held religious convictions be considered to be mental illnesses.“In a democratic society we recognize the rights of such individuals to have widely divergent religious preferences, as long as they do not attempt to force their beliefs on others who do not share them,” he wrote. “Our attitudes toward divergent sexual preferences, however, are quite different, obviously because moral values—couched in ‘medical’ and ‘scientific’ rationalizations—are involved.”Even though APA removed homosexuality from its manual of psychiatric illnesses in 1973, “Dr. Anonymous” did not reveal himself until 22 years later. He was John Fryer, M.D. (1938-2003), who was forced to leave his psychiatry residency at the University of Pennsylvania when it was discovered that he was gay. He eventually became a professor of psychiatry at Temple University. APA remembers the masked pioneer of gay rights in its annual John Fryer Award, which honors a person who has contributed to improving the mental health of sexual minorities. ■For a contemporary discussion of homosexuality and its relation to psychiatry, see “A Symposium: Should Homosexuality Be in the APA Nomenclature?” from the November 1973 issue of the American Journal of Psychiatry, can be accessed here. ISSUES NewArchived

Maximising follow-up participation rates in a large scale 45 and Up Study in Australia.

BackgroundThe issue of poor response rates to population surveys has existed for some decades, but few studies have explored methods to improve the response rate in follow-up population cohort studies.MethodsA sample of 100,000 adults from the 45 and Up Study, a large population cohort in Australia, were followed up 3.5 years after the baseline cohort was assembled. A pilot mail-out of 5000 surveys produced a response rate of only 41.7 %. This study tested methods of enhancing response rate, with three groups of 1000 each allocated to (1) receiving an advance notice postcard followed by a questionnaire, (2) receiving a questionnaire and then follow-up reminder letter, and (3) both these strategies.ResultsThe enhanced strategies all produced an improved response rate compared to the pilot, with a resulting mean response rate of 53.7 %. Highest response was found when both the postcard and questionnaire reminder were used (56.4 %) but this was only significantly higher when compared to postcard alone (50.5 %) but not reminder alone (54.1 %). The combined approach was used for recruitment among the remaining 92,000 participants, with a resultant further increased response rate of 61.6 %.ConclusionsSurvey prompting with a postcard and a reminder follow-up questionnaire, applied separately or combined can enhance follow-up rates in large scale survey-based epidemiological studies.

Abstract A33: Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project

Abstract Background: The stagnant breast cancer mortality rates and the increased number of younger American Indian (AI) women who are being diagnosed with breast cancer indicate that breast cancer remains an important public health issue among the AI community. This 4-year study is a continuation of two preliminary studies at a rural tribal clinic in Oklahoma. In the first study, we developed a culturally-sensitive survey of mammography screening practices and beliefs, entitled Women's Health Survey (WHS), based on the Theory of Planned Behavior. In the second study, we identified the salient mammography screening beliefs held by AI women. The results led to the development of a Logic Model of mammography screening behavior, involving both clinical and community components, which guided intervention development. In the current study, we implemented the intervention and evaluated its efficacy via Community-based Participatory Research. Methods: A Community Steering Committee (CSC) was formed. The priority population consisted of AI women without a history of breast cancer who lived in the target region between the ages of 52-74 years, and who have not had a screening mammogram within the last 2 years. The study had four aims: 1) Conduct a needs and resource assessment of the priority population, 2) Utilize the needs and resource assessment data to develop a community-driven intervention program, 3) Pilot-test and refine the intervention, and 4) Evaluate the intervention using a one-group pre- and post-evaluation design and mixed research methodology. A modified version of the WHS was used as the evaluation tool. Results: The results of the formative research (Aim 1) indicated that: a) AI women lack knowledge of mammograms, b) Fatalistic attitudes toward breast cancer exist among AI women, c) Many AI women prefer a holistic approach to their health, d) Physicians influence women's screening mammography decisions, and e) Social modeling is an important motivating factor. Using a prioritization process through the CSC and data triangulation, we concluded that the intervention would center on the concepts of social modeling, physician recommendation, breast cancer fatalism, and lack of knowledge about mammography screening. The Logic Model was finalized, educational intervention materials were developed, and alliances were built with regional grassroots initiatives (Aim 2). The intervention included four main strategies: a) Structured communication between medical practitioner and patient about screening mammography; b) Receipt of a breast cancer brochure and subsequent follow-up letter from the medical provider; c) Participation in a breast cancer discussion group at a community setting by using the Freire (raising consciousness) approach; and d) Receipt of a congratulatory bracelet upon receipt of a mammogram. Based on the evaluation results (Aim 4), the intervention is feasible despite its complexity; however, process evaluation revealed a shallow implementation of the clinic component. Almost half of the research participants (N=21) received a future mammogram, indicating moderate program success. Focus group research (N=4) showed that the participants became more conscious of their health and more vocal in discussing breast cancer with their friends and family. Moreover, sustainable environmental changes were introduced at the tribal clinic including a bulletin board poster on mammography and a screening mammography algorithm located in the exam rooms. Conclusions: Designing, implementing and evaluating a theory-based culturally-sensitive multi-component intervention on mammography screening within a Native American community is an exciting, yet challenging process. Replications of the current study with a bigger sample size and a controlled, comparative evaluation design are needed to further establish the efficacy of the intervention. Citation Format: Eleni L. Tolma, Kimberly Engelman, Cara Thomas, Stephanie Joseph, Julie Stoner, Ji Li, Norma Neely. Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A33.

Abstract A29: Native women's health project: An innovative approach toward promoting screening mammography in an American Indian community in Oklahoma

Abstract Background: There are significant disparities in breast cancer screening for American Indian (AI) relative to non-Hispanic white women. In Oklahoma, the incidence rate of breast cancer among AI women was 140.5/100,000 compared to 121.5/100,000 among non-Hispanic white women for 2005-2009. The current 3-year study is a continuation of two preliminary studies that took place at a rural tribal clinic in Oklahoma in 2005-2006 and 2011-2012. During the first study, we developed a culturally-sensitive survey of mammography screening practices and beliefs, entitled Women's Health Survey, based on the Theory of Planned Behavior. During the second study, we identified the salient mammography screening beliefs held by AI women. The results led to the development of a Logic Model, involving both clinical and community components, for the proposed intervention. In the current study, we hypothesize that a sustained multi-component intervention based on our developed Logic Model will yield higher mammography rates compared to the standard practices employed at this and other clinics. Methods: A Community Steering Committee (CSC), representing the tribal government, tribal clinic, other community partners, and individual community members (including breast cancer survivors), was formed and provides project direction. The priority population consists of AI women without a history of breast cancer who live in the target region between the ages of 52-74, and who have not had a screening mammogram within the last 2 years. The study, utilizing a Community Based Participatory Research approach has four aims: 1) Conduct a needs and resource assessment of the priority population, 2) Utilize the needs and resource assessment data to develop a community-driven intervention program, 3) Pilot-test and refine the intervention, and 4) Evaluate the intervention using a quasi-experimental evaluation design. Results: Aims 1, 2, and 3 have been completed and Aim 4 is underway. The results of the formative research (Aim 1) indicated that: a) AI women lack knowledge of mammograms, b) Many AI women prefer a holistic approach to their health, c) Fatalistic attitudes toward breast cancer do exist among AI women, d) Physicians influence women's screening mammography decisions, and e) Social modeling is an important motivating factor. Using a prioritization process through the CSC and data triangulation, we concluded that the intervention would center on the concepts of social modeling, physician recommendation, breast cancer fatalism, and lack of knowledge about mammography screening. The Logic Model was finalized, educational materials and intervention strategies were developed, and alliances were built with regional grassroots initiatives to promote long-term project sustainability (Aim 2). The intervention includes four main strategies: a) Structured communication between medical practitioner and patient about screening mammography; b) Receipt of a breast cancer brochure and subsequent follow-up letter from the medical provider; c) Participation in a mammography screening and breast cancer discussion group at a community setting; and d) Receipt of a congratulatory bracelet upon receipt of a mammogram. The intervention pilot testing is complete (Aim 3). The results indicated that modifications are needed to the discussion group component, and the recruitment process. Intervention modifications and project implementation are underway. Conclusions: Creating a theory-based culturally-sensitive multi-component intervention within a Native American community and translating research results into practical applications is an exciting, yet challenging process. The direct involvement of the community was instrumental for developing an intervention that was culturally-sensitive, responsive to community needs, and sustainable. Citation Format: Eleni L. Tolma, Cara Thomas, Julie Stoner, Stephanie Joseph, Kimberly Engelman, Ji Li. Native women's health project: An innovative approach toward promoting screening mammography in an American Indian community in Oklahoma. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A29.

Evaluation of Patients' Response Toward Osteoporosis Letter Intervention Versus Phone Call Plus Letter Intervention.

Introduction:The aim of this study was to compare the effectiveness of 2 interventions in prompting patients to obtain osteoporosis follow-up after a fracture. Our hypothesis was that a phone call plus letter would yield greater response toward osteoporosis evaluation versus a letter alone to patients after sustaining a fragility fracture.Materials and Methods:Prospective study randomized 141 patients age 50 years and older with a fragility fracture into 3 groups for comparison. Group 1 (letter only) patients received a letter 3 months after their diagnosis of fracture indicating their risk for osteoporosis and urging them to follow-up for evaluation. Group 2 (phone call plus letter) patients were contacted via phone 3 months after their diagnosis of fracture. A letter followed the phone call. Group 3 (control) patients were neither contacted via phone nor sent a letter. All groups were contacted via phone 6 months after their initial visit to determine if they followed up for evaluation.Results:In group 1, 23 (52.27%) of 44 had follow-up, and 21 (47.73%) of 44 did not follow-up. In group 2, 30 (62.5%) of 48 had follow-up, and 18 (37.50%) of 48 did not follow-up. In group 3, 6 (12.24%) of 49 had some sort of follow-up, and 43 (87.76%) of 49 did not have any follow-up. A statistical significance was achieved between group 3 (control) and both groups 1 and 2 with regard to follow-up (P < .0001). The results did not show a statistically significant difference between Groups 1 and 2, however, there was a trend toward improved response with a phone call plus letter (P = .321).Conclusion:A more personalized approach with a phone call plus follow-up letter to patients increased osteoporosis follow-up care by an additional 10%, however, this was not a statistically significant difference from just sending out a letter alone.