Mail Reminders Research Articles

Improving follow-up survey completion rates through pilot interventions in the All of Us Research Program: Results from a non-randomized intervention study.

Retention to complete follow-up surveys in extensive longitudinal epidemiological cohort studies is vital yet challenging. All of Us developed pilot interventions to improve response rates for follow-up surveys. The pilot interventions occurred from April 27, 2020, to August 3, 2020. The three arms were: (1) telephone appointment [staff members calling participants offering appointments to complete surveys over phone] (2) postal [mail reminder to complete surveys through U.S. Postal Service], and (3) combination of telephone appointment and postal. Controls received digital-only reminders [program-level digital recontact via email or through the participant portal]. Study sites chose their study arm and participants were not randomized. A total of 50 sites piloted interventions with 17,593 participants, while 47,832 participants comprised controls during the same period. Of all participants, 6,828 (10.4%) completed any follow-up surveys (1448: telephone; 522: postal; 486: combination; 4372: controls). Follow-up survey completions were 24% higher in the telephone appointment arm than in controls in bivariate analyses. When controlling for confounders, telephone appointment and combination arms increased rates of completion similarly compared to controls, while the postal arm had no significant effect (odds ratio [95% Confidence Interval], telephone appointment:2.01[1.81-2.23]; combination:1.91[1.66-2.20]; postal:0.92[0.79-1.07]). Although the effects of the telephone appointment and combination arms were similar, differential effects were observed across sub-populations. Telephone appointments appeared to be the most successful intervention in our study. Lessons learned about retention interventions, and improvement in follow-up survey completion rates provide generalizable knowledge for similar cohort studies and demonstrate the potential value of precision reminders and engagement with sub-populations of a cohort.

Abstract C117: Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results

Abstract PURPOSE: We partnered with the largest FQHC in New Haven, CT to address overdue colorectal cancer screening with evidence-based interventions (EBI). We report on the 12-month follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more evidence based interventions (EBIs) in October, 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) screening capacity. At the time of the study, colonoscopy was the front-line cancer screening strategy in this and other primary care settings in this region. METHODS: We tested the unique and additive value of multiple EBIs for increasing CRC screening in this low-income urban population. The EBIs included: medical reminder to all recipients (Arms 1-4), supplemented with information to address social determinants of health [SDOH]) barriers (Arm 2), offer of assistance from trained community health workers (CHW) to address SDOH barriers (Arm 3), and offer of educational intervention (video and pre- and post- survey) (Arm 4). Twelve-month outcomes include: 1) CRC screening test ordered; 2) CRC screening completed. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 12 months post-intervention, 1,692 (54.1%) of the cohort received an order for CRC screening, and 541 (17.3%) of the cohort completed screening. With no path to CRC screening other than a provider order, among patients for whom CRC screening was ordered, nearly one-third (32%) completed screening within 12 months of the intervention. There were no differences in either outcome based on intervention Arm. DISCUSSION: Among the 3,127 individuals who were due or overdue for screening at the time of intervention, only 9 had documented CRC cancer screening in the 5 years before randomization. The promotion of stool-based testing may have brought individuals into CRC screening. There were no differences in CRC screening (colonoscopy or FIT) orders or completed tests across the 4 arms of the study, suggesting that the provider endorsed mailed screening reminder with information on in-home, stool-based testing option (FIT), and notice that CRC screening is now recommended beginning at age 45 was key to behavior change. Provider engagement and post-pandemic care-seeking on part of patients, as well as increased awareness of CRC screening following the death of high-profile actor at age 43 likely contributed to increased uptake of CRC screening. SUMMARY: A mailed reminder is a cost effective, scalable intervention that may be effective in safety net primary care settings that serve high-risk individuals. Closing the screening gap in CRC screening should include educating patients about their CRC screening options as well as the change in recommended age to begin CRC screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Levita Robinson, Michael Couturie, Steven J. Parra, Louie M. Gangcuangco, Laney Zhang, Denise Stevens, Margarita Vargas-Torres. Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C117.

Development and Feasibility Testing of a Multilevel Intervention to Increase Hepatitis C Virus Screening Among Baby Boomers in Primary Care

Chronic infection with hepatitis C virus (HCV) results in an increased risk of cirrhosis and hepatocellular carcinoma (HCC). Only 15% of baby boomers (born 1945–1965) have ever been screened. We aimed to develop a multilevel intervention to increase HCV screening for baby boomers in a primary care setting. This study included two phases: intervention development (phase 1) and feasibility testing (phase 2). In phase 1, we partnered with a Community Advisory Board and a Provider Advisory Board to develop a multilevel intervention to increase HCV screening to be delivered to both providers and patients in primary care. Phase 2 assessed intervention feasibility, acceptability, and usability by conducting Concurrent Think Aloud (CTA) interviews and surveys using previously validated scales with patients (n = 8) and providers (n = 7). Phase 1 results: The patient-level intervention included a mailed reminder letter and CDC pamphlet and a 7-min in-clinic educational video. The provider-level intervention included a 30-min educational session and monthly performance feedback e-mails. Phase 2 results: Qualitatively, both the patient and provider-level intervention were feasible, acceptable, and usable by the target audiences. Quantitatively, on a 1–4 scale, the range of patient-level scores was 3.00–4.00 and provider level was 3.50–4.00 for feasibility, acceptability, and usability. This intervention could improve HCV screening among a high-risk population and therefore reduce HCV-related morbidity and mortality. This project developed a feasible, acceptable, and usable multilevel intervention aimed at increasing HCV screening in primary care.

Influence of WhatsApp and electronic mail reminders on oral hygiene compliance of orthodontic patients using planimetry : Arandomized clinical trial.

To determine the effect of WhatsApp (Facebook Inc., Menlo Park, CA, USA) and electronic mail reminders on oral hygiene compliance of orthodontic patients. Arandomized, parallel group, double blinded study was conducted on 54patients undergoing orthodontic treatment at auniversity clinic. They were randomized to 3groups, i.e., WhatsApp(W) group, electronic mail (email)(E) group and control(C) group with 18subjects in each group. Group(W) and group(E) received oral health messages once aweek through WhatsApp and email reminders, respectively, while group(C) did not receive any reminders. Plaque was measured at baseline (T0), after 4weeks (T1), and after 8weeks (T2). For each subject, intraoral photographs were taken after application of aplaque-disclosing agent; and the area covered by plaque was measured on teeth12, 13, 43, 22, 23 and33 by planimetry. Data were analyzed using SPSS (version22, IBM Corp., Armonk, NY, USA). Mixed analysis of variance (ANOVA) was used to compare plaque scores between and within the groups. Atotal of 54subjects (14males and 40females) with mean age of 22.43 years completed the study. At the end of 8weeks, no statistically significant difference in the mean plaque score was found between the groups at the different time intervals (p = 0.201). WhatsApp and email reminders did not significantly influence the oral hygiene compliance of orthodontic patients.

Diagnostic and treatment barriers to persistent somatic symptoms in primary care \u2013 representative survey with physicians

BackgroundMany patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe.MethodsWe mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected.ResultsWe analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced.ConclusionsThe PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care.Trial registrationGerman Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS)https://www.drks.de/drks_web/setLocale_EN.doThe date the study was registered: October 2nd 2017The date the first participant was enrolled: February 9th 2018DRKS-ID: DRKS00012942

Improving Fecal Immunochemical Testing Rates for Colon Cancer Screening in the Outpatient Setting.

The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

Abstract PO-255: A colorectal cancer screening intervention to help increase screening rate within the Harris Health safety-net health care system

Abstract Background: Colorectal Cancer (CRC) is often preventable through regular screening. CRC screening is an evidence-based intervention for early detection and prevention of CRC. However, screening rates are low among medically underserved, minority populations. In collaboration with a local safety-net healthcare system and community clinics, we are implementing a comprehensive, multi-modal CRC prevention program. Our CRC screening program includes community outreach, culturally and linguistically targeted educational point-of-care patient education videos, patient navigation services, and provider and staff training. In 2018, a new component was introduced that includes a CRC survivor led provider-targeted assessment intervention leveraging the American Cancer Society National Colorectal Roundtable’s “80% in Every Community” campaign. Methods: As part of the 80% in Every Community campaign, providers and clinical staff are trained by the CRC survivor staff member to employ strategies from the Roundtable’s toolkit to heighten clinic-level commitment to improving screening rates. Specific strategies include providing tips for evidence-based messaging to reach the unscreened, and training providers to consistently give a strong CRC screening recommendation. A baseline survey was administered ahead of the initial training to assess current clinical practices. Results: Survey data indicated 84.3% (N= 297, 14 clinics) of respondents identified patients not completing and returning FIT as a screening barrier (61.7%-Sometimes and 22.7%-Usually). When asked if they had mechanism to ensure patients given a FIT kit have completed and returned them -75.7 % said Yes and 24.3%-No. In the follow-up question, asking if they had a mechanism to ensure FIT were completed and returned, responses showed: 13.9 % said no mechanism, 43.0% reminder call, 8.1% mail reminder, and 28.6% said a chart reminder to return kit at next visit. 73 respondents wrote in various other mechanisms. Discussion: Respondents believed a systematic mechanism already existed to remind patients to complete their FIT and return it to their clinic. Our next steps are to present these findings to health system leadership and investigate the possibility to strengthen screening patient reminders in various forms of communication to increase FIT completion rate. Citation Format: Allison Rosen, Roshanda Chenier, Jane Montealegre, Maria Jibaja-Weiss. A colorectal cancer screening intervention to help increase screening rate within the Harris Health safety-net health care system [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-255.

Program Components and Results From an Organized Colorectal Cancer Screening Program Using Annual Fecal Immunochemical Testing

Background and AimsProgrammatic colorectal cancer (CRC) screening increases uptake, but the design and resources utilized for such models are not well known. We characterized program components and participation at each step in a large program that used mailed fecal immunochemical testing (FIT) with opportunistic colonoscopy.MethodsMixed-methods with site visits and retrospective cohort analysis of 51-75-year-old adults during 2017 in the Kaiser Permanente Northern California integrated health system.ResultsAmong 1,023,415 screening-eligible individuals, 405,963 (40%) were up to date with screening at baseline, and 507,401 of the 617,452 not up-to-date were mailed a FIT kit. Of the entire cohort (n = 1,023,415), 206,481 (20%) completed FIT within 28 days of mailing, another 61,644 (6%) after a robocall at week 4, and 40,438 others (4%) after a mailed reminder letter at week 6. There were over 800,000 medical record screening alerts generated and about 295,000 FIT kits distributed during patient office visits. About 100,000 FIT kits were ordered during direct-to-patient calls by medical assistants and 111,377 people (11%) completed FIT outside of the automated outreach period. Another 13,560 (1.3%) completed a colonoscopy, sigmoidoscopy, or fecal occult blood test unrelated to FIT. Cumulatively, 839,463 (82%) of those eligible were up to date with screening at the end of the year and 12,091 of 14,450 patients (83.7%) with positive FIT had diagnostic colonoscopy.ConclusionsThe >82% screening participation achieved in this program resulted from a combination of prior endoscopy (40%), large initial response to mailed FIT kits (20%), followed by smaller responses to automated reminders (10%) and personal contact (12%).

Non-Attendance to Post-Radiotherapy Follow-Up in Breast Cancer: Efficacy of Mail and Telephone Reminders

Background: To assess the efficacy of two reminder interventions in improving post-radiotherapy followup attendance rates of breast cancer patients. Methods: Three periods of three months were assessed, a baseline period, an intervention period and a confirmation period. In the intervention period, a two-step reminder system was used. This system consisted of a mail reminder (IV1) that was sent to all patients three to four weeks prior to the post-radiotherapy follow-up visit, which was followed by up to two telephone calls (IV2) for all patients who did not attend this follow-up visit. During the confirmation period, IV2 was used exclusively to assess the maximal possible efficacy of the telephone reminder. Results: The non-attendance rate of breast cancer patients was 18.1% (19/105) in the baseline period; this rate decreased to 13.1% in the intervention period (23/176; p=0.33) after IV1 and then decreased to 6.3% (11/176; p=0.03) after IV2. In the confirmation period, 24.4% (42/172) of breast cancer patients did not attend their post-radiotherapy follow-up visit; the non-attendance rate decreased significantly after (exclusive) IV2 from 24.4% (42/172) to 9.3% (16/172; p&lt;0.001). Significance was observed for the first call but not for the second call in the chi-square test. Conclusion: Telephone reminder is an effective tool for improving breast cancer patient adherence to the post-radiotherapy follow-up visit. In this study, the telephone reminder system was more effective than the mail reminder system.

Multiple mail reminders to increase adherence to influenza vaccination.

Different interventions have been proposed to reinforce the use of the influenza vaccine. The use of reminders, whether through letters, phone calls, pamphlets or technological applications, among others, has stood out among those aimed at increasing ad-herence to treatment. However, its effectiveness is not clear. In this summary, which is part of a series of reminder evaluations, we assess the use of multiple mail reminders. We conducted a search in Epistemonikos, the largest database of systematic health reviews, which is maintained by screening multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, analyzed the data from the primary studies, performed a meta-analysis and prepared a summary table of the results using the GRADE method. We identified eight systematic reviews including 35 primary studies, of which four analyze the use of more than one letter as a reminder. We conclude that the use of multiple mail reminders probably increase adherence to influenza vaccination in patients over 60; while it may make little or no difference in children under 6 years, but the certainty of the evidence is low.

The effect of postcard reminders on vaccinations among the elderly: a block-randomized experiment

AbstractPrior research in the behavioral sciences has demonstrated that reminders can be an effective tool for encouraging health-related behavior changes. This article extends that literature by reporting the outcome of a randomized controlled trial of mailed vaccination reminders. In addition to making a substantive contribution regarding the efficacy of mailed reminders, this article also makes a methodological contribution: it illustrates how researchers can study the causal impact of an intervention even when a pure parallel trial is not possible. In this study, the Louisiana Department of Health sent postcard reminders regarding four recommended vaccinations (influenza, tetanus, shingles and pneumonia) to 208,867 senior residents of Louisiana. We used block randomization and a stepped wedge design to assess the efficacy of the intervention. Individuals were blocked by their prior vaccine record and randomized to receive the postcard in one of four consecutive months (October–January). The reminder postcard had an overall positive effect on vaccination rates. The statistically significant and substantively small increase in overall vaccination rates was driven by participants who received the postcard reminder early in the intervention period.

Abstract C122: Efficacy of in-language mailers on receipt of colorectal cancer screening among Chinese Americans: A randomized controlled trial

Abstract Background: Colorectal cancer (CRC) is the second most common cancer among Chinese Americans, the largest group of Asian Americans. Asian Americans and Chinese Americans are less likely than non-Hispanic whites to be screened for CRC. There are few randomized controlled trials (RCT) of interventions to increase CRC screening among Chinese Americans. Methods: A community-academic research team consisting of academic researchers and community organization leaders collaborated with 3 health care systems to develop an intervention called Small Media Interventions for Limited English Speakers (SMILES) project. The SMILES intervention consisted of a mailed letter and brochure about CRC screening in English and Chinese sent twice over the course of 1 month. The mailer also included a link to a website which provided additional in-language written and video information about CRC screening. Chinese American patients aged 50 to 75 who were due for CRC screening in 3 healthcare systems (an academic medical center, a community hospital network, and a federally-qualified health center) in San Francisco were eligible for the RCT. Eligible patients were randomized to the intervention arm versus a usual care comparison arm. Intervention participants were also given the opportunity to return a postcard indicating that they had read the mailer. CRC screening status were assessed using electronic health record 9 months after the first mailing. Results: There were 1,707 enrolled patients with 929 in the intervention arm and 778 in the comparison arm. The average age was 59.6 years (SD 6.0), with 45.6% female, 12.4% English speakers, 63.2% Cantonese speakers, and 10.8% Mandarin speakers. At 9-month post-intervention initiation, the CRC screening rate was 51.9% in the intervention group and 49.5% in the comparison group (p=0.331). For the age group 50 to 60, the screening rate was 47.4% vs. 42.2% (p&amp;lt;0.0001). Multivariable analyses showed that the adjusted odds ratio for the intervention was 1.10 (95% CI: 1.001, 1.21). Other significant factors associated with CRC screening at post-intervention were female sex (OR: 1.37, 95% CI: 1.10, 1.71), age 61-75 (OR: 1.64, 95% CI: 1.57, 1.71, ref. age 50-60), and speaking a Chinese language (OR: 2.42, 95% CI: 1.22, 4.76). In multivariable analyses of the intervention group only, those who had documented engagement with the intervention (returning a postcard or going to the website) had an OR of 2.96 (95% CI: 2.08, 4.21) for CRC screening receipt compared to those who did not. Conclusions: A linguistically appropriate intervention to promote CRC screening among Chinese Americans using a mailed reminder, brochure, and access to a website led to a modest but significant increase in CRC screening compared to usual care among overdue patients in 3 healthcare systems. Mailed in-language materials should be considered as a low-resource intervention to increase CRC screening among Chinese Americans. Citation Format: Tung T Nguyen, Janice Tsoh, Angela Sun, Kent Woo, Joyce Cheng, Ching Wong, Jian Zhang, Janet Bernet, Stella Pan, Ginny Gildengorin. Efficacy of in-language mailers on receipt of colorectal cancer screening among Chinese Americans: A randomized controlled trial [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C122.

Effects of different reminder strategies on first-time mammography screening among women in Taiwan

BackgroundThe study’s purpose was to examine the effectiveness of different reminder strategies on first-time free mammography screening among middle-aged women in Taiwan.MethodsA quasi-experimental design with random assignment was adopted to divide the participants into three Reminder Strategies groups (mail reminder, telephone reminder, and combined mail and telephone reminders) and one control group. This study recruited 240 eligible middle-aged women, and 205 of them completed the study. Upon the completion of data collection, mail reminders were provided to women of the first group; telephone reminders were provided to the second group; mail followed by telephone reminders were provided to the third group, and the usual postcards were provided to the control group 1 month after the interventions. Two follow-up assessments were conducted 1 and 3 months after the intervention to collect mammography-screening behaviors from all groups.ResultsThe findings showed that, compared to the control group, more participants in the intervention groups underwent mammography screening after receiving reminder interventions. Telephone contact as reminder was found to have the most significant influence among the interventions (OR = 5.0556; 95% CI = 2.0422–13.5722).ConclusionsGovernment and healthcare providers are recommended to consider adopting the telephone reminder strategy to encourage women to undergo their first-time mammography screening.

Comparative effectiveness of mailed reminders with and without fecal immunochemical tests for Medicaid beneficiaries at a large county health department: A randomized controlled trial.

Colorectal cancer (CRC) screening is effective but underused. Screening rates are lower among Medicaid beneficiaries versus other insured populations. No studies have examined mailed fecal immunochemical testing (FIT)-based outreach programs for Medicaid beneficiaries. In a patient-level randomized controlled trial, a mailed CRC screening reminder plus FIT, sent from an urban health department to Medicaid beneficiaries, was compared with the same reminder without FIT. The reminder group could request FIT. Completed FIT kits were processed by the health department laboratory. Respondents were notified of normal results by mail. Abnormal results were given via phone by a patient navigator who provided counselling and assistance with follow-up care. The primary outcome was FIT return. In all, 2144 beneficiaries at average CRC risk were identified, and there was no evidence of screening with Medicaid claims data. To the reminder+FIT group, 1071 were randomized, and 1073 were randomized to the reminder group; 307 (28.7%) in the reminder+FIT group and 347 (32.3%) in the reminder group were unreachable or ineligible (previous screening). The FIT return rate was significantly higher in the reminder+FIT group than the reminder group (21.1% vs 12.3%; difference, 8.8%; 95% confidence interval, 3.7%-13.9%; P < .01). Eighteen individuals (7.2%) who completed FIT tests had abnormal results, and 15 were eligible for follow-up colonoscopy; 66.7% (n = 10) completed follow-up colonoscopy. A health department-based, mailed FIT program targeting Medicaid beneficiaries was feasible. Including a FIT kit resulted in greater screening completion than a reminder letter alone. Further research is needed to understand the comparative cost-effectiveness of these interventions.

Abstract PR12: Considering unintended effects of a colorectal cancer navigation program in a Federally Qualified Health Center in Chicago on mammography uptake

Abstract Introduction: Health care facilities often have competing public health priorities they must address, including different types of cancer. The burden of addressing these conditions is particularly great in Federally Qualified Health Centers, wherein marginalized populations suffer simultaneously from late-stage detection for various cancers. Patient navigation is an approach that has been documented to be effective across many of these cancers, including breast and colorectal (CRC). What is less known is if and how navigation for one site may influence patients' behaviors with regard to other cancer sites. Such information may be helpful for evaluating the benefits of different programs, and deciding which optimize patients' health maximally. Methods: During January 2015 through December 2015, a patient navigation intervention was implemented for cancer screening in three of the health clinics: Main site, Englewood, and Back of the Yards site (BOTY). Starting in January 2016, a 1,453-patient chart review was completed using electronic health records. The criteria for the review are as follows: 1) age 50-5 years old and 2) scheduled for a provider visit at one of the three participating sites during the 12-month study period. Neighborhood characteristics were added to the dataset by combining it with the American Community Survey at the zip code level. The sample size for this analysis was n = 863. The independent variable was CRC navigation, with the following categories: none (REFERENT), mailed reminders, provider education, lay patient navigator (LPN), and combined interventions (including 2+ of the intervention types). The outcome variable was mammogram status with the following categories: adherent (receipt of screening within 2 years), nonadherent with a lifetime history of mammography, and nonadherent without a lifetime history of mammography. The analysis conducted was a polychotomous logistic regression model. The association was adjusted by age, race/ethnicity, percent poverty, and percent non-Latino White. Results: The patient population had a mean age of 60.3. There was an average of 31.3% poverty in each zip code. 60% of the population were non-Latino Black. Latino represented 29% of the study population. Non-Latino White and other category consisted of 11% of the sample. The distribution of the insurance in the study population was as follows: private insurance made up 23% percent of the sample, public insurance represented 69% of the sample, and self-pay made up 8% of the population. Mammography status was associated with neighborhood poverty, %NLW residents, clinic site, and insurance status (all P &amp;lt;.05). In terms of our main question, women receiving LPN (OR = 0.25, 95%CI: 0.08, 0.77) and women receiving mailed reminders (2.16, 95%CI: 1.02, 4.58) were associated with odds of being nonadherent with a lifetime history of mammography. Conclusion: The results show certain colorectal interventions were associated with mammogram status. The navigation arm showed a protective effect against past-due mammograms if the patient was navigated by LPN. However, it was a risk factor for past-due mammogram for those in the mailed reminders arm. These results implicate that lay patient navigators may improve overall cancer-screening completion rates. This could be due to lay patient navigators' focus on overall patient health, and therefore emphasize the importance of all cancer screenings, whereas mailed reminders solely focus on colorectal cancer and thus do not affect other cancer-screening completion rates. Citation Format: Yazmin San Miguel, Karriem S. Watson, Keia Hobbs, Robert Winn, Yamile Molina. Considering unintended effects of a colorectal cancer navigation program in a Federally Qualified Health Center in Chicago on mammography uptake [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR12.

A235 EXPLORING PATIENT FACTORS FOR CANCELLED OR MISSED APPOINTMENTS TO AN URGENT GASTROENTEROLOGY OUTPATIENT CLINIC.

The Canadian Association of Gastroenterology reports that wait times to see a gastroenterologist are too long, even for urgent problems. Cancellations and no-shows compound this problem and lead to poor services utilization. A weekly urgent GI clinic started at St Joseph’s Healthcare Hamilton in March 2014 to improve timely access for patients. The clinic accepted referrals from the emergency room (ER) and urgent care with a capacity of 6 patients per week booked within 3 weeks of referral. The cancellation and absence rate from the clinic was 25% in the first 6 months despite patients receiving mail and phone reminder. Studies in no-show predictors focus on primary care, pediatric population and routine outpatient appointments. Published studies on absence rate in urgent clinic settings are very limited. The present study explores patient factors for the high absence rate at our urgent GI clinic. Retrospective review of patients booked to the urgent GI clinic between March and September 2014 that were absent at their appointment. The patient demographics, reasons for referrals, duration of symptoms were reviewed from the chart. The patients were contacted to explain why they missed their appointment and were offered to be rebooked. Between March and October 2014, 37 patients (25%) were absent for their appointment to the urgent GI clinic. The average age of patients was 51 years, and 43% were females. The mean duration of symptoms was 28.2 weeks, but 56% of patients had more acute symptoms for 1 week or less when presenting to ER or urgent care. The reasons for referrals included lower GI bleeding (24%), upper GI bleeding (22%), abdominal pain (16%), dysphagia (8%), anemia (5%) and inflammatory bowel disease (5%). Several attempts were made to contact patients, and 22/37 (59%) were reached. Of the 22 patients, 10 elected to cancel without rebooking, 3 were seen as inpatients, and 3 were seen by another outpatient gastroenterologist. Only 6/22 (27%) were rebooked to another urgent clinic appointment. The urgent GI clinic is a useful means for seeing patients with subacute GI illness but has an unacceptably high rate of missed appointments. Of the patients we contacted, only 27% were rebooked back to the urgent clinic. Almost half elected not to rebook suggesting that an urgent referral may not have been appropriate. On the other hand, 3 patients were admitted, suggesting that outpatient management may not have been suitable either, and 3 patients decided to follow up with their established gastroenterologist. The urgent GI clinic now screens all referrals for appropriateness, and does not see patients seen within the past year by another gastroenterologist. Follow-up data will hopefully demonstrate reduction in absence rate with this new strategy. None

No-Show Rates When Phone Appointment Reminders Are Not Directly Delivered.

Promoting patient engagement in treatment and reducing frequency of missed appointments result in higher value through both improved outcomes and improved efficiency. For this reason, continuous quality improvement (CQI) efforts to increase engagement are important in service operations. This column illustrates the results of a CQI study to determine the impact of method of delivery of phone appointment reminders on attendance rates for a cohort of 250 primary care patients with depression. Results indicated that the type of reminder had a significant impact on attendance. Live reminders had the lowest no-show rate (3%), then message or voice mail reminders (24%) and no answer (39%). These findings illustrate the value of CQI efforts for even such basic interventions as appointment reminders. Appointment attendance rates were considerably higher when there was a live contact. CQI efforts related to reminders therefore may benefit from rapid change cycles that incorporate monitoring of the type of reminder delivery and that continuously seek better strategies for engagement.

Implementation and process evaluation of three interventions to promote screening mammograms delivered for 4years in a large primary care population.

The optimal form of outreach to promote repeated, on time screening mammograms in primary care has not been established. The purpose of this study is to assess the implementation process and process outcomes for three interventions for promoting biannual screening mammography in a randomized trial. In a large urban primary care practice over a 4-year period, we randomized women aged 40-85 and eligible for mammograms to three interventions: reminder letter only (LO), reminder letter + reminder call (RC), and reminder letter + counseling call (CC). We tracked information system development, staff training, patient and provider recruitment, reach, dose delivered and received, fidelity, and context measures. Ninety-three of 95 providers approved participation by 80% (23,999) of age-eligible patients, of whom only 207 (0.9%) opted not to receive any intervention. Of 9161 initial reminder letters mailed to women coming due or overdue for mammograms, 0.8% were undeliverable. Of women in the RC and CC arms unresponsive to the first reminder letter (n=3982), 71.4% were called and reached, and of those, 49.1% scheduled a mammogram. Only 33.4% of women reached in the CC arm received full counseling, and women in the CC arm were less likely to schedule a mammogram than those in the RC arm. Implementing mail and telephone mammography reminders is feasible and acceptable in a large urban practice and reaches a majority of patients. Many schedule a mammogram when reached. A reminder letter followed by a simple reminder call if needed may be the optimal approach to promoting screening mammograms.

Observational study to evaluate the impact of internet reminders for GPs on colorectal cancer screening uptake in Northern Italy in 2013.

Colorectal cancer (CRC) is the third most common cancer worldwide and CRC-related mortality can be effectively reduced by population-based screening. Screening uptake is a key indicator of performance, susceptible of several implementation methods. Participation in ASL Milano 1 area (northern Italy) is increasing thanks to reminder invitation sent to non-responders. Here we evaluate the implementation of another strategy among those proved to be effective. In the years 2013-2014 we conducted an observational study in patients non-responder to first invitation and subsequent mailed reminder. A list of them was sent to their own GP, who had the task to evaluate possible exclusion criteria and make a reminder, either by personal interview, telephone call or via e-mail. Intervention could be conducted either by the GP himself or by an assistant. Primary outcomes were to assess the overall efficacy of the intervention and the efficacy of its single features (type of intervention and provider), measuring the consequent uptake of CRC screening. Participation in CRC screening was significantly higher (33,5%) in patients who received a reminder from GP, regardless of the type, vs those who did not (19,0%, p < 0.01). No statistically significant difference was detected either by method or by provider of the intervention. The results of our study demonstrate that even a modest intervention can have a significant effect in improving compliance to screening for CRC, one of the cancers with highest incidence in developed countries, for which an effective treatment is available in case of early diagnosis.

Patient Compliance in the Setting of BI-RADS Category 3: What Factors Impact Compliance With Short-Term Follow-Up Recommendations?

The study aims to define how imaging findings, patient demographics, patient-provider interactions, and health care practices may affect a woman's decision to follow-up in the setting of a BI-RADS Category 3. A total of 398 women from the University of Arizona Breast Imaging Center with a BI-RADS Category 3 assessment for mammography and/or ultrasound findings were evaluated between February 2012 and June 2014. Demographic information was analyzed for all patients, regardless of follow-up. Women who returned for follow-up within the recommended time period were given one survey at the time of their follow-up appointment, and women who returned for follow-up, but later than recommended, were given a separate survey to complete. Age, palpability of a lesion, and menopause status were related to follow-up. Self-rated general health was the only factor found to be associated with the decision to follow-up on time. The majority of patients who followed up on time reported that mailed reminder cards were the primary practice that prompted follow-up. Of patients who followed up later than recommended, the major reason was "no time." The findings suggest that additional counseling regarding the benefits of short-interval imaging follow-up might be advantageous for patients.