Reminder Letter Research Articles

Advancing mammography uptake among vulnerable groups: a systematic review of intervention strategies

Abstract With over 2 million cases diagnosed annually, breast cancer is a leading cause of cancer-related disability and mortality. Despite global efforts to implement mammography screening programs, uptake rates vary widely across settings due to socioeconomic factors and accessibility challenges. To improve participation, targeted interventions addressing barriers faced by underserved groups are essential for promoting inclusive screening and early detection. As part of the ENTER project, which aims to address disparities in breast cancer screening participation among women with low socioeconomic status (SES) in Flanders, Belgium, we conducted a systematic review and meta-analysis on the effectiveness of interventions to enhance mammography uptake. To explore the differential impact of interventions on mammography uptake among vulnerable groups, including individuals with low SES, underinsured, with immigrant background or part of an ethnic minority, subgroup analyses were performed. 7 databases were searched, resulting in the inclusion of 54 out of 9,366 papers for analysis. 14 types of interventions were identified. The meta-analysis showed significant pooled effects of interventions that increased mammography uptake [OR 1.8 (95%CI 1.6-2.2)], particularly among vulnerable populations [OR 2.2 (95%CI 1.7-2.8)]. The most effective interventions were educational interventions [OR 3.03 (95%CI 2.2-4.9); in vulnerable groups OR 2.7 (95%CI 1.9-3.9)]. As expected, interventions adapted to linguistic needs and culturally sensitive approaches showed a significant effect among vulnerable target groups [OR 2.9 (95%CI 1.1-7.9) and OR 2.5 (95%CI 1.1-5.6), respectively]. Reminders were also highly effective [OR 1.8 (95%CI 1.5-2.1); in vulnerable groups OR 2.5 (95%CI 1.9-3.1)]. This review underscores the critical role of targeted interventions in augmenting screening mammography uptake, particularly among vulnerable populations, where odds of participation can increase by up to 2-3 times. Key messages • Interventions adapted to the linguistic needs of the target population and culturally sensitive approaches, aligned with values and beliefs of a specific community, can greatly enhance screening rates. • Considering costs, practicality and impact, reminder letters with culturally and linguistically adapted content emerged as the most promising option for implementation in the ENTER project.

A Mail-Based HPV Self-Collection Program to Increase Cervical Cancer Screening in Appalachia: Results of a Group Randomized Trial.

Despite the promise of mail-based human papillomavirus (HPV) self-collection programs for increasing cervical cancer screening, few have been evaluated in the United States. We report the results of a mail-based HPV self-collection program for underscreened women living in Appalachia. We conducted a group randomized trial during 2021-2022 in the Appalachian regions of Kentucky, Ohio, Virginia, and West Virgnia. Participants were women ages 30-64 who were underscreened for cervical cancer and from a participating health system. Participants in the intervention group (n=464) were mailed an HPV self-collection kit followed by telephone-based patient navigation (if needed), and participants in the usual care group (n=338) were mailed a reminder letter to get a clinic-based cervical cancer screening test. Generalized linear mixed models compared cervical cancer screening between study groups. Overall, 14.9% of participants in the intervention group and 5.0% of participants in the usual care group were screened for cervical cancer. The mail-based HPV self-collection intervention increased cervical cancer screening compared to the usual care group (OR=3.30, 95% CI: 1.90-5.72, p=0.005). One or more high-risk HPV types were detected in 10.5% of the returned HPV self-collection kits. Among participants in the intervention group who patient navigators attempted to contact, 44.2% were successfully reached. HPV self-collection increased cervical cancer screening, and future efforts are needed to determine how to optimize such programs, including the delivery of patient navigation services. Mail-based HPV self-collection programs are a viable strategy for increasing cervical cancer screening among underscreened women living in Appalachia.

Barriers and facilitators to cervical cancer screening among under- and neverscreened women in Flanders, Belgium – a qualitative study on community and healthcare providers’ perspectives

BackgroundCervical cancer is detectable and preventable in premalignant stages. In 2013, a population-based cervical cancer screening (CCS) programme was set up in Flanders (Belgium) promoting screening by means of sending reminder letters. Yet, in 2021, only a CCS coverage of 63.6% has been reached, which is just a bare increase since the implementation of the programme (62.7% in 2013) (Jaarrapport 2022, Centrum voor Kankeropsporing (CvKO), 2022; Jaarrapport 2015, Centrum voor Kankeropsporing (CvKO), 2015).ObjectivesTo explore the characteristics of under- and neverscreened women in Flanders and to gain a better understanding of the barriers that prevent these women from attending CCS as well as factors that may facilitate CCS uptake.MethodsTwelve in-depth interviews and six focus group discussions were conducted with gynaecologists, general practitioners, community health workers and stakeholders providing support to women belonging to potentially underscreened population groups. Reported barriers and facilitators were subsequently classified using the Socio-Ecological Model (SEM). Finally, a causal loop diagram was constructed to visualise the dynamic interrelations among the barriers and facilitators.ResultsStakeholders and healthcare professionals confirm the vulnerability for cervical cancer screening in women with a substance use disorder and women with a migration background. The participation in screening among female sex workers is contingent upon their specific work environment. The group of never- or underscreened women is very heterogeneous and includes many women who are either unaware of CCS or have other priorities. A lack of focus on prevention is the most commonly reported barrier at the healthcare system level. Increasing awareness about cervical cancer (screening) and creating more opportunities for healthcare workers to offer prevention services are the primary facilitators.ConclusionTo improve screening participation in Flanders, different screening strategies tailored to a diversity of women are needed.

Effectiveness and Acceptability of Targeted Text Message Reminders in Colorectal Cancer Screening: Randomized Controlled Trial (M-TICS Study).

Mobile phone-based SMS text message reminders have the potential to improve colorectal cancer screening participation rates. This study assessed the effectiveness and acceptability of adding targeted SMS text message reminders to the standard procedure for those who picked up but did not return their screening kit at the pharmacy within 14 days in a colorectal cancer screening program in Catalonia, Spain. We performed a randomized control trial among individuals who picked up a fecal immunochemical test (FIT) kit for colorectal cancer screening at the pharmacy but did not return it within 14 days. The intervention group (n=4563) received an SMS text message reminder on the 14th day of kit pick up and the control group (n=4806) received no reminder. A 30-day reminder letter was sent to both groups if necessary. The main primary outcome was the FIT completion rate within 30, 60, and 126 days from FIT kit pick up (intention-to-treat analysis). A telephone survey assessed the acceptability and appropriateness of the intervention. The cost-effectiveness of adding an SMS text message reminder to FIT completion was also performed. The intervention group had higher FIT completion rates than the control group at 30 (64.2% vs 53.7%; P<.001), 60 (78.6% vs 72.0%; P<.001), and 126 (82.6% vs 77.7%; P<.001) days. Participation rates were higher in the intervention arm independent of sex, age, socioeconomic level, and previous screening behavior. A total of 339 (89.2%) interviewees considered it important and useful to receive SMS text message reminders for FIT completion and 355 (93.4%) preferred SMS text messages to postal letters. We observed a reduction of US $2.4 per participant gained in the intervention arm for invitation costs compared to the control arm. Adding an SMS text message reminder to the standard procedure significantly increased FIT kit return rates and was a cost-effective strategy. SMS text messages also proved to be an acceptable and appropriate communication channel for cancer screening programs. ClinicalTrials.gov NCT04343950; https://www.clinicaltrials.gov/study/NCT04343950. RR2-10.1371/journal.pone.0245806.

EMPLOYMENT OUTCOMES FOLLOWING THORACOLUMBAR FRACTURES: LONG-TERM FOLLOW-UP GREATER THAN FIVE YEARS

Study designRetrospective study.ObjectivesTo identify patient outcomes, in particular employment, &gt;5-years following traumatic thoracolumbar fracture.Methods235 patients between the ages of 18–65 were identified from the hospital radiology database having sustained a traumatic thoracolumbar fracture on CT or MRI between 01/01/2013 and 31/01/2017. Questionnaires were sent out via post and available emails, with a reminder letter and phone calls. Retrospective data was gathered about employment status pre-fracture and &gt;5-years post injury.Results26 patients had died at follow up leaving 209 patients. 108 (52%) were treated surgically and 101 (48%) conservatively. 106 replies were received with 85 (80%) opting in and 21 (20%) opting out. 68 (80%) patients completed the full questionnaire with 17 (20%) filling out a shortened questionnaire via a phone conversation. 52 (61%) patients underwent surgery and 33 (39%) were treated conservatively. The average follow up was 8 years. Prior to injury 66 (78%) were employed and 19 (22%) unemployed (of which 6 were full time students and 8 were retired). 49 (74%) of the previously employed patients returned to work at follow up with 35 (53%) working the same or increased hours. Regarding employment, there was no significant difference between surgically and conservatively treated patients (P=0.355) or the classification of the fracture (P=0.303). 16 (19%) patients reported back pain prior to their injury whilst 69 (81%) did not. There were 58 (68%) cases of new pain at follow up with the most affected area being the lumbar region in 43 (51%) patients. 32 (38%) patients reported neurological deficit post injury: 19 with subjective symptoms, 9 with objective symptoms and 4 suffered paralysis.Conclusion&gt;5-years following a traumatic thoracolumbar fracture most individuals return to employment. There was no significant difference between the severity of the fracture or how patients are treated on their employment outcomes.

A Randomized Trial of Choice Architecture and Mailed Colorectal Cancer Screening Outreach in a Community Health Setting

Mailed outreach for colorectal cancer (CRC) screening increases uptake but it is unclear how to offer the choice of testing. We evaluated if the active choice between colonoscopy and fecal immunochemical test (FIT), or FIT alone, increased response compared with colonoscopy alone. This pragmatic, randomized, controlled trial at a community health center included patients between ages 50 and 74 who were not up to date with CRC screening. Patients were randomized 1:1:1 to the following: (1) colonoscopy only, (2) active choice of colonoscopy or FIT, or (3) FIT only. Patients received an outreach letter with instructions for testing (colonoscopy referral and/or an enclosed FIT kit), a reminder letter at 2 months, and another reminder at 3 to 5 months via text message or automated voice recording. The primary outcome was CRC screening completion within 6 months. Among 738 patients in the final analysis, the mean age was 58.7 years (SD, 6.2 y); 48.6% were insured by Medicaid and 24.3% were insured by Medicare; and 71.7% were White, 16.9% were Black, and 7.3% were Hispanic/Latino. At 6 months, 5.6% (95% CI, 2.8-8.5) completed screening in the colonoscopy-only arm, 12.8% (95% CI, 8.6-17.0) in the active-choice arm, and 11.3% (95% CI, 7.4-15.3) in the FIT-only arm. Compared with colonoscopy only, there was a significant increase in screening in active choice (absolute difference, 7.1%; 95% CI, 2.0-12.2; P= .006) and FIT only (absolute difference, 5.7%; 95% CI, 0.8-10.6; P= .02). Both choice of testing and FIT alone increased response and may align with patient preferences. clinicaltrials.gov NCT04711473.

Social Information and Educational Investment—Nudging Remedial Math Course Participation

Abstract Using field experiments, I investigate if provision of (social) information can increase incoming university students' attendance in a voluntary remedial math course. In Intervention 1, treated students receive an invitation letter with or without information about a past sign-up rate for the course. In Intervention 2, among those who signed up for the course, treated students receive reminder letters including or excluding information on how helpful the course had been evaluated by previous students. On average, no treatment increases participation in the course, but further analyses reveal that the effects in Intervention 1 are heterogeneous along two dimensions: First, suggesting salience as a mechanism, both types of information raise attendance among students who enroll late in their study program, which in turn increases their first-year performance and closes the achievement gap to early enrollees. Second, the effect of the letter with information about the past sign-up rate depends on the predicted ex-ante sign-up probability. Students whose probability falls just short of the past sign-up rate increase sign-up and participation, while the opposite is true for students whose sign-up probability exceeds the social information. Along this dimension, however, the changes in attendance do not carry over to academic achievements.

Abstract C122: Patient perspectives on factors influencing repeat colorectal cancer screening in a Federally Qualified Health Center

Abstract Background. The life-saving benefits of colorectal cancer (CRC) screening can be maximized only if screening is completed at recommended intervals. The fecal immunochemical test (FIT), an inexpensive stool-based test recommended yearly, is the primary screening modality in many Federally Qualified Health Centers (FQHCs) and remains underutilized. To inform system interventions, we sought to identify patient perspectives on factors that influence the likelihood of repeated FIT screening over time in a large FQHC. Methods. Between September 2022 and March 2023, we conducted semi-structured interviews with patients who were due for FIT screening and completed at least one prior FIT test at a large FQHC that serves a primarily Latino population in Los Angeles County. Our interview guide explored patients’ perceived barriers and facilitators to repeat FIT over time and experiences with FIT clinic processes of care. Audio-recorded interviews were conducted in patients’ preferred language (English or Spanish), transcribed, and translated. Transcripts were coded using ATLAS.ti, and themes were summarized. Results. Among 17 interview participants, the majority were female (82%), Latino (94%), and Spanish-speaking (88%). The median age was 57 years (range 52-70), and 41% had an 8th grade education or less. Interviews revealed that patient, family, and provider/system factors influenced receipt of sequential rounds of annual FIT CRC screening. At the patient level, perceived importance of disease prevention and early detection on the part of patients facilitated proactive engagement in regular screening. Additionally, many patients thought the process of FIT completion and return was easy, although some patients did express low confidence in stool sample collection and time and work constraints impeding in-person FIT return. Another recurrent theme was motivation from family, both direct support (assistance with FIT completion and transportation to clinic) and indirect motivation (an intrinsic desire to stay healthy for family). At the provider/system level, language discordance hindered communication with providers, and in-language FIT instructions and availability of bilingual staff to translate were identified as facilitators. Patient suggestions to improve FIT completion included client text and letter reminders when due for CRC screening; print education that underscores the purpose of screening; and appointment consolidation for cancer and other preventive care screenings. Conclusion. Interventions to improve regular FIT-based CRC screening may benefit from emphasizing the importance of early detection; improving patient knowledge and confidence in how to perform stool sample collection; family support; and language-concordant staff and resources for multi-lingual and medically underserved populations. Citation Format: Narissa J. Nonzee, Beth A. Glenn, Debra Rosen, Genesis Sandoval, Diana Trujillo, Folasade P. May, Alison K. Herrmann, Christine Park, Alicia Lwin, Joanna Quintanilla, Jessica Tuan, Lauren Cai, Roshan Bastani. Patient perspectives on factors influencing repeat colorectal cancer screening in a Federally Qualified Health Center [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 C122.

A National Survey of Oncologists' Perspectives on the Ethical Implications of Artificial Intelligence in Cancer Care

Introduction Artificial Intelligence (AI) is an emerging technology that promises advancements across blood cancer discovery and care delivery. There are already FDA-approved uses of AI in hematology and oncology but few data available about its use or utility. Concerns have been raised over AI's potential biases, “explainability,” and who is responsible for its use. Oncologists' familiarity with AI and perspectives on these issues are not well known and are critical to understanding the ethical deployment of AI in blood cancer care. Methods From January to July 2023, we performed a national cross-sectional survey of practicing oncologists. A draft survey instrument was developed by a team with content and methodological expertise. Iterative refinement occurred through cognitive debriefing with 5 practicing hematologist/oncologists. The final instrument included 24 questions covering domains of AI familiarity, predictions, explainability, and responsibilities. A random sample of US oncologists was identified using the National Plan &amp; Provider Enumeration System. Paper surveys were mailed with $25 incentivizing gift cards. Reminder letters and phone calls were used for non-responders with an electronic survey option provided. Responses were analyzed descriptively. X2 testing assessed bivariate associations between responses and participant practice setting, with odds ratios (OR) reported. Results Of 399 mailed surveys, 12 were undeliverable and 201 were completed for a response rate of 51.9%. Question missingness was &amp;lt;1%. Participants were 63.2% White, 16.9% Indian Asian, 10.0% Eastern Asian or Pacific Islander, and 4.5% Black; 6.0% were Hispanic. They represented 37 states. The majority were male (63.7%), 40-59 years old (54.2%), and had no specific training in AI (52.2%); 68.2% had at least 11 years in practice and 29.9% practiced at a primary academic hospital. Questions assessing overall familiarity with and predictions related to AI are shown in Table 1. Those at primary academic hospitals were more likely to be familiar with radiology models (OR 2.82, p&amp;lt;0.001) but not pathology, prognostic, or clinical decision models (all p&amp;gt;0.05). They were more likely to predict that AI would improve side effect management (OR 2.01, p=0.03) and end-of-life decision making (OR 2.07, p=0.02). High proportions of respondents thought that AI prognostic (67.1%) and clinical decision models (62.1%) needed to be explainable by clinicians and researchers to be used in clinic. When posed with a scenario where an FDA-approved AI model selects a different regimen than the oncologist planned to propose (Figure 1), the largest proportion reported they would present both options and let the patient decide (37.3%). Of those recommending a regimen, respondents from primary academic hospitals more frequently recommend the AI-generated regimen (56.1%), while respondents from elsewhere recommended their original regimen (69.0%; OR 2.85, p=0.007). Acceptability of some direct-to-patient AI model applications is shown in Table 1. A majority of respondents (90.5%) thought that AI developers should be responsible for medico-legal problems caused by AI use; 47.8% thought that physicians using the tool should be responsible. Though most (76.1%) agreed that it was oncologists' responsibility to protect patients from biased AI tools, few (27.3%) were confident in their ability to identify how representative the data used in an AI model was relative to the population with that cancer (including 66.7% of those who agreed it was oncologists' responsibility). More respondents thought that patients should need to consent to the use of AI tools in cancer treatment decisions (81.1%) than cancer diagnosis (55.7%); those from primary academic hospitals were less likely to respond that patients should consent for treatment or diagnosis (OR 0.43, p=0.02 and OR 0.44, p=0.009). Conclusions In this national survey of oncologists' views on AI, there was optimism about its impact on care with notable caveats related to end-of-life care, patient trust, and care disparities. Despite many approving use of AI models too complex for patients to explain, a substantial proportion deferred to patient choice when AI and physician recommendations differed. There was also dissonance between accepting responsibility to protect patients from bias and respondents' self-perceived ability to do so.

The Effect of Multimodal Interventions Regarding Early Cervical Cancer Diagnosis on the Women's Knowledge, Attitude and Participation in Cervical Screening Program.

The objective of the present study was to assess the effect of multimodal interventions on women's knowledge, attitude, and behavior towards the participation in the cervical screening test. A quasi-experimental design is executed with a multi-stage sampling of 300 women residing in rural India. Various multimodal interventions, including a documentary film, face-to-face meetings, written booklets, reminder letters, SMS, and telephone calls, are used to motivate the women for cervical cancer screening. Following the interventions, 99% of the participants became aware of cervical cancer and increased their participation in screening from 3.0 % (Pretest) to 79.9% (Posttest). Three reminders have been sent to the participants, throughout the intervention period which has led to a considerable rise in the participants' willingness to participate in screening, hiking from 58% to 79.9%. The Pap smear test results have shown that: among 288 women, 21 have Typical Malignant cells on their cervix, and two women have been diagnosed with cervical cancer (Stage 1a and Stage 1b). The findings of the study indicate that utilizing diverse interventions in health education alters women's behavior, enhances the compliance of cervical cancer screening, and ultimately helps to prevent life-threatening risks.

Evaluation of the impact of letters to GP practices to promote asthma prescription uptake in school-age children during summer (TRAINS study): a pragmatic cluster-randomised controlled trial

BackgroundAsthma exacerbations peak in school-aged children after the return to school in September. Previous studies have shown a decline in collections of asthma prescriptions during August. The PLEASANT trial demonstrated that sending a reminder letter to parents increased prescription uptake; reduced unscheduled care, and was cost saving to the health service. We aimed to assess whether informing general practitioner (GP) practices about the PLEASANT trial and its results could lead to its implementation in routine practice. MethodsThe trial to assess implementation of new research in a primary care setting (TRAINS) was a pragmatic cluster-randomised (1:1) trial conducted in England involving GP practices contributing to the Clinical Practice Research Datalink (CPRD). The intervention was a letter informing the GP practice of the PLEASANT trial results with recommendations for implementation. GP practices in the control group continued with usual care without receiving any letters about PLEASANT trial. The intervention was distributed via CPRD by both mail and email in June 2021. The trial received both University of Sheffield Ethics approval and Independent Scientific Advisory Committee (ISAC) approval. The primary outcome was the proportion of children with asthma (aged 4–15 years) who had a prescription for a preventer between Aug 1 and Sept 30, 2021. This trial is registered with ClinicalTrials.gov, NCT05226091. FindingsA total of 1326 GP practices, including 90 583 children with asthma, were included in the study. These practices were randomly allocated to the intervention group (664 practices, 44 708 children) or the control group (662 practices, 45 875 children). In assessing the impact of the intervention on the proportion of children collecting a preventer prescription, 15 716 (35·3%) of 44 708 children from the intervention group and 16 001 (35·1%) of 45 559 children from the control group picked up a prescription. There was no statistically significant difference observed (odds ratio [OR] 1·01, 95% CI 0·97–1·05), indicating that the intervention had no effect. InterpretationThe study findings suggest that passive intervention of providing a letter to GPs did not achieve the intended outcomes. To bridge the gap between evidence and practice, alternative, more proactive strategies could be explored to address the identified issues. FundingJazan University.

Impact of a patient reminder letter from their general practitioners on influenza vaccination: A quasi-experimental study in Paris, France

BackgroundSeasonal influenza vaccination coverage levels remain too low in many countries.ObjectivesThis study aimed to evaluate the impact of a reminder letter from their general practitioner (GP) on patients’ influenza vaccination.MethodsEligible patients for this controlled non-randomised study were the vulnerable categories targeted by the 2019–2020 national health insurance fund (NHIF) vaccination campaign, on the lists of 14 GPs from three practices in Paris (France) and unvaccinated on January 2, 2020 (mid-campaign). The choice of practices and assigning five GPs to the intervention arm were made for convenience. At mid-campaign, GPs in the intervention arm sent a standardised letter reminding each eligible patient to be vaccinated. In the control arm, GPs worked as usual. The intervention effect, calculated from the NHIF databases, was estimated by the difference between the groups in their vaccination coverage at the end of the campaign, with a linear mixed model adjusted for age, sex, chronic disease (at the patient level) and medical practice (at the GP level).ResultsThe vaccination coverage at the end of the campaign was 14.7% in the intervention group (n = 317) and 1.7% in the control group (n = 493): a difference of 13.1% points (95% confidence interval [9.0–17.2], number needed to send 7.7). At the campaign’s end, vaccination coverage among patients from the lists of GPs in the intervention arm was 62.7%, and 46.2% among patients from the control-arm GP lists.ConclusionReminder letters could help increase influenza vaccination coverage.

Colorectal cancer screening with faecal immunochemical test: Patterns of participation.

To evaluate participation and participation patterns in a population-based screening programme for colorectal cancer (CRC) using the faecal immunochemical test (FIT). All individuals invited to three consecutive screening rounds in the population-based CRC screening between October 2015 and December 2020 in the Stockholm-Gotland Region, Sweden were included. Patterns of participation were assessed. The study included 26 541 individuals which resulted in 79 623 screening events. The overall uptake rate was 71.5% and women had a significantly higher participation rate. The participation rate increased significantly between the first and third screening round for both men and women, and the increase was larger among men than women (66.1 to 70.7% vs. 73.1 to 75.4%). In total, 80.9% participated at least once. Consistent participation was the most common participation pattern (61.0%). The probability of attending all three consecutive rounds after initial participation was 87.7%. Over the three rounds, 17.4% participated after a reminder letter. Screening individuals attending after a reminder letter had a higher proportion of drop-outs in the following screening round compared to initial participants (15.4% vs 6.2%). A constant and high participation rate was observed in population-based FIT-screening for CRC. Initial participation was a strong predictor for continuous participation. The need for a reminder letter before participation was a risk factor for subsequent drop-out.

Addressing barriers to colorectal cancer screening in a federally qualified health center.

Colorectal cancer (CRC) is a leading cause of death from cancer in the United States, despite the availability of high-quality screening options. Multiple barriers to CRC screening have been identified, including cost (noninsured), younger age, racial or ethnic minority, recent immigration to the United States (non-English speaking), fear or distrust of the health care system, and rural residence. The mean CRC screening rate for the designated Federally Qualified Health Center (FQHC) was 33.7% for the 5 months preceding this quality improvement (QI) project. The benchmark target for CRC screening was 60.1%. The Model for Improvement and Plan-Do-Study-Act cycle created the framework for the CRC screening targeted interventions used in this FQHC patient population. Multiple targeted interventions were implemented over a 4-month period that emphasized a strong provider recommendation, a team-based approach to identify and offer CRC screening options to the overdue patient. A chart audit was followed by a mailed fecal immunochemical test (FIT) and colonoscopy reminder letter initiative. The performance metric for CRC screening reached 40% within 4 months. A second chart audit confirmed the CRC screening rate improved to 41.5% among patients aged 50-75 years. An overall 55% return rate was achieved with the mailed FIT initiative within 2 months. Continued quality improvement initiatives are needed to achieve the benchmark target for this FQHC. These team-based interventions can be used by the primary care nurse practitioner to improve health equity for CRC screening in other underserved populations.

Preparation of employee performance assessment with a combination of management by objective and behaviorally anchor rating scale

PT XYZ is an independent power producer (IPP) and green energy company that provides energy for the needs of non-public sector end users. PT XYZ has the vision to become a company that provides professional customer satisfaction and the concept of good governance. PT XYZ also has a mission to provide quality service and customer satisfaction as well as to achieve added value to all related parties. The majority of the employee sample stated that there was a discrepancy between expectations and reality regarding performance appraisal. This study aims to design and assess the performance of PT XYZ employees. The research is oriented towards achieving the vision and mission by combining the Management by Objective (MBO) and Behaviorally Anchor Rating Scale (BARS) methods and processing them using the AHP and 360-degree Feedback methods and the final evaluation using a traffic light system. From the results of measuring the performance of PT XYZ. The results of the design of employee performance get different sub-criteria for each position. Based on the results of the assessment, the coordinator gets a good performance rating which will be given an incentive appreciation, the staff gets a disappointed performance rating and this will be given the second level of the reminder letter, the technician gets an excellent performance rating which will be given an appreciation in the form of a promotion, the administrator gets an intermediate performance rating that needs to be evaluated by superiors, and the last operator with a poor performance rating, and will be given the third level of a reminder letter. The results of the design will be used as a reference so that the assessment is more objective and focused.

Cervical Screening Reminders for Aboriginal and Torres Strait Islander Women in Primary Care-Randomised Controlled Trial of Letter vs. Phone/SMS Reminders.

(1) Background: Aboriginal women have a higher mortality from cervical cancer, yet cervical screening rates are lower than for other Australian women. (2) Methods: A randomised controlled trial of reminder letter vs. phone call/SMS for routine cervical screening testing in an Aboriginal Community Controlled Health Organisation in NSW. (3) Results: 256 women aged between 25 and 74 who were due for cervical screening were randomised to receive a reminder letter (and up to two further letters for non-responders) or a phone call (followed by up to two SMS) to attend the screening. A total of 15 women (12.5%) attended for cervical screening test within 3 months following a letter, and 24 women (17.6%) after a phone call/SMS reminder; this difference was not significant (p = 0.252). Time spent on sending letters vs. phone calls/SMS was similar; the cost was lowest for SMS. (4) Conclusion: Response to reminders was lower than expected. While there was no significant difference in effectiveness in letter vs. phone call/SMS for cervical screening recalls, reminder systems, including opportunistic reminders, can play a role in encouraging women to participate in screening programs in conjunction with national screening registers. The choice of reminder type should be left to service and consumer preference.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial

BackgroundMissed appointments (“no-shows”) are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments.ObjectiveTo determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance.DesignCluster randomized controlled pragmatic trial.PatientsThere were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis.InterventionsPrimary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments.Main MeasuresPrimary and secondary outcomes were missed appointments and canceled appointments, respectively.Statistical AnalysisResults are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.Key ResultsMissed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96–1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90–1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed.ConclusionsAppointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates.Trial NumberClinicalTrials.gov, Trial number NCT03850431.

Implementing a Combined Phone and Mail Recall to Increase Screening Colonoscopy Rates in Adults With Chronic Ulcerative Colitis.

Colon cancer is the third leading cancer nationally. To prevent colon cancer and decrease healthcare costs, high-risk individuals such as adults with chronic ulcerative colitis are recommended to stay up-to-date on screening colonoscopies. Despite these recommendations, screening colonoscopy rates remain low both globally and locally. The purpose of this article is to increase surveillance colonoscopy rates among adult patients with chronic ulcerative colitis. Research supports increasing surveillance colonoscopy rates by implementing a combined phone and mail recall with included educational material on the risks of colon cancer. At a clinic for inflammatory bowel disease patients in Southeast Alabama, participants with chronic ulcerative colitis who were overdue for screening colonoscopies were issued two reminder phone calls and a reminder letter coupled with educational material. Both the calls and letters reminded participants that they were due for a surveillance colonoscopy and provided them with an option to schedule the procedure. A pre- and post-survey was used to evaluate screening colonoscopy rates before and after the intervention. The survey indicated whether a patient had scheduled a colonoscopy, intended to schedule a colonoscopy, or completed a colonoscopy within 3 months of project completion. Survey results revealed an 83% increase in screening colonoscopies post-intervention. A chart audit was also performed 3 months after project completion and results indicated a 70% increase in completed colonoscopy rates. The findings from this evidence-based practice project indicate that implementing a phone and mail recall is successful in increasing screening colonoscopy rates.

Effect of Electronic Nudges on Influenza Vaccination Rate in Older Adults With Cardiovascular Disease: Prespecified Analysis of the NUDGE-FLU Trial.

Influenza vaccines have been demonstrated to effectively reduce the incidence of influenza infection and potentially associated risks of cardiovascular events in patients with cardiovascular disease (CVD). Despite strong guideline and public health endorsements, global influenza vaccination rates in patients with CVD are highly variable. This prespecified analysis of NUDGE-FLU (Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake) examined the effect of digital behavioral nudges on influenza vaccine uptake based on the presence of CVD. NUDGE-FLU was a randomized, pragmatic, nationwide, register-based trial that included Danish citizens 65 years of age or older during the 2022 to 2023 influenza season. Households were randomized in a 9:1:1:1:1:1:1:1:1:1 ratio to usual care or 9 electronic letters with designs based on behavioral concepts. Danish nationwide registers were used to collect baseline and outcome data. The primary end point was receipt of an influenza vaccine on or before January 1, 2023. The effects of the intervention letters were examined according to the presence of CVD and across cardiovascular subgroups that included heart failure, ischemic heart disease, and atrial fibrillation. Of 964 870 NUDGE-FLU participants from 691 820 households, 264 392 (27.4%) had CVD. During follow-up, 83.1% of participants with CVD versus 79.2% of participants without CVD received an influenza vaccination (P<0.001). Compared with usual care, a letter emphasizing the potential cardiovascular benefits of influenza vaccination increased vaccination rates; this effect was consistent in participants with CVD (absolute difference, +0.60 percentage points [99.55% CI, -0.48 to 1.68]) and without CVD (+0.98 percentage points [99.55% CI, 0.27-1.70; P for interaction=0.41). A repeated letter strategy with a reminder follow-up letter 14 days later was also effective in increasing influenza vaccination, irrespective of CVD (CVD: absolute difference, +0.80 percentage points [99.55% CI, -0.27 to 1.86]; no CVD: +0.67 percentage points [99.55% CI, -0.06 to 1.40]; P for interaction=0.77). Effectiveness of both nudging strategies was consistent across all major CVD subgroups. None of the other 7 nudging strategies were effective, regardless of CVD status. Electronic letter interventions emphasizing the potential cardiovascular benefits of influenza vaccination and using a reminder letter strategy were similarly beneficial in increasing influenza vaccination rates among older adults with and without CVD and across cardiovascular subgroups. Electronic nudges may improve influenza vaccine uptake in individuals with CVD. URL: https://www. gov; Unique identifier: NCT05542004.

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.