Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Computerized reminders increased use of mammography

ACP J Club. 1995 Jan-Feb;122:25. doi:10.7326/ACPJC-1995-122-1-025


Source Citation

Burack RC, Gimotty PA, George J, et al. Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care. 1994 Jun;32:609-24.


Abstract

Objective

To determine the effectiveness of a practice-based intervention in promoting the use of mammography among inner-city women.

Design

1-year randomized controlled trial.

Setting

5 sites: 2 operated by a health department, 1 health maintenance organization, and 2 private clinics.

Patients

4401 women who were ≥ 40 years of age and who had visited a primary care provider at 1 of the 5 study sites within the preceding year. Women known to have breast cancer were excluded. 2725 (62%) women visited a study site during the intervention year and were included in this evaluation.

Intervention

Patients were stratified by 5-year age groups and allocated to a limited intervention (LI) (n = 1343) or a full intervention (FI) (n = 1382). LI included a breast cancer awareness program for physicians and staff at all study sites, a dedicated mammography appointment phone line, telephone reminders to patients with scheduled mammography appointments, and reduced or eliminated mammography patient expense. FI included all the components of LI plus a computerized mammography reminder form for physicians, a mammography appointment postcard reminder for patients, and an appointment rescheduling system for patients unable to keep their appointments.

Main outcome measures

Rates of women who had a scheduled mammography appointment were used to measure the effect of the medical record reminder; rates of mammography completion within 2 months of the first scheduled appointment were used to evaluate the patient postcard reminder; and the effect of the appointment rescheduling system was measured by subsequent mammography completion rates.

Main results

The FI group had a 6-month mammography appointment rate of 47% (range 38% to 65%), and the LI group had a rate of 25% (range 11% to 37%). Compared with the LI group, the FI group had a greater increase in mammography appointments ranging from 13% (95% CI 5.9% to 20%) to 29.3% (CI 21.1% to 37.5%) across the sites. The patient postcard reminder was effective at 1 of the 5 sites but not overall. Telephone follow-up for rescheduling appointments was not effective at any of the sites. After 12 months, rates from completed mammography were a mean of 18% higher in the FI group than in the LI group.

Conclusion

A computerized physician reminder system effectively increased the use of mammography among inner-city women.

Source of funding: National Cancer Institute.

For article reprint: Dr. R.C. Burack, Wayne State University, School of Medicine, 5C University Health Center, 4201 St. Antoine, Detroit, MI 48201, USA. FAX 313-745-4707.


Commentary

In this well-designed randomized trial, Burack and colleagues have confirmed the effectiveness at 1 year of computerized physician reminders in improving the delivery of mammography among various providers. In an inner-city patient population, reminders significantly increased the rate of completed mammograms beyond the baseline intervention, which included reduction of financial barriers. As with previous studies done in settings without a computerized medical record, considerable resources were required to develop the physician reminder system because this development necessitated manual review of medical records and data entry into a separate computer system operated by the research team. This system was not integrated into routine practice at any of the intervention sites, and physician reminders, although effective, were apparently terminated when funding from the research project was no longer available.

Whether the effectiveness of computerized physician reminders persists over time remains to be shown. Perhaps more importantly, strategies now known to be effective in improving rates of mammography, including removal of financial barriers (1) and computerized reminder systems, require a substantial investment of resources. The next task of researchers is to show the effectiveness of affordable interventions that can be sustained beyond the project period. Readily adaptable computerized systems for reminders are limited (2), and manual (paper) systems may be more practical in many practice settings (3). Whether the Put Prevention Into Practice materials recently released by the U.S. Public Health Service will fulfill this need remains to be shown.

Joy Melnikow, MD, MPH
University of California, DavisSacramento, California, USA


References

1. Kiefe CI, McKay SV, Halevy A, Brody BA. Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial. Arch Intern Med. 1994;154:1217-24.

2. Frame PS. Can computerized reminder systems have an impact on preventive services in practice? J Gen Intern Med. 1990;5(Suppl):S112-5.

3. Kohatsu ND, Cramer E, Bohnstedt M. Use of a clinician reminder system for screening mammography in a public health clinic. Am J Prev Med. 1994;10:348-52.