提醒系統可以增加乳房攝影接受率

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　July 14, 2009 — 根據線上發表在7月14日美國預防醫學期刊上的一項研究結果，多模組提醒系統可以有效地執行，且在一個大型健康照護系統中維持，並且增加乳房攝影接受率。
　　
　　主要作者來自奧勒岡州波特蘭Kaiser Permanente健康研究中心的Adrianne C. Feldstein醫師在一篇新聞稿中表示，我們知道乳房攝影是有效的，但許多女性卻忽略它，即使她們有醫療保險。這項研究首次證實這些提醒系統對這一大群女性來說是有效的。如果我們可以使乳房攝影接受率加倍，每年可以多偵測到25,000件乳癌病例。
　　
　　透過電子病歷，研究者們比較提醒系統上線前（2004年）、上線執行後（2006年），以及上線後維持期（2007年1月1日至7月1日）之間對乳房攝影的依從性。試驗樣本包括35,104位42歲以上，距離上次乳房攝影（標的時間）至少20個月後的女性，且這些女性都是Kaiser Permanente西北健康維持組織成員。
　　
　　針對50至69歲女性進行的介入，包括自上次乳房攝影20個月後寄出「乳房攝影到期日將屆」的明信片，接著對沒有反應者進行至多兩次的自動電話提醒，與一次人工電話提醒。主要比較組的女性受試者年齡介於42至49歲之間，臨床指引建議這些女性接受乳房攝影，但是她們並沒有接受提醒系統提醒。主要的試驗終點是在標的日期後10個月間受試者接受乳房攝影的比例。
　　
　　在提醒系統上線前的階段，63.4%標的女性受試者接受乳房攝影，上線後則是75.4%、上線後維持期為80.6%。在這段時間中，比較組接受篩檢率並未改善。
　　
　　在提醒系統上線後的階段，接受介入的女性接受乳房攝影的比例，相較於比較組，在控制流行病學與造訪診所次數後高出1.51倍（95%信賴區間[CI]為1.40-1.62）。這個效應在上線後維持期仍然是顯著的（危險比值為1.81；95% CI為1.65-1.99）。
　　
　　研究共同作者、Kaiser Permanente’s健康研究中心資深研究者Nancy Perrin博士表示，我們的研究證實提醒系統在很短時間內有很大的改善。自動提醒系統對於接受他們所需的篩檢來維持健康的人們來說是很方便的。
　　
　　這項研究的限制包括沒有隨機分派、介入組與比較組的女性受試者年齡差異、超越這單一健康照護系統之外的應用性有限、以及可能的未經量測的共同影響因子。
　　
　　研究作者們的結論是，這項研究發現多模組提醒系統可以有效地執行，且在一個大型的健康照護系統中維持。如果廣泛地執行，這項介入將可以改看社區乳房攝影篩檢率，未來的研究應該針對執業為主的因素，在提醒系統範圍內協助病患完成乳房攝影，以及在不同情況下，其他影響對不同病患提供介入達成與經濟效益的因子。
　　
　　國家癌症機構贊助這項研究。研究作者們表示沒有相關資金上的往來。

Reminder Program Boosts Mammography Rates

By Laurie Barclay, MD
Medscape Medical News

July 14, 2009 — A multimodal reminder system can be both effectively implemented and maintained in a large health system and increase mammography rates, according to the results of a study reported online July 14 in the American Journal of Preventive Medicine.

"We know mammograms are effective, but too many women put them off, even when they have health insurance," lead author Adrianne C. Feldstein, MD, from Kaiser Permanente's Center for Health Research in Portland, Oregon, said in a news release. "This study is the first to show that these reminder programs can be effective in such a large group of women. If we could improve the country's mammography rate by the same amount, we could detect as many as 25,000 additional cases of breast cancer each year."

Using electronic medical record data, the investigators compared compliance with mammography during a prereminder phase (2004), a postreminder implementation phase (2006), and a postreminder maintenance phase (January 1 – July 1, 2007). The study sample consisted of 35,104 women aged 42 years or older who were 20 months past their last mammogram (index date) and who were members of the Kaiser Permanente Northwest health maintenance organization.

The intervention, which targeted women aged 50 to 69 years, consisted of a "mammogram due soon" postcard mailed 20 months after the last mammogram, followed by up to 2 automated phone calls and 1 live call for nonresponders. The primary comparison group was women aged 42 to 49 years, for whom clinical guidelines also recommend mammography, who did not receive the reminder system intervention. The main study endpoint was the time until participants underwent mammography during the 10 months after the index date.

In the prereminder phase, 63.4% of targeted women underwent mammography, compared with 75.4% in the postreminder implementation phase and 80.6% in the maintenance phases. During the same time, screening rates in the comparison group did not improve.

In the postreminder implementation phase, women who received the intervention were 1.51 times more likely to undergo mammography than those in the comparison group (95% confidence interval [CI],1.40 – 1.62), after controlling for demographics and clinic visits. This effect was maintained in the postreminder maintenance phase (hazard ratio, 1.81; 95% CI, 1.65 – 1.99).

"Our study shows that a reminder program can spark a big improvement in a short amount of time," said study coauthor Nancy Perrin, PhD, senior investigator at Kaiser Permanente's Center for Health Research. "Automated reminder programs make it more convenient for people to focus on staying healthy by getting the screenings they need."

Limitations of this study include lack of randomization, age difference between women in the intervention and comparison groups, lack of generalizability beyond the single health maintenance organization studied, and possible unmeasured confounders.

"The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system," the study authors conclude. "If widely implemented, this intervention could substantially improve community mammography screening.... Future studies should address practice-based factors that assist patients in completing mammograms within the context of a reminder program, as well as other factors that affect the reach and cost effectiveness of delivering the intervention to diverse patient groups in multiple settings."

The National Cancer Institute supported this study. The authors have disclosed no relevant financial relationships.

Am J Prevent Med. Published online July 14, 2009.