Interventions That Increase Use of Adult Immunization and Cancer Screening Services

A Meta-Analysis

  1. Erin G. Stone, MD;
  2. Sally C. Morton, PhD;
  3. Marlies E. Hulscher, PhD;
  4. Margaret A. Maglione, MPP;
  5. Elizabeth A. Roth, MA;
  6. Jeremy M. Grimshaw, MD, PhD;
  7. Brian S. Mittman, PhD;
  8. Lisa V. Rubenstein, MD;
  9. Laurence Z. Rubenstein, MD; and
  10. Paul G. Shekelle, MD, PhD
  1. From the Southern California Evidence-Based Practice Center (which includes the RAND Health Division), Santa Monica, Cedars–Sinai Medical Center and the Greater Los Angeles Veterans Administration Health Care System, Los Angeles, and Center for the Study of Health Care Provider Behavior, Sepulveda, California; the University of Nijmegen, Centre for Quality of Care Research, Nijmegen, the Netherlands; and the University of Aberdeen, Health Services Research Unit, Aberdeen, Scotland, United Kingdom.

    Abstract

    Purpose: The relative effectiveness of the diverse approaches used to promote preventive care activities, such as cancer screening and adult immunization, is unknown. Despite many high-quality published studies, practices and policymakers attempting to improve preventive care have little definitive information on which to base decisions. Thus, we quantitatively assessed the relative effectiveness of previously studied approaches for improving adherence to adult immunization and cancer screening guidelines.

    Data Sources: MEDLINE, the Cochrane Effective Practice and Organization of Care Review Group register, previous systematic reviews, and the Medicare Health Care Quality Improvement Project database.

    Study Selection: Controlled clinical trials that assessed interventions to increase use of immunizations for influenza and pneumococcal pneumonia and screening for colon, breast, and cervical cancer in adults.

    Data Extraction: Two reviewers independently extracted data on characteristics and outcomes from unmasked articles. Intervention components to increase use of services were classified as reminder, feedback, education, financial incentive, legislative action, organizational change, or mass media campaign.

    Data Synthesis: Of 552 abstracts and articles, 108 met the inclusion criteria. To assess the effect of intervention components, meta-regression models were developed for immunizations and each cancer screening service by using 81 studies with a usual care or control group. The most potent intervention types involved organizational change (the adjusted odds ratios for increased use of services from organizational change ranged from 2.47 to 17.6). Organizational change interventions included the use of separate clinics devoted to prevention, use of a planned care visit for prevention, or designation of nonphysician staff to do specific prevention activities. The next most effective intervention components were patient financial incentives (adjusted odds ratios, 1.82 to 3.42) and patient reminders (adjusted odds ratios, 1.74 to 2.75); the adjusted odds ratios ranged from 1.29 to 1.53 for patient education and from 1.10 to 1.76 for feedback.

    Conclusions: Rates of adult immunization and cancer screening are most likely to improve when a health care organization supports performance of these activities through organizational changes in staffing and clinical procedures. Involving patients in self-management through patient financial incentives and reminders is also likely to positively affect performance.

    Article and Author Information

    • Note: The authors are responsible for the content of this report, and the views expressed are theirs alone. Statements in the report should not be construed as endorsement by the Centers for Medicare & Medicaid Services or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

    • Acknowledgments: The authors thank Preethi Srikanthan, MD, Walter Mojica, MD, MPH, Michael Hirt, MD, and Tommy Tomizawa, MD, for article abstraction; John Adams for statistical advice; Roberta Shanman for library searching; Brian Chao for database management; Shannon Rhodes and Jeri Jackson for secretarial assistance; and Pauline Lapin for continued support.

    • Grant Support: By a contract (500-98-0281 “Healthy Aging”) from the Centers for Medicare & Medicaid Services to RAND. The Health Services Research Unit is funded by the Chief Scientist Office, Scottish Executive Health Department. EPOC is funded by the National Health Service Research and Development Programme.

    • Requests for Single Reprints: Paul G. Shekelle, MD, PhD, RAND, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407-2138; e-mail, shekelle{at}rand.org.

    • Current Author Addresses: Dr. Stone: Department of Urgent Care, Kaiser Permanente, 5601 De Soto Avenue, Woodland Hills, CA 91365.

    • Drs. Morton and Shekelle, Ms. Maglione, and Ms. Roth: RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138.

    • Dr. Hulscher: Department of General Practice and Social Medicine, Centre for Quality of Care Research, Box 9101, 6500 HB Nijmegen, the Netherlands.

    • Dr. Grimshaw: Ottawa Health Research Institute, Clinical Epidemiology Programme, 1053 Carling Avenue, Ottawa, Ontario K1Y 4EY, Canada.

    • Drs. Mittman, L.V. Rubenstein, and L.Z. Rubenstein: Sepulveda Veterans Affairs Medical Center, Center for the Study of Health Care and Provider Behavior, 16111 Plummer Street, Sepulveda, CA 91343.

    • Author Contributions: Conception and design: S.C. Morton, M.E. Hulscher, M.A. Maglione, J.M. Grimshaw, B.S. Mittman, L.V. Rubenstein, L.Z. Rubenstein, P.G. Shekelle.

    • Analysis and interpretation of the data: E.G. Stone, S.C. Morton, B.S. Mittman, L.V. Rubenstein, L.Z. Rubenstein, P.G. Shekelle.

    • Drafting of the article: E.G. Stone, S.C. Morton, M.A. Maglione, P.G. Shekelle.

    • Critical revision of the article for important intellectual content: E.G. Stone, S.C. Morton, M.E. Hulscher, J.M. Grimshaw, L.V. Rubenstein, L.Z. Rubenstein, P.G. Shekelle.

    • Final approval of the article: E.G. Stone, M.E. Hulscher, B.S. Mittman, L.V. Rubenstein, L.Z. Rubenstein, P.G. Shekelle.

    • Provision of study materials or patients: E.G. Stone, M.E. Hulscher, J.M. Grimshaw.

    • Statistical expertise: S.C. Morton, P.G. Shekelle.

    • Obtaining of funding: L.Z. Rubenstein, P.G. Shekelle.

    • Administrative, technical, or logistic support: M.E. Hulscher, M.A. Maglione.

    • Collection and assembly of data: E.G. Stone, M.E. Hulscher, E.A. Roth, B.S. Mittman, P.G. Shekelle.

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    1. Ann Intern Med May 7, 2002 vol. 136 no. 9 641-651
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