An effective telephone counseling intervention was provided in approximately 99 minutes per woman over an 18 month period, or about 5 minutes per woman per month. Approximately an hour of this time was spent on the phone with each woman; the rest was spent on follow-up tasks to help women overcome barriers to screening.
While other telephone counseling interventions have increased cancer screening rates with substantially less than an hour of telephone time,13-17
this intervention was unique in packaging all 3 cancer screenings recommended for this population – breast, cervical, and colorectal – into one multiple-call intervention, delivered to a primarily low-income and minority population. Champion et al. found increased mammography rates following 30 to 45 minutes of in-person or telephone counseling provided by a practice-based graduate nursing assistant, but suggested that spending this amount of time for one test may amount to an unaffordable luxury to many health care practices.18
Integrating 2 additional cancer screenings into the counseling protocol is one clear step toward greater efficiency19
; PCMs worked with women on up to 3 cancer screenings, spending an average of 64 minutes of phone contact time, considerably less than 3 times the phone time reported by Champion. While other telephone interventions which have devoted less time or fewer calls to each woman failed to increase screening rates among previously non-adherent women,20, 21
half of our timing subjects who had never been screened for colon cancer screening became up-to-date during the intervention period. Once screened for the first time, these women may be more likely to be screened in the future, with these future tests representing additional rewards for the PCM time invested. As women shared their barriers and then worked with a PCM to overcome them, they experienced an interpersonal connection that may result in more positive long-term impacts on screening rates than less-intensive interventions or more generic approaches such as mass mailings.16, 22
We also found that PCMs spent significantly more time providing test-specific support to women who were still overdue at the end of the study on cancer screenings than they did to women who were up-to-date at follow-up. This is partly a function of the intervention protocol, in which PCMs continued calling women and providing test-specific support for willing subjects until a woman was up-to-date. Women who quickly became up-to-date required fewer calls and less PCM time than those with more persistent barriers who remained overdue for the entire intervention period. It also indicates that some women may be unreceptive to the PCM approach no matter how much PCM time is spent; these women represent a potential source of inflation of the timing figures reported in this study. A less intensive protocol, with fewer calls to resistant women, might have achieved comparable increases in screenings at a lower cost of PCM time. This also suggests that further PCM intervention with resistant patients is unlikely to result in further cancer screening, and that other types of intervention should be evaluated for use with these patients. Future research is needed to determine the appropriate threshold of time or number of calls beyond which further telephone contact with women is ineffective.
Additional research is also needed to explore whether individual characteristics can be used to identify women who will be more or less receptive to this particular type of intervention. Saywell, Stockdale and Crane have recommended using patient cancer screening history to tailor cancer screening interventions.13, 21, 23
This screening data can be collected efficiently through a simple query of health plan or health center administrative electronic data. A two-tiered intervention, in which previously adherent women receive a less intensive intervention than those who have never been screened or are many years overdue, could help direct PCM resources where they are most needed. For example, of the timing subjects who became up-to-date on colon cancer screening, PCMs spent an average of 27 minutes with those who had never been screened, and only 10 minutes with those who were previously adherent.The less time-intensive intervention for recently adherent women could involve fewer and/or shorter telephone calls, reminding them that it is time to be screened rather than exploring and addressing barriers. An automated reminder system could be used to deliver these reminder calls. Time spent on follow-up tasks for all subjects could also be substantially reduced by batching and automating PCM mailings, using data lists and personalized letter templates downloaded from electronic health records where available, or electronic billing and scheduling records.
Finally, it is important to note that the most PCM time was spent providing test-specific support for colorectal screening as compared to either mammography or Pap testing, which reflects the more recent addition of colorectal cancer screening to the routine screening regimen and lower baseline colorectal screening rates.
Some limitations should be noted. Timing data were recorded by the PCMs, rather than directly observed, and may be subject to under or over-reporting. An electronic timing device could reduce error and reporting bias. The timing subset, although representative of the entire study population, was small, which limited our ability to conduct meaningful outcome analyses on further subsets. We did not explicitly calculate the actual costs of the intervention, but used staff time as a proxy for cost in this analysis, and did not attempt to factor in costs for supplies or overhead.
A number of recent studies have assessed the actual dollar costs and cost-effectiveness of colon cancer screening interventions. While not directly comparable to our estimates of personnel time required, the cost per additional individual screened in these studies varied widely, from $43 to $319 for customized mailings to patients,24, 25
$106 to $978 for physician-directed interventions,26, 27
and up to nearly $6000 for a patient-directed mail intervention which included a telephone reminder call.25
“Patient navigators” have also been found to be effective at increasing colon cancer screening rates. 28-33
These navigators closely resemble the PCMs described in this study, except that they often begin their work after
a patient has received a colon cancer screening referral from a provider, while much PCM time was spent working toward the provision of just such a referral. A cost effectiveness analysis of one Colonoscopy Patient Navigator program in New York City reported costs at three participating hospitals ranging from $199 to $708 for each additional colonoscopy completed.34
Factoring in the increased hospital revenue provided by these additional colonoscopies, two of the three hospitals achieved a net revenue benefit from their Colonoscopy Navigation Programs.34
A streamlined version of the PCM intervention has been subsequently tested in a National Cancer Institute- funded dissemination pilot study conducted through Affinity Health Plan, a Medicaid Managed Care organization (MMCO) serving primarily low-income and minority women in and around New York City (that provides reimbursements to the participating FQHCs).35
Affinity's electronic administrative and claims data were used to select eligible women and for outcome analyses, and the PCM intervention was made more efficient by reducing the number of calls, shortening the total length of the intervention, and batching mailings. Further testing of a streamlined PCM intervention among female patients of a larger sample of MMCOs in New York City is currently underway.
Our findings highlight the potential of utilizing an individualized, multi-dimensional, multiple call approach to address the array of barriers faced by underserved and minority populations in obtaining cancer early detection services. As Yarnall et al. have pointed out, there is simply not enough time in the day for primary care physicians to provide all recommended preventive services to their patients.36
Focussed help from non-clinicians, such as PCMs, may increase the chance of these preventive services being delivered in a timely manner. While the PCM intervention was effective at increasing access to cancer early detection in a multi-lingual, low-income population, the cost in PCM time is potentially high. Additional less-staff intensive strategies should be considered, including automated telephone reminder systems, personalized form letters, and group visits, as MMCOs and other organizations seek to improve patient outcomes and screening rates in this and other clinical areas. We are currently evaluating a similar PCM intervention set in three NYC-based MMCOs, and will be able to explore differences in time requirements and implementation in future publications.