Effectiveness of Interventions to Increase adherence to followup after abnormal Papanicolaou Smear:

1

• Effectiveness of Interventions to Increase
  adherence to follow-up after abnormal
  Papanicolaou Smear a meta-analysis

2

• The utility of Papanicolaou smear screening is
  widely accepted and there is evidence that
  screening not only decreases mortality from
  cervical cancer but also reduces the incidence of
  invasive disease through early detection and
  prevention
• Largely as a result of increased screening,
  incidence and mortality rates of cervical cancer
  have declined 75-80 over the past 50 years.
  (Ries et al., 2004)

3

• In spite of this decline, an estimated 10,520
  women will be diagnosed with cervical cancer in
  2004 and approximately 3,900 will die from the
  disease (Ries et al., 2004)
• In particular, low-income, young, Hispanic and
  African American women are disproportionately
  affected by the disease

4

• While interventions to increase screening have
  proven effective (Yabroff et al., 2003), studies
  have shown that 30-80 of women who receive an
  abnormal test result fail to adhere to the
  recommended follow-up examination (Marcus et al.,
  1992).
• If left untreated, approximately 50 of mild
  dysplasias will progress to more severe lesions
  and 70 of women with more severe lesions will
  develop invasive cervical cancer (Creasman et
  al., 1983), thus eliminating any benefit of early
  detection through screening

5

• Barriers for adhering to these follow-up
  recommendations have been identified in the
  literature. Some of these barriers include
• Psychological distress, fear of cancer,
  femininity concerns
• Lack of understanding/knowledge
• Forgetfulness
• Lower perceived risk of cancer
• Reliance on doctors recommendation/opinion
• Practical considerations (cost, transportation,
  time hassles, child care problems)
• Low SES
• Other correlates of reduced adherence after a
  positive Pap test result include younger age,
  being unmarried, and having less education

6

• To address this public health problem,
  interventions have been developed in an effort to
  address and overcome these barriers to increase
  adherence to follow-up after an abnormal pap
  smear result.
• The current review summarizes the overall
  effectiveness of these interventions in achieving
  this goal.

7
Methods

• Study identification and eligibility
• PUBMED and the Ovid search mechanism for MEDLINE
  were searched for English language articles
  utilizing human subjects published between 1980
  and October 2004 for interventions to increase
  adherence to follow-up after an abnormal Pap
  smear result.
• Reference lists of relevant published narrative
  reviews were reviewed and a hand search of
  Preventive Medicine, American Journal of
  Preventive Medicine, and Journal of the American
  Board of Family Practice from 2001 through
  October 2004 was conducted.

8

• Study eligibility
• Studies must have utilized a randomized or
  concurrent comparison group and must have
  evaluated adherence to recommended Pap follow-up
  following an abnormal result as an outcome in
  order to be eligible
• Unpublished studies, dissertation studies,
  letters or commentaries, and studies published in
  other languages were excluded due to time and
  resource limitations.
• Randomized noncontrolled designs, pre-post
  designs, and retrospective cohort studies were
  also considered ineligible due to their failure
  to include an appropriate comparison group

9

• RESULTS
• A total of 7 studies were eligible for inclusion
  in the current meta-analysis
• Study level characteristics were coded, as were
  specific characteristics of the interventions

10

• Interventions were classified according to the
  underlying theoretical mechanism to increase
  follow-up adherence
• Behavioral Strategies (e.g. financial incentive,
  reminder letter)
• Cognitive Strategies (e.g. educational brochure,
  barriers counseling)
• Combination Cognitive and Behavioral Strategies
  (e.g. educational brochure plus reminder phone
  call)
• While all studies implemented patient-targeted
  interventions, two studies additionally included
  a practice-targeted IV component in which an
  extensive tracking system was implemented in an
  effort to better track Pap follow-up behaviors
  among patients

11
(No Transcript)
12
(No Transcript)
13

• May add to more than 7 because of multiple IVs
  per study

14
(No Transcript)
15

• Aggregate Analysis
• The inverse-variance weighted aggregate effect
  size was calculated across all studies to
  determine the impact of study-level interventions
  on adherence
• The aggregate random effects ES was 8.75 (95 CI
  4.80, 15.64) and there was significant
  heterogeneity (Q 74.15, p lt .01)
• This suggests that overall, regardless of the
  nature of the intervention, women receiving the
  intervention are almost 9 times more likely to
  adhere to follow-up recommendations than women
  receiving standard care

16
Follow-up moderator analyses

• Analysis 1 Evaluation of whether the underlying
  mechanism of the intervention (e.g. behavioral,
  cognitive, or combined) accounts for significant
  heterogeneity in adherence to follow-up
• 13 non-independent ES across 7 studies (3 beh, 5
  cog, 5 combined) included in analysis
• Analogue to ANOVA mixed effects fit statistic was
  not significant (Q 2.70, p .25)
• This suggests that any differences in adherence
  to Pap follow-up are not significantly accounted
  for by the underlying mechanism of the IV

17

• Analysis 2 Evaluation of whether the addition
  of a practice-targeted tracking system component
  in addition to the patient-targeted intervention
  produces significantly higher levels of adherence
  to follow-up as compared to patient-targeted
  interventions alone
• 7 independent study effect sizes 2
  practice-targeted plus patient-targeted, 5
  patient-targeted alone
• Analogue to ANOVA mixed effects fit statistic was
  again not significant (Q .41, p .52)
• This suggests that any difference produced by
  multi-target versus patient-target only
  interventions does not significantly account for
  the heterogeneity in overall adherence to Pap
  Smear follow-up

18
CONCLUSIONS

• Overall, it appears that existing interventions
  do significantly increase adherence to follow-up
  after an abnormal Pap smear
• However, there is no evidence that the underlying
  mechanism of change on which the intervention is
  based significantly accounts for differences in
  adherence outcomes.
• Additionally, there is no evidence that
  interventions targeted toward both patients and
  practices/providers produced significantly
  different results when compared to
  patient-targeted interventions alone.

19

• This latter result is consistent with a previous
  meta-analysis of interventions to improve Pap
  smear use which found no significant improvement
  in Pap smear utilization with the use of a
  multi-target intervention (Yabroff et al., 2003).
• However, Yabroff et al. (2003) found behavioral
  interventions targeted to patients increased Pap
  smear use significantly while cognitive
  interventions were only marginally effective.
• Although results from this meta-analysis reveal
  no significant moderating effect of the
  theoretical nature of the intervention
  (behavioral, cognitive, or combined), it may be
  presumptuous to conclude the underlying mechanism
  is of little importance

20

• It may be that the nature of the barriers to
  adhering to follow-up treatment differ from the
  barriers for general Pap screening and therefore
  render underlying mechanisms more/less effective,
  or it may be that the failure to detect a
  difference in this analysis was due to the few
  number of interventions included in the overall
  analysis

21

• OTHER LIMITATIONS
• Variation in adherence rates due to the nature of
  the abnormality and recommended follow-up
  treatment
• Paskett et al. (1995) found that the strongest
  predictor of adherence was the type of cervical
  abnormality
• Most studies included mixed samples of women
  therefore moderator analyses assessing the role
  of type of abnormality on outcome were not able
  to be conducted
• Future studies may benefit from implementing more
  focused interventions on women with specific
  abnormalities