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Rates of Adult Immunization and Cancer Screening

Although the value of adult immunizations, such as influenza and pneumococcal pneumonia, and screening for breast, cervical, and colon cancer has been clearly established, the rate at which these services are provided is unacceptably low. Many interventions aimed at increasing these services have been explored, but the outcomes have been unclear. Stone and associates reviewed prevention literature using meta-analysis techniques to evaluate specific interventions intended to increase the rates of prevention activities among clinicians.

Seven intervention activities (see the accompanying table) were evaluated, as were multiple key features of each specific intervention. Multiple databases were reviewed through February 1999 for suitable studies. Adequate studies were obtained to develop models for immunizations (combining studies of influenza and pneumococcal pneumonia), screening mammography, cervical cytology screening, and fecal occult blood testing. Articles looking at other techniques of colon cancer screening were inadequate. Of the 108 studies accepted for inclusion in the analysis, 95 were randomized clinical trials, and 13 were controlled clinical trials.

Efficacy of Specific Intervention Activities in Increasing Preventive Care Services Intervention Efficacy Reminders to physicians and/or patients Reminders to patients were shown to be moderately effective. Physician feedback to stimulate improvement Ineffective Education for physicians and patients Patient education was moderately effective. Financial incentives to patients or physicians Financial incentives to patients were consistently effective; physician incentives could not be evaluated. Regulatory or legislative action to change the context in which medicine is practiced Could not be evaluated Organizational changes within the medical care organization to improve performance Most effective Mass media campaigns to educate the public Could not be evaluated

Organizational change was one of the interventions most effective at increasing the rate of preventive services. Some of the most successful organizational changes included (1) establishing a separate clinic for screening and preventive services, (2) using a planned visit for preventive care, (3) using techniques modeled on continuous quality improvement, and (4) having specific nonphysician staff dedicated to performing preventive care services. Patient financial incentives also increased preventive care services. Patient reminders were effective, although less so than the previously mentioned activities. Personalized reminders seemed to be more effective than generic reminders. Patient education demonstrated moderate effectiveness in increasing these services, while provider feedback showed little improvement.

The authors conclude that organizational change is clearly the most effective way to increase preventive care services, especially when used with teamwork and collaboration. Combining more than one effective action can lead to even greater services.

In an editorial in the same issue, Laine discusses the importance of the annual physical examination in the minds of many patients and its value in providing preventive services. Benefits of the annual physical examination include regular screening, establishing a relationship with a physician, and discussions of health promotion. Regular examinations centered around prevention should be evaluated more objectively before they are eliminated.

RICHARD SADOVSKY, M.D.

Stone EG, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med May 7, 2002;136:641-51, and Laine C. The annual physical examination: needless ritual or necessary routine? [Editorial] Ann Intern Med May 7, 2002;136:701-3.

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