TBM page 328 to 335 TBM A 4-year randomized trial comparing three outreach interventions to promote screening mammograms Roger Luckmann, 1 Mary E. Costanza, 1 Mary Jo White, 1 Christine F. Frisard, 2 Milagros Rosal, 2 Susan Sama, 3 Michelle R. Landry, 4 Robert Yood 5 Abstract As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the efectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the efectiveness in pro- moting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40–84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were rand- omized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less efective, due to limited participation of patients, a focus on ambivalence, lack of fol- low-up, and other factors. Keywords Mammogram, Reminder system, Breast cancer, Screening, Telephone counseling INTRODUCTION Most authorities now recommend screening mam- mograms every 1–2 years for women aged 50–74 [1–4]. For women aged 40–49 at average risk for breast cancer, recommendations are to start screening at age 45 [4] or consider screening after a discussion of benefits and harms [3, 4]. For women aged 75 and older, recommendations are to stop screening [2] or continue until life expectancy is <10 years [4] after a discussion of benefits and harms [1, 3]. The Healthy People 2020 target for biannual mam- mographic screening is 81.1% for women aged 50–74 [5]. In 2015, however, rates were 71.3% and 72.2% for women aged 50–64 and 65–74 respectively. To address suboptimal rates of breast and other cancer screenings, health care payers and providers have been reaching out through mail, phone, and other means to patients due or coming due for screenings [6], but the most cost-effective approaches to out- reach have not been definitively identified. Studies of mammography reminder calls have shown a 5–21 percentage points (pct pts) increase in mammogram completion for a live or automated call compared with a mailed reminder [7–11]. Thirteen studies of tailored telephone counseling, mostly among women overdue for mammograms, have shown gains in mammography completion of 3–25 pct pts over a mailed reminder [12–25]. Research, then, has confirmed that telephone out- reach can be more effective than mailed remind- ers, but two key questions remain to be answered: (i) How effective will these efforts be when deliv- ered routinely for several years in large populations with high baseline screening rates? and (ii) How do mailed reminders, telephone reminders, and tai- lored telephone counseling calls compare in effec- tiveness and cost in these populations? Taplin et al. [8] found no significant difference between a reminder call and a counseling call in Implications Practice: To increase adherence to cancer screen- ing, a personalized reminder letter plus reminder call may be cost-effective. Motivational interview- ing–based telephone counseling and tailored education should be avoided until research iden- tifies approaches that are engaging and effective. Policy: Reminder calls to increase cancer screen- ing should be considered as potentially valuable population health improvement measures and explored in selected populations. Research: Studies are needed to identify more cost-effective ways of increasing adherence to cancer screening than live reminder calls. 1 Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA 01655, USA 2 Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA 3 Department of Research, Reliant Medical Group, Worcester, MA 01605, USA 4 Center for Health Policy and Research, University of Massachusetts Medical School, Worcester, MA 01545, USA 5 Department of Medical Specialties, Reliant Medical Group, Worcester, MA 01609, USA ORIGINAL RESEARCH © Society of Behavioral Medicine 2018. All rights reserved. For permis- sions, please e-mail: journals.permis- sions@oup.com. Correspondence to: Roger Luckmann, LuckmanR@ummhc. org Cite this as: TBM 2019;9:328–335 doi: 10.1093/tbm/iby031