Kaplan C P, Bastani R, Belin T R, Marcus A, Nasseri K, Hu M Y
Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California 94143-0856, USA.
J Womens Health Gend Based Med. 2000 Sep;9(7):779-90. doi: 10.1089/15246090050147754.
The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.
宫颈癌控制项目的成功取决于定期进行巴氏涂片检查以及对早期肿瘤病变进行及时且恰当的治疗。鉴于认识到对异常巴氏涂片缺乏后续跟进可能产生的严重后果，众多干预研究已对各种提高后续跟进回访率的策略的影响进行了测试。这些研究大多是在可控的实验条件下进行评估的。尽管这些试验取得了令人鼓舞的结果，但在研究的后续阶段，在全面实施之前，需要在现实环境中证明这些干预措施的有效性。我们报告了一项评估研究的结果，该研究评估了在之前的随机研究中被证明有效的三种干预方式的综合效果：跟踪随访方案、交通激励措施和经济激励措施。本研究采用前后对比、非等效对照组设计，以评估一项多方面干预措施的影响，该干预措施包括带有交通和经济激励措施的计算机化跟踪方案。该研究在洛杉矶县卫生服务部管辖的两家主要医院、两个综合健康中心（CHC）和九个公共卫生中心（PHC）开展。在CHC服务区域内的一家医院、一个CHC和四个PHC被选为实验地点。对照地点——一家医院、一个CHC和五个PHC——提供常规护理。干预地点和对照地点所有巴氏涂片异常的女性都被纳入研究。该研究包括为期1年的基线数据收集期（1989年9月 - 1990年8月），随后是为期2.5年的干预期（1990年9月 - 1993年2月）。在干预期内，在实验地点实施干预方案，对照地点提供常规护理。总体而言，我们发现后续护理的接受率与类似研究中的结果一致。与这些之前的随机试验所获得的结果不同，我们没有找到关于干预效果的有力且一致的证据。显著的结果仅在CHC和医院层面出现，且仅在特定年份出现。结果强调了在大规模实施之前在现实条件下测试干预措施的重要性。此外，本研究凸显了在大规模研究中检测干预效果的挑战，因为与对照实验相比，现场研究中的测量困难更大。
