Burack R C, Gimotty P A, George J, McBride S, Moncrease A, Simon M S, Dews P, Coombs J
Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA.
Cancer. 1998 Jun 15;82(12):2391-400. doi: 10.1002/(sici)1097-0142(19980615)82:12<2391::aid-cncr13>3.0.co;2-k.
Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention.
The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use.
In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38).
Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect.
尽管巴氏涂片检测作为一种控制宫颈癌的方法很有效,但该检测的应用仍不全面,在初级保健机构中推广该检测提供了一个重要的干预机会。
作者进行了一项随机对照试验,涉及一个为城市少数民族人口服务的健康维护组织(HMO)的三个地点。他们的目的是评估向患者和医生发出提醒对患者就诊和巴氏涂片检测使用情况的影响。符合条件的女性(n = 5801)被随机分配到4种干预组合中的一种(即分别向患者、医生、两者或两者都不发出提醒)。如果患者不符合接受患者提醒干预的条件,则仅将其随机分配到医生提醒干预组(有或无该干预)。寄给患者的提醒信邀请应进行巴氏涂片检测的女性前往HMO地点就诊,给医生的提醒是一份病历通知,提示巴氏涂片检测到期。采用逻辑回归和生存分析来研究干预状态与就诊情况、就诊时间间隔以及巴氏涂片检测使用情况之间的相关性。
在主要的意向性分析中,患者或医生提醒干预对就诊率或巴氏涂片检测完成率均无显著影响。次要疗效分析表明,患者或医生提醒均无总体效果,但在各个HMO地点的女性亚组中观察到了影响。在地点3,患有慢性病的女性亚组下次就诊时间明显延长(干预组为16周,无干预组为9周)。对于医生提醒,在地点1之前未进行过巴氏涂片检测的女性(调整后的优势比 = 1.39)以及地点2患有慢性病的女性(调整后的优势比 = 3.38)在研究年度内进行巴氏涂片检测的几率增加。
向患者和医生发出提醒对患者前往HMO地点就诊或巴氏涂片检测完成情况的影响有限。虽然一些女性亚组可能会受益,但作者也观察到在其他亚组中可能存在不利影响。这些结果强调了识别更有效干预措施的重要性,将这些措施针对最可能受益的女性,并且不要忽视预防性干预可能产生意外不良影响的可能性。