Studies have shown that out-of-pocket costs and the type of health care delivery system may influence follow-up rates. Women in HMOs who made copayments waited an average of 1.25 months longer between initial suspicion of cancer and obtaining a definitive diagnosis than women without copayments (Greenwald, 1987). In another study, colorectal cancer patients treated in HMOs had delays in diagnosis or treatment relative to patients in fee-for-service settings (Francis et al., 1984).
Some inadequate follow-up may be traced to poor provider-patient communication. In one study, more than half of the women with abnormal mammograms who had not sought follow-up care indicated that they thought their mammograms were normal (McCarthy et al., 1996b).
Among those who are informed of an abnormal screening test, some may not seek follow-up care for a variety of reasons:
- concern about cost,
- fear of learning that something is wrong,
- anxiety about painful diagnostic procedures (Rojas et al., 1996), or
- concern that they are too old for treatment (Mandelblatt, 1993a).
Interventions To Improve Follow-Up Rates
Several techniques have been tested to improve follow-up rates. Findings from key studies include the following:
- Telephone reminders are more effective than letters in increasing the follow-up of screening tests among women with abnormal Pap smears (Lerman et al., 1992; Marcus et al., 1992; Miller et al., 1997; Paskett, 1990).
- Computerized tracking systems can improve follow-up of abnormal screening results, but their success depends on adequate system staffing and support (Monticciolo and Sickles, 1990; Mandelblatt et al., 1998).
- A comprehensive review of interventions to increase colorectal cancer screening adherence found that the most intensive strategies delivered to eligible persons rarely increased adherence to FOBT above 50 percent. These intensive strategies included the use of a letter signed by one's own physician and including FOBT kits in the mailout to intensive follow-up with instructional telephone calls (Vernon, 1997).
- A review of the literature on strategies to increase adherence to breast and cervical cancer screening among underserved women determined that management systems directed to both patients and providers were consistently effective for most underserved women. Community-based outreach and integration of preventive services at the primary health care site are effective strategies for both African-American and Hispanic women. Use of mass media has been successful when targeted toward Hispanic women, but not when targeted toward African-American women. Mobile units and integration of preventive services at primary health care sites are effective strategies for elderly women (Vellozzi et al., 1996).