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Journal Article

Rebecca Anhang Price,

Affiliations of authors: Clinical Monitoring Research Program, SAIC-Frederick, Inc., National Cancer Institute-Frederick, Frederick, MD (RAP, HE); Department of Medicine, Division of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC (JZ); Applied Research Program/Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD (ST)

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  Rebecca Anhang Price, Jane Zapka, Heather Edwards, Stephen H. Taplin, Organizational Factors and the Cancer Screening Process, JNCI Monographs, Volume 2010, Issue 40, April 2010, Pages 38–57, https://doi.org/10.1093/jncimonographs/lgq008

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Abstract

Cancer screening is effective at reducing morbidity and mortality from breast, cervical, and colorectal cancers (1–4). Screening is a process of care (5), consisting of several steps and interfaces between patients, providers, and health-care organizations. Interruptions, or “breakdowns,” in the screening process can lead to failure to detect and diagnose cancer promptly (6,7). Approximately half of women aged 50 and older who are diagnosed with late-stage breast cancer have not received a screening mammogram (8), and approximately half of cervical cancers are diagnosed among women who have not been screened in the past 3 years or ever (9). Nonadherence to recommended periodic screening is also an important attributable factor in colorectal cancer mortality, particularly among lower socioeconomic populations (10).

Steps and interfaces in the cancer screening process range from patient recruitment to results reporting (Figure 1) and may vary by screening modality (ie, fecal occult blood test [FOBT] vs colonoscopy) and from organization to organization. Screening processes may be divided into two primary categories, represented by the upper and lower branches of Figure 1. The upper branch illustrates screening offered within an organization at the time of a health-care visit, whereas the lower branch illustrates screening offered by referral to another health-care provider or organization. The former category requires “intraorganizational” coordination of screening activities, whereas the latter requires “interorganizational” coordination across departmental or organizational boundaries, necessarily resulting in more interfaces and increasing challenges to communication and coordination.

Figure 1.

Steps and interfaces in the cancer screening process.

Papanicolaou testing for cervical cancer is most often performed as part of an intraorganizational process; mammography, sigmoidoscopy, and colonoscopy are more likely to occur in interorganizational processes, as most primary care practices do not have the facilities, equipment, or trained professionals to perform them (11). FOBTs, which have faded in popularity over the last decade (12), can be self-administered by patients, thereby escaping intraorganizational or interorganizational processes. However, communication and coordination still are required between providers and patients, and between patients and the organizations to which they must return completed tests.

Organizational changes have been shown to have a major impact on rates of breast, cervical, and colorectal cancers screening (13). Few studies explore the role of organizational factors in addressing the interfaces presented by intra- and interorganizational screening processes, however. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes.

Methods

Definitions

“Steps” in the cancer screening process are medical encounters or actions, including patient recruitment, attendance at a health-care visit, and performance of a screening test (14) (Figure 1). “Interfaces” are transfers of information and/or responsibility between patients, providers, and health-care organizations, including provider recommendation or referral to screening, appointment scheduling, and results reporting. Interfaces are not only within and between organizations but also between organizations and providers, organizations and patients, and patients and providers.

We use the term “health-care organization” to refer to entities that provide, coordinate, or refer patients to cancer screening. This definition includes primary care practices, community health clinics, hospitals, and health maintenance organizations, for example, but excludes faith-based organizations or community groups involved in cancer screening promotion or population-level registries used to identify patients in need of screening.

Organizational factors affecting both intraorganizational and interorganizational cancer screening include “structures,” such as capital or human resources and administrative or fiscal arrangements (15), and “processes,” activities done to and for patients within these structures (16). Organizational structures and processes can be designed to overcome interface challenges between and among health-care organizations, providers, and patients.

We classify organizational factors according to 1) which steps and interfaces they address within the screening process; 2) their target audience (patients and/or health-care providers); and 3) the mechanism through which they change screening behaviors (predisposing, enabling, or reinforcing, per the Precede/Proceed model) (Figure 2) (17). This classification acknowledges that screening is the result of interactions between provider and patient behaviors that occur within organizational contexts.

Figure 2.

Classification of organizational interventions by cancer screening steps or interfaces, target audience, and mechanism.

“Predisposing factors,” such as knowledge, attitudes, perceptions, or beliefs, provide rationale or motivation for behavior. Strategies aimed at positively predisposing patients include counseling or educational materials. Strategies aimed at positively predisposing providers may involve continuing education regarding current evidence-based guidelines, for example.

“Enabling factors,” such as skills, resources, and technology, facilitate patient or provider behaviors. Organizational strategies that enable providers include clinical information systems, such as reminders and delivery system design, including care coordination and management via clinician teams. For patients, enabling strategies include logistical assistance, such as access to convenient transportation and appointment scheduling.

“Reinforcing factors” provide a continuing encouragement, reward, or incentive for behaviors. For example, pay-for-performance initiatives that provide financial rewards for meeting screening targets act as reinforcement for providers. Strategies aimed at reinforcing repeat screening among patients who have screened in the recent past include anniversary reminder mailings, for example.

Literature Search

We conducted a selective search to identify studies that assessed the association between organizational structures and processes and cancer screening rates.

To identify rigorous evaluations of interventions to promote cancer screening occurring within health-care organizations, we gathered references from systematic reviews of interventions to promote screening published in 2008 (18–20) and updated in 2009 (21). Fifty-nine of the referenced articles described interventions occurring within health-care organizations from 1990 through 2008 and were retained for review.

To describe the relationship between organizational structure and process factors and cancer screening outside of the intervention context, we searched the MEDLINE database for English-language articles published from 1990 through 2008, applying the search terms “cancer screening“ and “organization” or “cancer screening” and “primary care” to the title and abstract fields. To locate articles not detected by the search terms, we electronically searched by author for articles by researchers whose previous published work explored organizational influences in cancer screening. We identified articles that may have been missed in electronic searches by manually reviewing references from bibliographies of articles from the initial search and from reviews of cancer screening interventions. These search techniques resulted in 20 nonintervention articles that assessed the relationship between organizational factors and cancer screening.

Two of the authors (R. Anhang Price and H. Edwards) reviewed the primary articles, summarized the findings concerning screening outcomes, and identified the target audience (patient or provider), intervention mechanism (predisposing, enabling, or reinforcing), and cancer screening process or interface addressed (recruitment, visit with on-site screening, recommendation and/or referral, appointment scheduling, test performance, or results reporting). Discrepancies were resolved by discussion with all authors.

Results

Of the 79 studies under review, 49 measured the association between organizational factors and breast cancer screening, 21 measured associations with cervical cancer screening, and 20 measured associations with colorectal cancer screening. Study settings varied considerably and included primary care practices, community health centers, local and national health plans, health maintenance organizations, and Department of Veterans Affairs medical centers. Patient populations included those who had never participated in screening, those who were up to date for screening, and patients with and without health insurance that provided coverage for screening tests. Study details are described in Appendix 1,  Tables 1 and  2.

Organizational Processes

Evidence of the association between organizational processes and cancer screening outcomes is summarized in Table 1. Fifty of the studies we reviewed evaluated the effects of processes to promote patient recruitment; three evaluated visits with on-site screening; 23 provider recommendations or referrals to screening; 15 appointment scheduling; two provider or patient training to perform screening tests; and none reporting of screening test results. Two cross-cutting processes had the potential to influence multiple steps or interfaces by promoting continuity of patient care.

Table 1.

Evidence of association between organizational processes and breast, cervical, and colorectal cancer screening outcomes, by cancer screening step/interface, target audience, and behavioral mechanism*

*

Bolded citations indicate a significant association between the organizational variable and cancer screening. Italicized citations indicate no association. In some cases, associations are negative. Jibaja-Weiss, Volk, Kingery, Smith and Holcomb (47) found a negative association between tailored letters and Papanicolaou test and mammography participation; Wee, Phillips, Burstin, et al. (99) found a negative association between provider productivity incentives and Papanicolaou test provision. FOBT = fecal occult blood test

Table 1.

Evidence of association between organizational processes and breast, cervical, and colorectal cancer screening outcomes, by cancer screening step/interface, target audience, and behavioral mechanism*

*

Bolded citations indicate a significant association between the organizational variable and cancer screening. Italicized citations indicate no association. In some cases, associations are negative. Jibaja-Weiss, Volk, Kingery, Smith and Holcomb (47) found a negative association between tailored letters and Papanicolaou test and mammography participation; Wee, Phillips, Burstin, et al. (99) found a negative association between provider productivity incentives and Papanicolaou test provision. FOBT = fecal occult blood test

Recruitment.

Standard reminder mailings effectively increased mammography and Papanicolaou test rates in several settings, including community health centers serving low-income women, health maintenance organizations, and general practices (23,26,46,47,50,53,58,64,66,70,77), but several other studies conducted in similar settings found standard letters to be no more effective than no letter (28–30,45,65,71). By providing a cue to action, standardized mailings act as predisposing interventions for patients who are up to date for screening or those who have intention to attend timely screening in the future. More intensive predisposing interventions, such as tailored communications, may be needed for patients who are not highly motivated to participate in screening.

Tailored mailings or telephone counseling are customized according to patients’ logistical, cognitive, and affective barriers to screening; intention to participate in screening; past screening behaviors; and/or data available from medical records. There is mixed evidence for the effects of tailored mailings on screening rates; however, tailored telephone counseling has shown more consistently positive results for promotion of mammography.

Distribution of FOBT request cards, FOBT kits, and FOBT kits with prepaid postage successfully increased rates of FOBT use in all interventions under study (38,42,49,57,58,62,63); these interventions enable screening by offering patients the tools to perform screening independently, thereby avoiding steps and interfaces of either intra- or interorganizational cancer screening.

Visit With On-site Screening.

Availability of on-site screening facilities and personnel can reduce the number of interfaces required to complete screening and enable patient participation by helping to overcome time-, cost-, and transportation-related barriers. Patients offered the opportunity to receive a mammogram nearby immediately after scheduled internal medicine appointments were significantly more likely to receive mammograms than those who were required to schedule a mammogram for a later date (37). Provision of free on-site screening at community health centers either in a bimonthly mammography van or a routinely available traditional mammography facility was also associated with increased screening participation among low-income women (53,80).

Recommendation and/or Referral.

Provider recommendation is strongly associated with patient screening behavior (101). Chart reminders, either electronic or paper prompts that remind clinicians that a patient is due for screening, were assessed by 10 studies under review. Positive associations were found for four of seven reminders of mammography (40,52,66,73), three of four reminders of Papanicolaou testing (26,64,73), and two of two reminders of colorectal cancer screening (76,88). Chart reminders have a more limited reach than recruitment strategies, as they enable screening only among those patients who attend a health-care visit or those who attend visits but fail to receive screening.

Audit and feedback interventions consist of medical chart reviews for patients’ screening eligibility, referral and completion, and verbal or written feedback to clinicians regarding their compliance with screening guidelines. These interventions reinforce providers’ screening behaviors by underscoring the importance of screening and stimulating changes in screening practices, as needed. Two primary studies of audit and feedback among medical residents reported increases in referral to mammography or sigmoidoscopy and completion of Papanicolaou testing and/or FOBT (39,48). A third study of primary care physicians found no association between feedback and on-site screening for cervical cancer or referral to off-site breast or colorectal cancer screening (44).

Productivity and quality incentive payments, sometimes referred to as “pay for performance,” have been proposed to reinforce clinician behaviors. However, little empirical evidence supports their effectiveness (102). In our review, the six studies evaluating financial incentives reported mixed results. Token rewards of less than $100 were not associated with increases in mammography referral among primary care physicians (40); similarly, small periodic bonuses offered to primary care practice sites based on compliance with breast, cervical, and colorectal cancers screening were ineffective (44), as were quarterly bonuses to multispecialty physician organizations (69). The latter study did find a positive association between bonuses and Papanicolaou test administration, however. Armour et al. (22) found that an end-of-year bonus for primary care physicians treating managed care patients was associated with increased referral to colorectal cancer screening, especially FOBT. Wee, Phillips, Burstin, et al. (99) found that patients of physicians paid by salary plus productivity incentives were significantly less likely to receive Papanicolaou tests than patients of physicians paid by salary only.

Together, the findings of these studies suggest that financial incentives may be more influential when targeted to individual clinicians, rather than to physician groups, when they are large enough to be meaningful and noticeable to their recipients, and when the targeted behaviors do not require further interfaces of care (ie, appointment scheduling and/or administration of screening tests by an additional health-care provider at a later time, as in the cases of mammography or colonoscopy). Financial incentives, like all organizational strategies that enable or reinforce provider referral, may be more effective in achieving increased screening participation when screening is provided in an intraorganizational process, rather than an interorganizational one.

Appointment Scheduling.

Enabling appointment scheduling through telephone calls was associated with increases in mammography use in all eight studies that assessed this approach (24,27,34,54,58,60,74,77); an additional study found a positive relationship between scheduling telephone calls and use of Papanicolaou tests (54). Some of these telephone call interventions combined scheduling and tailored counseling; however, the scheduling component, rather than counseling, was likely the primary mechanism for improved patient screening in many instances [see, eg (34,74)].

Test Performance.

Training can predispose or enable clinicians to recommend or conduct screening. Training or education that transmits screening data or recommendations may build the knowledge base that predisposes a clinician to recommend screening, whereas skills-based courses may enable providers to perform new or unfamiliar screening tests. Similarly, instruction can enable patients to perform self-tests like FOBT, when available. In our review, an educational curriculum for physicians emphasizing instruction in mammography counseling and clinical breast examination did not significantly alter patients’ mammography adherence, as most of the physicians under study participated in only part of the program (33). However, an instructional telephone call to patients regarding how to use FOBT kits was successful in promoting FOBT use (61).

Results Reporting.

No studies under review focused explicitly on enabling reporting of screening test results.

Cross-cutting Organizational Processes.

In addition to organizational processes designed to address specific steps and interfaces in cancer screening, our review identified processes aimed at improving continuity of care. Joint responsibility for patients across clinicians in a group practice—especially among those who have worked together over an extended tenure—was shown to facilitate improvements in breast and cervical cancer screening rates (94). Patient assignment to primary care providers in Department of Veterans Affairs medical centers was associated with improvements in breast cancer screening rates, but not cervical cancer screening rates (85).

Organizational Structures

Evidence of the association between selected organizational structures and cancer screening outcomes is summarized in Table 2. Like the cross-cutting organizational processes mentioned above, organizational structures have the potential to influence multiple steps and interfaces in cancer screening.

Table 2.

Evidence of association between selected organizational structures and breast, cervical, and colorectal cancer screening outcomes*

*

Bolded citations indicate a significant association between the organizational variable and cancer screening. Italicized citations indicate no association. In some cases, associations are negative. Soban and Yano (97) and Yano, Soban, Parkerton and Etzioni (100) found that higher patient volume is a negative predictor of cancer screening tests; Greiner, Engelman, Hall, and Ellerbeck (86) found that having no endoscopy available in the practice was significantly associated with patients’ self-report that they were up to date on colorectal cancer screening.

Table 2.

Evidence of association between selected organizational structures and breast, cervical, and colorectal cancer screening outcomes*

*

Bolded citations indicate a significant association between the organizational variable and cancer screening. Italicized citations indicate no association. In some cases, associations are negative. Soban and Yano (97) and Yano, Soban, Parkerton and Etzioni (100) found that higher patient volume is a negative predictor of cancer screening tests; Greiner, Engelman, Hall, and Ellerbeck (86) found that having no endoscopy available in the practice was significantly associated with patients’ self-report that they were up to date on colorectal cancer screening.

A positive relationship between patient volume and clinical outcomes has been established for many procedures, including cancer surgeries (103,104), but provision of preventive care services may suffer in a high-volume practice environment (105). Our review found mixed evidence for the relationship between patient volume and cancer screening adherence. Studies of Department of Veterans Affairs medical centers and primary care practices found that higher patient volume was a strong negative predictor of breast, cervical, colorectal cancers screening (97,100), whereas a study of California physician groups found no relationship between patient volume and rates of cervical screening, and a positive relationship between volume and mammography rates (92).

There are also conflicting findings for the association between the number of providers in a provider group—another measure of practice size—and screening rates. One study reported that physicians in group practice were no more or less likely to provide mammograms or colon cancer screening to Medicare beneficiaries than physicians in solo practice (95), whereas another study attributed higher rates of up-to-date colorectal screening in group or multispecialty practices to time to discuss screening, rather than to the screening capacity of group practices (86). The effects of organizational size and practice type may be mediated by the presence of care processes to promote screening, efforts to coordinate across health-care providers and organizational units, and the human and capital resources dedicated to screening.

Availability of facilities and staff for screening has the potential to increase the likelihood that patients receive screening on-site. Our review found mixed results regarding this relationship. Studies of Department of Veterans Affairs medical centers and primary care practices reported that sufficiency of appropriately equipped examining and treatment rooms, equipment for pelvic exams, personal computers, and patient education space was associated with higher rates of cervical and colorectal cancer screening (97,100). A positive association was not found for breast cancer screening, however, perhaps because the screening resources assessed did not include mammography equipment (97). Availability of flexible sigmoidoscopy in family practices was shown by one study to be positively associated with increased likelihood of patients having up-to-date colorectal screening (81). A study of rural primary care practices did not find an association between availability of endoscopy in the practice and increased rates of screening (86), and attributed failure to screen to inadequate discussions between clinicians and patients. These findings suggest that facilities and equipment for screening can influence screening by allowing for intraorganizational screening, but that resources alone may be insufficient in the absence of efforts to promote patient recruitment, provider recommendation, and patient–provider communication.

Nonphysician personnel to identify patients eligible for screening mammography was not found to be significantly associated with mammography rates in one study of primary care practices (83). Although administration of screening by nonphysician staff has been suggested to expand capacity, especially in the context of colorectal cancer screening (106), no studies in our review assessed the effects of assigning nonphysician personnel to perform screening.

Discussion

Given sparse data and mixed findings, we cannot make conclusive statements about the relationship between specific organizational factors and cancer screening outcomes. Nonetheless, we can infer a theme: Organizational structures, such as practice size and type, do not dictate screening rates for a given organization. Rather, screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care.

Limiting Interfaces Through On-site Screening.

Interorganizational screening processes, which require interfaces across departmental and organizational boundaries, are often challenged by incompatibility of information technology systems, loss of information during patient handoff, and limited financial reward for successful interorganizational transfers of information and responsibility. Whenever possible, strategies to promote on-site screening reduce the number of interfaces for organizations, health-care providers, and patients, and thereby increase the likelihood that patients are screened. For this reason, on-site, same-day screening mammography was among the most consistently effective organizational strategies in our review.

Addressing Steps and Interfaces.

A number of organizational strategies can influence steps and interfaces in both intra- and interorganizational screening processes. Stepped approaches to recruitment, beginning with inexpensive, standardized reminder letters for patients who are highly motivated to screen, and advancing, as needed, to tailored mailings or telephone counseling to predispose and reinforce patient screening, are well supported by the literature, and address the first interface in Figure 1. Such “outreach” reminders do not necessitate a provider–patient encounter. For patients who attend health-care visits, reminders to clinicians enable “inreach,” improved recommendation or referral to screening, as well. Strategies to reinforce provider screening referrals and recommendation, such as financial incentives, have been less effective than enabling interventions, such as chart reminders.

Providing Continuous Care.

Ensuring that patients pass through each of the necessary steps and interfaces requires strategies that address not only each step and interface individually but also emphasize continuous flow across the screening process. Studies in our review reported conflicting results for the relation between usual provider continuity, care of a patient by a single health-care provider or provider team over time, and breast and cervical cancer screening (84,89,93,94). Mixed findings are not surprising because continuity is not an inherent organizational feature, but rather the product of organizational structures and processes designed to ensure that patients do not get lost in interfaces with health-care providers and organizations.

Continuity can be classified into three categories: 1) informational continuity, the use of information about patients’ histories and personal circumstances to make care decisions; 2) management continuity, the delivery of appropriate and timely health-care services that respond to patients’ changing needs; and 3) relational continuity, an ongoing therapeutic relationship between patients and their provider(s) (107). All three types of continuity may influence interface activities by affecting whether providers know a patient’s screening status, whether a patient is seen regularly and receives routine screening reminders, and whether a patient has an ongoing relationship with a health-care provider whose recommendations he or she trusts. A number of proven organizational strategies can address the types of continuity. For example, informational continuity can be fostered through consistent use of electronic medical records, management continuity through development and implementation of practice guidelines and protocols, and relational continuity through role assignments that free clinicians to see patients for longer visits (108).

Applying Research Findings in Practice

Identifying Organizational Priorities for Improving Screening Rates.

Cancer screening may be promoted or impeded by factors at several levels, including characteristics of the patient; characteristics of the health-care provider and of the health-care team in which the provider works; the organization or practice setting in which the screening test takes place; and the larger health-care environment (14). Consequently, the success of organizational strategies to promote screening depends on characteristics of the organization, the providers who work within it, and the patients it serves. For example, predisposing strategies may be necessary for some providers and patients, but insufficient in the absence of enabling and reinforcing strategies. To select and prioritize strategies, organizations must assess their performance at each step and interface of the cancer screening process, and examine the causes of process breakdowns at the organizational-, provider-, and patient-level. Successful organizational strategies will vary by screening modality and for each organization, and must reflect interfaces across departments or organizational boundaries.

Adapting Organizational Processes and Interventions for Implementation.

Once priority screening steps and interfaces are identified, proven strategies must be tailored to the particular organization. Tailoring involves retention of the strategy's core components, such as counseling or appointment scheduling, and adaptation of peripheral elements, such as counseling messages or timing of appointments, to integrate the strategy into the organization's ongoing activities (109). Tailoring strategies based on assessments of practices’ clinical operations, culture, approaches to prevention, and relationships between personnel have been shown to increase cancer screening in primary care practice settings (110) and may be particularly useful for improving intraorganizational screening processes.

Implementation of screening process improvements is influenced by factors both internal and external to the organization. These factors have been codified in a model of primary care practice change that considers interrelationships between motivation of key stakeholders, such as medical directors or others who influence the behavior of the clinical practice; resources for change, such as management infrastructure, communication, and leadership; outside “motivators,” such as events and systems in the community and health-care environment; and perceived opportunities to make changes (111). Stakeholder motivation stems from a belief in the importance and effectiveness of systems approaches to improve screening; however, many practice leaders and clinicians do not hold this belief (51). Consistent and committed leadership is required to help organizations overcome the resistance and disruptions that may result from process changes (112).

Priorities for Future Research

Our review identified more than 40 discrete organizational factors that may promote cancer screening, encompassing most of the commonly measured factors of health-care organizations (113). However, some important organizational features are notably absent in the cancer screening studies we reviewed. For example, both team effectiveness and quality reporting have been associated with organizational changes and processes that improve care quality, especially for chronic conditions [see, eg, (114,115)]. The ways in which organizations address competing demands of acute, chronic, and preventive care also substantially affect the likelihood that patients receive adequate preventive services (116). Organizational leaders’ commitment is also critical to pursuit of quality improvements (117). These concepts are worthy of further assessment in the context of cancer screening, as the comprehensive set of organizational factors shown to influence chronic and acute care may be relevant in the context of preventive care, as well (118).

Few of the studies in our review examined the component steps and interfaces within organizations’ cancer screening processes or explicitly described the interdepartmental or interorganizational communication and coordination that needed to occur to accomplish cancer screening. Assessment of the intra- or interorganizational cancer screening process is a critical first phase for the development and implementation of effective organizational solutions and is a priority for future research. Development and application of measures that systematically describe organizational factors that influence screening steps and interfaces for both intra- and interorganizational processes would result in actionable findings for health-care organizations seeking to improve screening.

Ideally, organizational strategies to improve screening should address ongoing cancer screening performance—that is, screening participation leading to appropriate follow-up among those with abnormal results and repeated routine screening among those with normal results (119). However, the vast majority of studies in our review measured single screening events. Future research should address the effectiveness of organizational factors to promote long-term screening that bridges the transition to diagnosis and treatment, as needed.

Limitations

Our review has a number of important limitations. First, the search terms and techniques we applied may have missed some relevant articles. In particular, we included only those intervention studies that met the rigorous inclusion criteria of the Task Force on Community Preventive Services (120). Second, we focused on organizational structures and processes associated with cancer screening. Much research has investigated the association between organizational factors and a variety of other health-care outcomes, most notably patient safety and chronic care delivery. A number of systematic measurement tools, including the Assessment of Chronic Illness Care, the Survey of Organizational Attributes for Primary Care, and clinical microsystem assessments, are available to evaluate organizational attributes and assess strengths and weaknesses in care delivery (121–123). This extensive body of work is beyond the scope of our review. Integration of cancer screening as a prevention outcome in this work is a critical priority, as is the development of systematic organizational approaches that span across different types of preventive care services (124). Third, much of the intervention literature we reviewed focused on improving mammography and FOBT participation; further research is needed on organizational factors to improve cervical and colorectal cancer screening, as the cancer screening process—and the organizational factors that influence it—varies by screening modality. Finally, as new screening tests emerge, existing tests grow in popularity, and clinical guidelines are updated, the cancer screening process must be reexamined to determine which steps and interfaces are most critical.

Conclusions

A variety of organizational strategies has the potential to improve cancer screening rates substantially by limiting the number of interfaces across organizational boundaries; recruiting patients, promoting referrals, and facilitating appointment scheduling; and promoting continuous patient care. Optimal screening can be achieved if health-care organizations tailor their organizational processes to the cancer screening steps and interfaces that are most critical for their organizations, the providers who work within them, and the patients they serve.

Funding

This project has been funded in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E.

The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

We gratefully acknowledge the insightful comments of Mary Fennell and an anonymous reviewer.

Appendix 1: Organizational Factors and the Cancer Screening Process

Appendix Table 1.

Description of organizational intervention studies*

* FOBT = fecal occult blood test; HMO = health maintenance organization; VA = Department of Veterans Affairs.

Appendix Table 1.

Description of organizational intervention studies*

* FOBT = fecal occult blood test; HMO = health maintenance organization; VA = Department of Veterans Affairs.

Appendix Table 2.

Description of cross-sectional studies assessing relationship between organizational factors and cancer screening*

* HMO = health maintenance organizations; VA = Department of Veterans Affairs.

Appendix Table 2.

Description of cross-sectional studies assessing relationship between organizational factors and cancer screening*

* HMO = health maintenance organizations; VA = Department of Veterans Affairs.

References

1.

, et al. 

Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force

,

Ann Intern Med.

,

2002

, vol.

137

5 pt 1

(pg.

347

-

360

)

2.

, et al. 

Screening for breast cancer: an update for the U.S. Preventive Services Task Force

,

Ann Intern Med

,

2009

, vol.

151

10

(pg.

727

-

737

)

W237–W242

3.

, et al. 

Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force

,

Ann Intern Med

,

2002

, vol.

137

2

(pg.

132

-

141

)

4.

, et al. 

American Cancer Society guideline for the early detection of cervical neoplasia and cancer

,

CA Cancer J Clin

,

2002

, vol.

52

6

(pg.

342

-

362

)

5.

, et al. , et al. 

Screening

,

Oncology: An Evidence-Based Approach

,

2006

New York, NY

Springer Science and Business Media, Inc

6.

, et al. 

Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims

,

Ann Intern Med

,

2006

, vol.

145

7

(pg.

488

-

496

)

7.

, et al. 

Process of care failures in breast cancer diagnosis

,

J Gen Intern Med

,

2009

, vol.

24

6

(pg.

702

-

709

)

8.

, et al. 

Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow-up?

,

J Natl Cancer Inst.

,

2004

, vol.

96

20

(pg.

1518

-

1527

)

9.

, et al. 

Cervical cancer in women with comprehensive health care access: attributable factors in the screening process

,

J Natl Cancer Inst

,

2005

, vol.

97

9

(pg.

675

-

683

)

10.

, et al. 

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

,

Cancer

,

2000

, vol.

88

10

(pg.

2398

-

2424

)

11.

, et al. 

Health plan policies and programs for colorectal cancer screening: a national profile

,

Am J Manag Care

,

2004

, vol.

10

4

(pg.

273

-

279

)

12.

, et al. 

Colorectal cancer screening by primary care physicians: recommendations and practices, 2006–2007

,

Am J Prev Med.

,

2009

, vol.

37

1

(pg.

8

-

16

)

13.

, et al. 

Interventions that increase use of adult immunization and cancer screening services: a meta-analysis

,

Ann Intern Med.

,

2002

, vol.

136

9

(pg.

641

-

651

)

14.

,  . 

Toward improving the quality of cancer care: addressing the interfaces of primary and oncology-related subspecialty care

,

J Natl Cancer Inst Monogr

,

2010

40

(pg.

3

-

10

)

15.

. 

Evaluating the quality of medical care. 1966

,

Milbank Q

,

2005

, vol.

83

4

(pg.

691

-

729

)

16.

,  . 

Findings of innovation research applied to quality management principles for health care

,

Health Care Manage Rev.

,

1995

, vol.

20

2

(pg.

16

-

33

)

17.

,  . ,

Health Promotion Planning: An Educational and Ecological Approach

,

1999

3rd ed

Mountain View, CA

Mayfield Publishing Co

18.

, et al. 

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

,

Am J Prev Med

,

2008

, vol.

35

1 suppl

(pg.

S34

-

S55

)

19.

, et al. 

Client-directed interventions to increase community access to breast, cervical, and colorectal cancer screening a systematic review

,

Am J Prev Med

,

2008

, vol.

35

1 suppl

(pg.

S56

-

S66

)

20.

, et al. 

Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives

,

Am J Prev Med

,

2008

, vol.

35

1 suppl

(pg.

S67

-

S74

)

21.

, et al. 

Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: Updates of Systematic Reviews

Paper presented at: United States Preventive Services Task Force; 2009; Atlanta, GA

22.

, et al. 

The influence of year-end bonuses on colorectal cancer screening

,

Am J Manag Care

,

2004

, vol.

10

9

(pg.

617

-

624

)

23.

, et al. 

Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care

,

J Med Screen

,

2001

, vol.

8

2

(pg.

99

-

105

)

24.

, et al. 

A randomized intervention to improve ongoing participation in mammography

,

Am J Manag Care

,

2001

, vol.

7

9

(pg.

887

-

894

)

25.

, et al. 

Institutional commitment to rectal cancer screening results in earlier-stage cancers on diagnosis

,

Ann Surg Oncol

,

2004

, vol.

11

11

(pg.

970

-

976

)

26.

, et al. 

Pap smear outreach: a randomized controlled trial in an HMO

,

Am J Prev Med

,

1997

, vol.

13

6

(pg.

425

-

426

)

27.

,  ,  . 

Does telephone contact with a physician's office staff improve mammogram screening rates?

,

Fam Med

,

1999

, vol.

31

5

(pg.

324

-

326

)

28.

,  . 

Effectiveness of a call/recall system in improving compliance with cervical cancer screening: a randomized controlled trial

,

CMAJ

,

1997

, vol.

157

5

(pg.

521

-

526

)

29.

, et al. 

The effect of patient and physician reminders on use of screening mammography in a health maintenance organization. Results of a randomized controlled trial

,

Cancer

,

1996

, vol.

78

8

(pg.

1708

-

1721

)

30.

, et al. 

How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial

,

Cancer

,

1998

, vol.

82

12

(pg.

2391

-

2400

)

31.

, et al. 

Comparisons of tailored mammography interventions at two months postintervention

,

Ann Behav Med

,

2002

, vol.

24

3

(pg.

211

-

218

)

32.

, et al. 

Comparison of three interventions to increase mammography screening in low income African American women

,

Cancer Detect Prev

,

2006

, vol.

30

6

(pg.

535

-

544

)

33.

, et al. 

Promoting mammography: results of a randomized trial of telephone counseling and a medical practice intervention

,

Am J Prev Med

,

2000

, vol.

19

1

(pg.

39

-

46

)

34.

, et al. 

Evaluation of a phone intervention to promote mammography in a managed care plan

,

Am J Health Promot

,

1997

, vol.

11

4

(pg.

247

-

249

)

35.

, et al. 

Intervention to increase mammography utilization in a public hospital

,

J Gen Intern Med

,

1998

, vol.

13

4

(pg.

230

-

233

)

36.

,  . 

A patient-held minirecord to promote adult preventive care

,

J Fam Pract

,

1992

, vol.

34

4

(pg.

457

-

463

)

37.

, et al. 

Impact of same-day screening mammography availability: results of a controlled clinical trial

,

Arch Intern Med

,

1999

, vol.

159

4

(pg.

393

-

398

)

38.

,  . 

A simple strategy to improve patient adherence to outpatient fecal occult blood testing

,

J Gen Intern Med

,

1994

, vol.

9

8

(pg.

462

-

464

)

39.

. 

A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic

,

Jt Comm J Qual Improv

,

1997

, vol.

23

4

(pg.

196

-

202

)

40.

, et al. 

Enhancing mammography referral in primary care

,

Prev Med

,

1997

, vol.

26

6

(pg.

791

-

800

)

41.

, et al. 

A general practice-based recruitment strategy for colorectal cancer screening

,

Aust N Z J Public Health

,

2000

, vol.

24

4

(pg.

441

-

443

)

42.

, et al. 

The effect on compliance of a health education leaflet in colorectal cancer screening in general practice in central England

,

J Epidemiol Community Health

,

1997

, vol.

51

2

(pg.

187

-

191

)

43.

,  ,  . 

Improving compliance with breast cancer screening in older women. Results of a randomized controlled trial

,

Arch Intern Med

,

1995

, vol.

155

7

(pg.

717

-

722

)

44.

, et al. 

Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care

,

Am J Public Health

,

1998

, vol.

88

11

(pg.

1699

-

1701

)

45.

, et al. 

Randomized controlled study of customized preventive medicine reminder letters in a community practice

,

Can Fam Physician

,

1998

, vol.

44

(pg.

81

-

88

)

46.

,  ,  . 

A randomised trial of general practitioner-written invitations to encourage attendance at screening mammography

,

Commun Health Stud.

,

1990

, vol.

14

4

(pg.

357

-

364

)

47.

, et al. 

Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data

,

Patient Educ Couns

,

2003

, vol.

50

2

(pg.

123

-

132

)

48.

, et al. 

Use of an outpatient medical record audit to achieve educational objectives: changes in residents’ performances over six years

,

J Gen Intern Med

,

1990

, vol.

5

3

(pg.

218

-

224

)

49.

, et al. 

Colorectal cancer screening: optimal compliance with postal faecal occult blood test

,

Aust N Z J Surg

,

1992

, vol.

62

9

(pg.

714

-

719

)

50.

, et al. 

Promoting mammography use through progressive interventions: is it effective?

,

Am J Public Health

,

1994

, vol.

84

1

(pg.

104

-

106

)

51.

, et al. 

Using an office system intervention to increase breast cancer screening

,

J Gen Intern Med

,

1998

, vol.

13

8

(pg.

507

-

514

)

52.

,  ,  . 

Enhancing adherence with mammography through patient letters and physician prompts. A pilot study

,

N C Med J

,

1992

, vol.

53

11

(pg.

575

-

578

)

53.

,  . 

Strategies to increase mammography utilization among community health center visitors. Improving awareness, accessibility, and affordability

,

Med Care

,

1993

, vol.

31

2

(pg.

175

-

181

)

54.

, et al. 

Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls

,

Am J Public Health

,

1995

, vol.

85

6

(pg.

834

-

836

)

55.

,  . 

A motivational message, external barriers, and mammography utilization

,

Cancer Detect Prev.

,

1999

, vol.

23

3

(pg.

254

-

264

)

56.

, et al. 

Can tailored interventions increase mammography use among HMO women?

,

Am J Prev Med

,

2000

, vol.

18

1

(pg.

1

-

10

)

57.

, et al. 

Patient compliance with colorectal cancer screening in general practice

,

Br J Gen Pract

,

1992

, vol.

42

354

(pg.

18

-

20

)

58.

, et al. 

Facility-based inreach strategies to promote annual mammograms

,

Am J Prev Med

,

1994

, vol.

10

6

(pg.

353

-

356

)

59.

,  . 

Reducing financial barriers enhances the return rate of stool Hemoccult packets

,

Am J Med Sci.

,

1993

, vol.

306

2

(pg.

98

-

100

)

60.

. 

Enhancing compliance with screening mammography recommendations: a clinical trial in a primary care office

,

Fam Med

,

1995

, vol.

27

2

(pg.

117

-

121

)

61.

, et al. 

Behavioral interventions to increase adherence in colorectal cancer screening

,

Med Care

,

1991

, vol.

29

10

(pg.

1039

-

1050

)

62.

, et al. 

Screening with faecal occult blood test (FOBT) for colorectal cancer: assessment of two methods that attempt to improve compliance

,

Eur J Cancer Prev

,

2001

, vol.

10

3

(pg.

251

-

256

)

63.

,  . 

Cancer screening utilization: is there a role for social work in cancer prevention?

,

Soc Work Health Care

,

1995

, vol.

21

4

(pg.

59

-

70

)

64.

,  ,  . 

Cervical screening in general practice

,

Aust J Public Health

,

1995

, vol.

19

2

(pg.

167

-

172

)

65.

, et al. 

Increasing mammography among women aged 40–74 by use of a stage-matched, tailored intervention

,

Prev Med.

,

1998

, vol.

27

5 pt 1

(pg.

748

-

756

)

66.

, et al. 

Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening

,

J Med Screen

,

2001

, vol.

8

2

(pg.

91

-

98

)

67.

, et al. 

The impact of tailored interventions on a community health center population

,

Patient Educ Couns

,

1999

, vol.

37

2

(pg.

125

-

140

)

68.

, et al. 

Effects of a mammography decision-making intervention at 12 and 24 months

,

Am J Prev Med

,

2002

, vol.

22

4

(pg.

247

-

257

)

69.

, et al. 

Early experience with pay-for-performance: from concept to practice

,

JAMA

,

2005

, vol.

294

14

(pg.

1788

-

1793

)

70.

, et al. 

The cost effectiveness of 5 interventions to increase mammography adherence in a managed care population

,

Am J Manag Care.

,

2003

, vol.

9

1

(pg.

33

-

44

)

71.

, et al. 

The effect of patient reminders on the use of screening mammography in an urban health department primary care setting

,

Breast Cancer Res Treat

,

2001

, vol.

65

1

(pg.

63

-

70

)

72.

,  ,  . 

Physicians’ recommendations for mammography: do tailored messages make a difference?

,

Am J Public Health

,

1994

, vol.

84

1

(pg.

43

-

49

)

73.

, et al. 

The effect of patient and provider reminders on mammography and Papanicolaou smear screening in a large health maintenance organization

,

Arch Intern Med

,

1997

, vol.

157

15

(pg.

1658

-

1664

)

74.

, et al. 

Testing reminder and motivational telephone calls to increase screening mammography: a randomized study

,

J Natl Cancer Inst

,

2000

, vol.

92

3

(pg.

233

-

242

)

75.

, et al. 

Screening HMO women overdue for both mammograms and pap tests

,

Prev Med.

,

2002

, vol.

34

1

(pg.

40

-

50

)

76.

, et al. 

The role of family physicians in increasing annual fecal occult blood test screening coverage: a prospective intervention study

,

Isr Med Assoc J

,

2002

, vol.

4

6

(pg.

424

-

425

)

77.

, et al. 

The safety net: a cost-effective approach to improving breast and cervical cancer screening

,

J Womens Health (Larchmt)

,

2003

, vol.

12

8

(pg.

789

-

798

)

78.

, et al. 

Stepped-care, community clinic interventions to promote mammography use among low-income rural African American women

,

Health Educ Behav

,

2004

, vol.

31

4 suppl

29S–44S

79.

, et al. 

Increased cancer screening behavior in women of color by culturally sensitive video exposure

,

Prev Med

,

1995

, vol.

24

2

(pg.

142

-

148

)

80.

,  ,  . 

A breast cancer education and on-site screening intervention for unscreened African American women

,

J Cancer Educ

,

2002

, vol.

17

4

(pg.

231

-

236

)

81.

, et al. 

Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery

,

Prev Med

,

2003

, vol.

36

2

(pg.

131

-

140

)

82.

,  . 

Primary care physicians’ use of office resources in the provision of preventive care

,

Arch Fam Med

,

1996

, vol.

5

7

(pg.

399

-

404

)

83.

, et al. 

Office systems and their influence on mammography use in rural and urban primary care

,

J Rural Health

,

2004

, vol.

20

1

(pg.

36

-

42

)

84.

, et al. 

Continuity of care and cancer screening among health plan enrollees

,

Med Care

,

2008

, vol.

46

1

(pg.

58

-

62

)

85.

, et al. 

Primary care practice and facility quality orientation: influence on breast and cervical cancer screening rates

,

Am J Manag Care

,

2004

, vol.

10

4

(pg.

265

-

272

)

86.

, et al. 

Barriers to colorectal cancer screening in rural primary care

,

Prev Med

,

2004

, vol.

38

3

(pg.

269

-

275

)

87.

, et al. ,

Cancer Collaborative Project Survey.

,

2006

88.

, et al. 

The effects of teamwork and system support on colorectal cancer screening in primary care practices

,

Cancer Detect Prev

,

2007

, vol.

31

5

(pg.

417

-

423

)

89.

, et al. 

The relationship between continuity of care and trust with stage of cancer at diagnosis

,

Fam Med

,

2004

, vol.

36

1

(pg.

35

-

39

)

90.

, et al. 

Organizational systems used by California capitated medical groups and independent practice associations to increase cancer screening

,

Cancer

,

2000

, vol.

88

12

(pg.

2824

-

2831

)

91.

, et al. 

Exploring environmental barriers to participation in mammography screening in an HMO

,

Cancer Epidemiol Biomarkers Prev

,

1993

, vol.

2

6

(pg.

599

-

605

)

92.

,  ,  . 

Do integrated medical groups provide higher-quality medical care than individual practice associations?

,

Ann Intern Med

,

2006

, vol.

145

11

(pg.

826

-

833

)

93.

, et al. 

Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community

,

Arch Intern Med

,

1997

, vol.

157

13

(pg.

1462

-

1470

)

94.

,  ,  . 

Primary care practice coordination versus physician continuity

,

Fam Med.

,

2004

, vol.

36

1

(pg.

15

-

21

)

95.

, et al. 

Delivery of preventive services to older adults by primary care physicians

,

JAMA

,

2005

, vol.

294

4

(pg.

473

-

481

)

96.

, et al. 

Primary care provider turnover and quality in managed care organizations

,

Am J Manag Care

,

2007

, vol.

13

8

(pg.

465

-

472

)

97.

,  . 

The impact of primary care resources on prevention practices

,

J Ambul Care Manage

,

2005

, vol.

28

3

(pg.

241

-

253

)

98.

, et al. 

Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex

,

Am J Prev Med

,

1992

, vol.

8

2

(pg.

78

-

85

)

99.

, et al. 

Influence of financial productivity incentives on the use of preventive care

,

Am J Med

,

2001

, vol.

110

3

(pg.

181

-

187

)

100.

, et al. 

Primary care practice organization influences colorectal cancer screening performance

,

Health Serv Res.

,

2007

, vol.

42

3 pt 1

(pg.

1130

-

1149

)

101.

, et al. 

Which women aren't getting mammograms and why? (United States)

,

Cancer Causes Control

,

2007

, vol.

18

1

(pg.

61

-

70

)

102.

,  . 

What is the empirical basis for paying for quality in health care?

,

Med Care Res Rev.

,

2006

, vol.

63

2

(pg.

135

-

157

)

103.

, et al. 

Hospital volume and surgical mortality in the United States

,

N Engl J Med

,

2002

, vol.

346

15

(pg.

1128

-

1137

)

104.

,  ,  . 

Is volume related to outcome in health care? A systematic review and methodologic critique of the literature

,

Ann Intern Med

,

2002

, vol.

137

6

(pg.

511

-

520

)

105.

, et al. 

Trade-offs in high-volume primary care practice

,

J Fam Pract

,

1998

, vol.

46

5

(pg.

397

-

402

)

106.

, et al. 

Improving colorectal cancer screening in primary care practice: innovative strategies and future directions

,

J Gen Intern Med

,

2007

, vol.

22

8

(pg.

1195

-

1205

)

107.

, et al. 

Continuity of care: a multidisciplinary review

,

BMJ.

,

2003

, vol.

327

7425

(pg.

1219

-

1221

)

108.

, et al. 

Continuity of care matters

,

BMJ

,

2008

, vol.

337

a867

109.

, et al. 

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

,

Implement Sci.

,

2009

, vol.

4

pg.

50

110.

, et al. 

A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP)

,

Am J Prev Med

,

2001

, vol.

21

1

(pg.

20

-

28

)

111.

, et al. 

A practice change model for quality improvement in primary care practice

,

J Healthc Manag

,

2004

, vol.

49

3

(pg.

155

-

168

)

discussion 169–170

112.

, et al. 

Cancer early-detection services in community health centers for the underserved. A randomized controlled trial

,

Arch Fam Med

,

1998

, vol.

7

4

(pg.

320

-

327

)

discussion 328

113.

. 

The role of organizational research in implementing evidence-based practice: QUERI Series

,

Implement Sci.

,

2008

, vol.

3

pg.

29

114.

, et al. 

External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases

,

JAMA

,

2003

, vol.

289

4

(pg.

434

-

441

)

115.

, et al. 

The role of perceived team effectiveness in improving chronic illness care

,

Med Care

,

2004

, vol.

42

11

(pg.

1040

-

1048

)

116.

, et al. 

Delivery of clinical preventive services in family medicine offices

,

Ann Fam Med

,

2005

, vol.

3

5

(pg.

430

-

435

)

117.

, et al. 

Organizational factors associated with high performance in quality and safety in academic medical centers

,

Acad Med

,

2007

, vol.

82

12

(pg.

1178

-

1186

)

118.

,  ,  . 

Does the chronic care model serve also as a template for improving prevention?

,

Milbank Q

,

2001

, vol.

79

4

(pg.

579

-

612

)

iv–v

119.

. 

Interventions to improve cancer screening: commentary from a health services research perspective

,

Am J Prev Med

,

2008

, vol.

35

1 suppl

(pg.

S6

-

S9

)

120.

, et al. 

Methods for conducting systematic reviews of evidence on effectiveness and economic efficiency of interventions to increase screening for breast, cervical, and colorectal cancers

,

Am J Prev Med

,

2008

, vol.

35

1 suppl

(pg.

S26

-

S33

)

121.

, et al. 

Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement

,

Health Serv Res.

,

2002

, vol.

37

3

(pg.

791

-

820

)

122.

, et al. 

Measuring organizational attributes of primary care practices: development of a new instrument

,

Health Serv Res.

,

2007

, vol.

42

3 pt 1

(pg.

1257

-

1273

)

123.

,  . 

Improving safety on the front lines: the role of clinical microsystems

,

Qual Saf Health Care

,

2002

, vol.

11

1

(pg.

45

-

50

)

124.

, et al. 

Delivering clinical preventive services is a systems problem

,

Ann Behav Med

,

1997

, vol.

19

3

(pg.

271

-

278

)

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Topic:

• patient referral
• appointments and schedules
• cancer screening
• health care

What type of postage would the medical assistant use to mail a normal mammogram letter?

Which type of mail should be used when proof is needed that a patient received a letter sent by a physician's office?

Which of the following types of mail provides proof that a letter has been received?

How is a postage meter used in a medical office?