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PubMed1998

Lexical access via letter naming in a profoundly alexic and anomic patient: a treatment study.

We report the results of a letter naming treatment designed to facilitate letter-by-letter reading in an aphasic patient with no reading ability. Patient M.R.'s anomia for written letters reflected two loci of impairment within visual naming: impaired letter activation from print (a deficit commonly seen in pure alexic patients who read letter by letter) and impaired access to phonology via semantics (documented in a severe multimodality anomia). Remarkably, M.R. retained an excellent ability to pronounce orally spelled words, demonstrating that abstract letter identities could be activated normally via spoken letter names, and also that lexical phonological representations were intact when accessed via spoken letter names. M.R.'s training in oral naming of written letters resulted in significant improvement in her oral naming of trained letters. Importantly, as M.R.'s letter naming improved, she became able to employ letter-by-letter reading as a compensatory strategy for oral word reading. M.R.'s success in letter naming and letter-by-letter reading suggests that other patients with a similar pattern of spared and impaired cognitive abilities may benefit from a similar treatment. Moreover, this study highlights the value of testing the pronunciation of orally spelled words in localizing the source of prelexical reading impairment and in predicting the functional outcome of treatment for impaired letter activation in reading.

Aged↗
PubMed2005

Learning to identify contrast-defined letters in peripheral vision.

Performance for identifying luminance-defined letters in peripheral vision improves with training. The purpose of the present study was to examine whether performance for identifying contrast-defined letters also improves with training in peripheral vision, and whether any improvement transfers to luminance-defined letters. Eight observers were trained to identify contrast-defined letters presented singly at 10 degrees eccentricity in the inferior visual field. Before and after training, we measured observers' thresholds for identifying luminance-defined and contrast-defined letters, embedded within a field of white luminance noise (maximum luminance contrast=0, 0.25, and 0.5), at the same eccentric location. Each training session consisted of 10 blocks (100 trials per block) of identifying contrast-defined letters at a background noise contrast of 0.5. Letters (x-height=4.2 degrees) were the 26 lowercase letters of the Times-Roman alphabet. Luminance-defined letters were generated by introducing a luminance difference between the stimulus letter and its mid-gray background. The background noise covered both the letter and its background. Contrast-defined letters were generated by introducing a differential noise contrast between the group of pixels that made up the stimulus letter and the group of pixels that made up the background. Following training, observers showed a significant reduction in threshold for identifying contrast-defined letters (p<0.0001). Averaged across observers and background noise contrasts, the reduction was 25.8%, with the greatest reduction (32%) occurring at the trained background noise contrast. There was virtually no transfer of improvement to luminance-defined letters, or to an untrained letter size (2 x original), or an untrained retinal location (10 degrees superior field). In contrast, learning transferred completely to the untrained contralateral eye. Our results show that training improves performance for identifying contrast-defined letters in peripheral vision. This perceptual learning effect seems to be stimulus-specific, as it shows no transfer to the identification of luminance-defined letters. The complete interocular transfer, and the retinotopic (retinal location) and size specificity of the learning effect are consistent with the properties of neurons in early visual area V2.

Adult↗
PubMed2001

Cost effectiveness of computer tailored and non-tailored smoking cessation letters in general practice: randomised controlled trial.

OBJECTIVES: To develop and evaluate, in a primary care setting, a computerised system for generating tailored letters about smoking cessation. DESIGN: Randomised controlled trial. SETTING: Six general practices in Aberdeen, Scotland. PARTICIPANTS: 2553 smokers aged 17 to 65. INTERVENTIONS: All participants received a questionnaire asking about their smoking. Participants subsequently received either a computer tailored or a non-tailored, standard letter on smoking cessation, or no letter. MAIN OUTCOME MEASURES: Prevalence of validated abstinence at six months; change in intention to stop smoking in the next six months. RESULTS: The validated cessation rate at six months was 3.5% (30/857) (95% confidence interval 2.3% to 4.7%) for the tailored letter group, 4.4% (37/846) (3.0% to 5.8%) for the non-tailored letter group, and 2.6% (22/850) (1.5% to 3.7%) for the control (no letter) group. After adjustment for significant covariates, the cessation rate was 66% greater (-4% to 186%; P=0.07) in the non-tailored letter group than that in the no letter group. Among participants who smoked <20 cigarettes per day, the cessation rate in the non-tailored letter group was 87% greater (0% to 246%; P=0.05) than that in the no letter group. Among heavy smokers who did not quit, a 76% higher rate of positive shift in "stage of change" (intention to quit within a particular period of time) was seen compared with those who received no letter (11% to 180%; P=0.02). The increase in cost for each additional quitter in the non-tailored letter group compared with the no letter group was pound 89. CONCLUSIONS: In a large general practice, a brief non-tailored letter effectively increased cessation rates among smokers. A tailored letter was not effective in increasing cessation rates but promoted shift in movement towards cessation ("stage of change") in heavy smokers. As a pragmatic tool to encourage cessation of smoking, a mass mailing of non-tailored letters from general practices is more cost effective than computer tailored letters or no letters.

Adolescent↗
PubMed2005

Multiple levels of letter representation in written spelling: evidence from a single case of dysgraphia with multiple deficits.

In this paper, we report a detailed analysis of the impaired performance of a dysgraphic individual, AD, who produced similar rates of letter-level errors in written spelling, oral spelling, and typing. We found that the distribution of various letter error types displayed a distinct pattern in written spelling on the one hand and in oral spelling and typing on the other. In particular, noncontextual letter substitution errors (i.e., errors in which the erroneous letter that replaces the target letter does not occur elsewhere within the word) were virtually absent in oral spelling and typing and mainly found in written spelling. In contrast, letter deletion errors and multiple-letter errors were typically found in oral spelling and very exceptional in written spelling. Only contextual letter substitution errors (i.e., errors in which the erroneous letter that replaces the target letter is identical to a letter occurring earlier or later in the word) were found in similar proportions in the three tasks. We argue that these contrasting patterns of letter error distribution result from damage to two distinct levels of letter representation and processing within the spelling system, namely, the amodal graphemic representation held in the graphemic buffer and the letter form representation computed by subsequent writing-specific processes. Then, we examined the relationship between error and target in the letter substitution errors produced in written and oral spelling and found evidence that distinct types of letter representation are processed at each of the hypothetized levels of damage: symbolic letter representation at the graphemic level and representation of the component graphic strokes at the letter form processing level.

Aged↗
PubMed2006

fMRI correlates of cortical specialization and generalization for letter processing.

The present study used functional magnetic resonance imaging to examine cortical specialization for letter processing. We assessed whether brain regions that were involved in letter processing exhibited domain-specific and/or mandatory responses, following Fodor's definition of properties of modular systems (Fodor, J.A., 1983. The Modularity of Mind. The MIT Press, Cambridge, MA.). Domain-specificity was operationalized as selective, or exclusive, activation for letters relative to object and visual noise processing and a baseline fixation task. Mandatory processing was operationalized as selective activation for letters during both a silent naming and a perceptual matching task. In addition to these operational definitions, other operational definitions of selectivity for letter processing discussed by [Pernet, C., Celsis, P., Demonet, J., 2005. Selective response to letter categorization within the left fusiform gyrus. NeuroImage 28, 738-744] were applied to the data. Although the left fusiform gyrus showed a specialized response to letters using the definition of selectivity put forth by [Pernet, C., Celsis, P., Demonet, J., 2005. Selective response to letter categorization within the left fusiform gyrus. NeuroImage 28, 738-744], this region did not exhibit specialization for letters according to our more conservative definition of selectivity. Instead, this region showed equivalent activation by letters and objects in both the naming and matching tasks. Hence, the left fusiform gyrus does not exhibit domain-specific or mandatory processing but may reflect a shared input system for both stimulus types. The left insula and some portions of the left inferior parietal lobule, however, did show a domain-specific response for letter naming but not for letter matching. These regions likely subserve some linguistically oriented cognitive process that is unique to letters, such as grapheme-to-phoneme translation or retrieval of phonological codes for letter names. Hence, cortical specialization for letters emerged in the naming task in some peri-sylvian language related cortices, but not in occipito-temporal cortex. Given that the domain-specific response for letters in left peri-sylvian regions was only present in the naming task, these regions do not process letters in a mandatory fashion, but are instead modulated by the linguistic nature of the task.

Adult↗
PubMed2002

The organization of letter-form representations in written spelling: evidence from acquired dysgraphia.

We report on an Italian brain-damaged patient with impaired written spelling. The patient's errors, in different fonts and scripts, consist mainly of letter substitutions (e.g., filo [thread] --> TILO). The results of various tests indicate that letter substitution errors arise because of a deficit in accessing the letter-form representations supporting written spelling. Letter substitutions occurred predominantly between letters with common strokes (e.g., C and G; b and p). Similarities in terms of global letter shape or letter sound were not valid predictors of letter substitution errors. Letter frequency, consonant-vowel status, and letter gemination were factors affecting letter substitution errors. The results of our investigation suggest that information about letter strokes are stored at the level of letter-form representations, and that access to these representations is sensitive to letter frequency. The results further indicate that letter-form representations do not specify whether a letter is a consonant or a vowel, or is a geminate.

Agraphia↗
PubMed2007

Shift in spatial scale in identifying crowded letters.

Crowding refers to the increased difficulty in identifying a letter flanked by other letters. The purpose of this study was to determine if the peak sensitivity of the human visual system shifts to a different spatial frequency when identifying crowded letters, compared with single letters. We measured contrast thresholds for identifying the middle target letters in trigrams, for a range of spatial frequencies, letter separations and letter sizes, at the fovea and 5 degrees eccentricity. Plots of contrast sensitivity vs. letter frequency exhibit spatial tuning, for all letter sizes and letter separations tested. The peak tuning frequency grows as the 0.6-0.7 power of the letter size, independent of letter separation. At the smallest letter separation, peak tuning frequency occurs at a frequency that is 0.17 octaves higher for flanked than for unflanked letters at the fovea, and 0.19 octaves at 5 degrees eccentricity. This finding suggests that the human visual system shifts its sensitivity toward a higher spatial-frequency channel when identifying letters in the presence of nearby letters. However, the size of the shift is insufficient to account for the large effect of crowding in the periphery.

Contrast Sensitivity↗
PubMed2002

Spatial-frequency properties of letter identification in amblyopia.

Amblyopia is characterized by a deficit in identifying small letters (acuity deficit) in the absence of identifiable ocular pathology. One explanation for this deficit is that the amblyopic visual system lacks appropriate channels tuned to high spatial frequencies for identifying small letters. The purpose of this study was to examine the spatial-frequency properties of letter identification in the amblyopic visual system. To do so, we measured contrast thresholds for identifying letters that were band-pass filtered to different bands of spatial frequencies, for letter sizes ranging from 2x to 19.2x larger than acuity letters. Letters were digitally filtered using a set of band-pass filters, with peak object spatial frequencies ranging from 0.88 to 10 c/letter. The bandwidth of the filters was 1 octave. For any given letter size, contrast sensitivity for identifying letters exhibits a spatial-tuning function. The shape of these tuning functions was found to be similar between amblyopic and non-amblyopic eyes, and across all letter sizes. The peak of these functions shifted progressively toward lower object spatial frequency when the letter size became smaller. When compared with the non-amblyopic eyes, the amblyopic eyes have a limited range of tuning functions sensitive to letters. However, when scaled with respect to acuity, the relationship between the peak frequency of the tuning functions and letter size becomes essentially identical in the amblyopic and non-amblyopic eyes. An ideal-observer analysis that takes into account spectral information about letter identity and the contrast-sensitivity function of the observer, but does not invoke narrow-band channels, also shows that the properties of the tuning functions for letter identification are similar between the amblyopic and non-amblyopic eyes. We conclude that the deficit in identifying small letters in amblyopes is not attributable to differences in the shape or selection of "channels", when compared with the normal visual system. Rather, it is a consequence of the difference in the resolution limit between the amblyopic and the non-amblyopic eyes.

Adolescent↗
PubMed1995

Writing to referring doctors after a new patient consultation. What is wanted and what was contained in letters from one medical oncologist?

BACKGROUND: There are no Australasian data on the preferred information content of letters from consultant physicians to referring doctors. AIMS: To survey referring general practitioners (GPs) and specialists concerning their preferences for letters from a consultant physician after a new patient consultation to include different categories of information. To investigate the information content of letters written by one medical oncologist to referring doctors after a new patient consultation and contrast with that of individualised letters written to patients. METHODS: Fifty-five referring GPs and 53 specialists were sent a questionnaire seeking their views on the information content of letters from consultant physicians. Ninety-four letters after a new patient consultation were selected at random and analysed for their information content, and compared with 182 individualised letters sent to patients. RESULTS: Referring doctors wanted letters to contain details of diagnosis, clinical findings, test results and recommended future tests, treatment options, side effects and prognosis. Letters to referring doctors contained 19 items of information (range 8-33), while letters to patients contained a mean of 5.6 'salient' points (range 5-7). Both letters almost always stated the diagnosis, the presenting history and recommended treatment. Letters to patients more commonly presented information about prognosis, further tests, and explanation of symptoms than letters to doctors. In contrast, letters to referring doctors contained more information concerning the past medical, family, and drug history, clinical findings and test results. CONCLUSIONS: Letters sent by a consultant oncologist are not well tailored to the information needs of the referring clinician. Summary letters sent to patients may be modified to include information required by referring doctors.

Cross-Over Studies↗
PubMed1994

Letters of recommendation for surgical residencies: what they say and what they mean.

Screening of applicants and selection of interns for surgical residency programs continue to rely heavily on letters of recommendation from surgical faculty. To define important aspects of letters useful for screening and selection, letters written on behalf of housestaff with known performance and those of new applicants were circulated to a sample of 120 academic surgeons. Eighty letters, written on behalf of 42 students, were divided into 10 groups of 8; each group was sent to 12 individuals. Half of the letters were "open" (full letter-head and signature), and half were "text only" (i.e., no identification). Candidate names were omitted. Each faculty reviewer was asked to rank the candidate represented by each letter, for their program, on a scale of 1 to 5, and indicate key negative or positive phrases on individual letters. Reviewers were also asked to indicate the importance they generally ascribe in evaluating such letters to the school of origin, academic rank of the letter writer, personalization (of letter to reader), formal vs informal reference to the candidate, and mention of interest in specialty training. A response rate of 60% was obtained. Faculty reviewers stated explicitly that school of origin, personalization of the letter, and the academic rank of the writer are important factors influencing their ranking of candidate letters. The scores they gave to "open" and "text only" letters, however, do not differ significantly (P > 0.05). Letters were scored similarly, indicating that school of origin or writer may not be as critical as implied or believed.(ABSTRACT TRUNCATED AT 250 WORDS)

Correspondence as Topic↗
PubMed1996

The effects of foveal load and visual context on peripheral letter recognition.

Peripheral letter recognition was examined by presenting subjects with a letter triad centered 7.16 degrees to the right of fixation. At the same time, a single letter was presented at the point of fixation that was either the same as one of the letters in the triad or different from any of the triad letters. On other trials, no letter was presented at the point of fixation. Results supported and extended previous foveal load research. The disruptive effect of foveal load does not depend solely on the presence or absence of a foveal stimulus. Recognition of the first letter in non-words was disrupted when a foveal letter was presented that was different from the peripheral letter. Recognition of the middle letter for both words and non-words was disrupted when a foveal letter was presented that was the same as the middle letter. A significant interaction between foveal letter and triad type was also found. No evidence was found to suggest that recognition of a peripheral letter is significantly better when that same letter is also present at the point of fixation.

Adult↗
PubMedDate not supplied

Audit of consultant physicians' reply letters for referrals to clinics in a tertiary teaching hospital.

BACKGROUND: Doctors referring patients to consultant physicians seek reply letters which both educate and assist in ongoing patient management. Highly desirable attributes in specialist letters include clearly stated and justified: (i) diagnostic formulations, (ii) management regimens, (iii) use of clinical investigations, (iv) prognostic statements, (v) contingency plans and (vi) follow-up arrangements. AIM: To explicitly evaluate the quality of reply letters for new patients referred to clinics at a tertiary teaching hospital. METHODS: Letters were sampled from outpatient clinics of 10 different medical specialties at Princess Alexandra Hospital in Brisbane, Australia. Reply letters for new patient referrals between 1 August 2000 and 31 October 2000 were retrieved, from which data were abstracted to calculate the proportion of letters satisfying prespecified quality attributes. RESULTS: Of 297 new patient referrals, reply letters were retrieved for 204 (69%). Of these, 147 (72%) referrals were accompanied by a referral letter, mostly (113/147; 77%) from general practitioners. For 120 referrals involving diagnostic issues, 69 (56%) letters stated a diagnostic formulation. Of 114 letters recommending further clinical investigations, 61 (53%) described a rationale for such testing. In 125 cases where therapy was a key issue, 83 (66%) letters recommended changes to current treatment for which reasons were specified in 46 (55%) cases, and contingency plans provided in 13 (16%). Prognosis was mentioned in only 18 (9%) cases. Follow-up arrangements were detailed in 123 (60%) letters. Assessments of patient understanding and likely adherence to therapy were stated in less than 15% of -letters. CONCLUSIONS: Opportunities exist for improving quality of consultant physicians' reply letters in terms of greater use of problem lists, contingency plans, prognostic statements and patient-centred assessments, as well as more frequent enunciation of consultants' reasoning behind requests for further tests and changes to current management. Use of structured letter templates may facilitate more consistent inclusion of key information to referring doctors.

Australia↗
PubMed1989

Detection of intraword and interword letter repetition: a test of the word unitization hypothesis.

Do words, as familiar units or gestalts, tend to swallow up and conceal their letter components (Pillsbury, 1897)? Letters typically are detected faster and more accurately in words than in nonwords (i.e., scrambled collections of letters), and in more frequent words than in less frequent words. However, a word advantage at encoding, where the representation of the string is formed, might compensate for, and thus mask, a word disadvantage at decoding and comparison, where the component letters of the representation are accessed and compared with the target letter. To better reveal any such word disadvantage, a task was used in this study that increased the amount of letter processing. Subjects judged whether a letter was repeated within a six-letter word or a nonword (Experiment 1; intraword letter repetition) or was repeated between two adjacent unrelated six-letter words or nonwords (Experiment 2; interword letter repetition). Contrary to Pillsbury's word unitization hypothesis, both types of letter repetition (intraword and interword) were detected faster and just as accurately with words as with nonwords. In Experiment 2, however, interword letter repetition was detected less accurately on common words (but not on rare words or third-order pseudowords) than on the corresponding nonwords. Thus, although the familiar word does not deny access to its own component letters, it does make their comparison with letters from other words more difficult.

Adult↗
PubMed2002

Spatial-frequency characteristics of letter identification in central and peripheral vision.

Spatial-frequency characteristics of letter identification are much better understood in the fovea than in the periphery. The purpose of this study was to compare the spatial-frequency characteristics of letter identification in central and peripheral vision. We measured contrast thresholds for identifying single, Times-Roman lower-case letters that were spatially band-pass filtered. Each of the 26 letters was digitally filtered with a set of nine cosine log filters, with peak object spatial frequencies ranging from 0.63 to 10 c/letter, in half-octave steps. Bandwidth of the filters was 1 octave. Three observers with normal vision were each tested monocularly at the fovea, and at 5 degrees and 10 degrees in the inferior visual field. Letter sizes were 0.2, 0.4 and 0.6 log units larger than high contrast, unfiltered acuity letters. Plots of contrast sensitivity for letter identification vs. frequency of the band-pass filters exhibit spatial tuning. In general, the spatial-frequency characteristics of letter identification are fundamentally identical between central and peripheral vision. These characteristics include the scaling of the peak frequency of the spatial-tuning functions with letter size and the bandwidth of the tuning functions. The only difference between the fovea and the periphery is that for the same physical letter size, peak sensitivity of the spatial-tuning functions occurs at a higher retinal frequency at the fovea than in the periphery. To test whether or not the contrast sensitivity function (CSF) can account for the differences in the spatial-frequency characteristics of letter identification between central and peripheral vision, we incorporated a human CSF into an ideal-observer model, and tested the performance of this ideal-observer on the same letter identification task used with the human observers. Data from this CSF-ideal-observer resemble closely those of human observers, suggesting that the spatial-frequency characteristics of human letter identification can be accounted for by the CSF and the letter-identity information, without invoking selection among narrow-band spatial-frequency channels.

Contrast Sensitivity↗
PubMed1987

Temporal separation of two part-letter arrays and size changes in a nonmasking work-superiority effect.

In two experiments subjects were asked to report the identity of a position-cued critical letter in an array of four letters. Four types of arrays were used: (i) unpronounceable nonwords; (ii) pronounceable nonwords ('pseudowords'); (iii) words in which the critical letter was minimally constrained by the context letters; and (iv) words in which the critical letter was maximally constrained by the context letters. All four-letter stimuli were presented in two parts. A leading array in which the information from two quadrants of a vertical by horizontal division of each letter was presented, and, after intervals of 0, 20, 40, 80, 100, 120, 160, 320, and 480 ms and infinity (ie, no trailing array), a trailing array of the complementary letter parts. In experiment 1 a single group of eight subjects responded to the one hundred and sixty combinations of the four types of letter strings, the four serial positions, and the ten stimulus onset asynchrony values. In experiment 2 the stimulus onset asynchrony values were varied among subjects, with twelve subjects responding at each value. The results from these two studies were generally similar. Performance in the word conditions was consistently superior to performance in the nonword conditions, and the magnitude of this difference (ie, the word-superiority effect) increased with increasing stimulus onset asynchrony up to 120 ms, and then gradually declined. The fact that the magnitude of the word-superiority effect initially increased with the separation of leading and trailing arrays was interpreted as support for Johnston's suggestion that letters in words are represented during visual encoding both in the form of individual letter percepts and in a decay-resistant word percept, as opposed to letters in nonwords, which are represented only as decay-susceptible letter percepts. The experimental findings are discussed in relation to the 'interactive activation' model of word perception.

Cues↗
PubMed2003

Mechanisms of pure alexia: spatially based impairment, letter identification deficit, or both?

We studied reading performance for words and for isolated letters in a pure alexic patient. She performed reasonably well when naming isolated letters but was slower in reading letters than a control subject when reaction times (RTs) were recorded. When the patient read isolated letters, RTs were slower for a subset of letters that cannot be recognized from their left part alone (e.g. "b", an ambiguous letter, could be read "b" "h" "l" or "k" whereas "a" has no predictable confounders). We observed a significant positive correlation between the RTs for reading a word and the mean RTs for reading each of its composing letters before its uniqueness point (i.e. the point, when reading from the left to the right, where a word cannot be a word other than the one it is). This result suggests that, in our patient, the letter identification deficit can account for the slow, letter-by-letter reading behaviour, insofar as each letter represents a perceptual problem. Our findings can be accounted for by a deficit in the parallel processing of the left and right parts of each letter, compounded with a bias to process first the left part of the letter, and may thus reconcile the hypotheses of spatially-based deficit (Rapp and Caramazza, 1991) and of a perceptual deficit occurring at the letter identification level (Behrmann and Shallice, 1995; Perri et al., 1996).

Aged↗
PubMed2004

Do dermatology outpatients value a copy of the letter sent to their general practitioner? In what way and at what cost?

Dermatology services are largely outpatient based. Time for satisfactory patient communication is limited, with an average of around 15 min per new patient. The amount of new information that can be retained after verbal communication alone is limited during such consultations. One way to reinforce such information is to send patients a copy of the hospital specialist's letter to the general practitioner. Before advocating this unreservedly, it is important to explore the value patients attach to receiving such a letter and to estimate the cost of this practice. In order to explore patients' views of copy letters more fully, all patients attending dermatology outpatients at Queen's Medical Centre, Nottingham during a week in October 2001 were sent copy letters and later interviewed by telephone using a structured questionnaire that gathered information on content, usage, clarity and perceived usefulness. Direct costs were also calculated. Of 70 patients invited to participate, 59 (85%) could be contacted by telephone at the 2-week follow-up period. Of those 59 patients contacted by telephone, surprisingly only 46 (78%) had actually received a copy letter at 14 days post-consultation. Of the 46 patients receiving a copy letter, 45 (98%) thought the information in the letter was consistent with their consultation; the letter was read a mean number of two times; nine patients (20%) understood most and 36 (78%) all of the letter; 25 (54%) found it useful and a further 21 (46%) found it very useful. Patients' views as to the value in receiving the letter included improved communication, recall and a sense of increased involvement in health care decisions. The direct total cost of sending a copy letter was 25.3 pence per patient. Consultants who participated in the exercise did not perceive any additional difficulties in implementing this practice. This small study found that 100% of patients receiving a copy letter found it useful. The fact that around one-fifth of patients did not receive such copy letters within 2 weeks as intended is worrying, and requires further investigation. Sending a copy letter involves a relatively trivial cost for a practice which patients view as a valuable resource.

Ambulatory Care↗
PubMed2005

How much does a reminder letter increase cervical screening among under-screened women in NSW?

OBJECTIVE: To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months. METHODS: Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups. RESULTS: After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups. CONCLUSIONS AND IMPLICATIONS: Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.

Adult↗