Physician Recruitment for a Community-Based Smoking Cessation Intervention
Eighty percent of recruitment came from Phase 3, from phone calls by the physician recruiters. Approximately two thirds of study participants were recruited by the principal investigator. However, the ground work from publicity, endorsements from physician leadership, and familiarity with the aims of the trial were clearly important in getting agreement during the recruitment phone call.
Among all eligible physicians, 81% (N=259) were successfully recruited into the study: 80% (n=106) of targeted control area physicians (Providence/Bristol); 85% (n=88) of physicians in the first intervention area (Newport/Washington); and 77% (n=65) of physicians in the second intervention area (Kent) were enrolled. Characteristics of the sample are displayed in Table 1.
The 18% of physicians who refused to take part cited the following reasons for not participating: (1)they preferred not to participate in studies or fill out surveys; (2) they had a shortage of resources and did not have the time; (3) they were undergoing significant staff turnover or felt that their office staff were already overburdened; (4) they felt they were already providing effective smoking cessation interventions to their patients; or (5) they did not accept smokers into their practice. Chi square tests indicated that refusers were significantly more likely to be male (F=6.5, P < .05) and to have been out of medical school for more than 25 years (F=20.7, P < .001). Less than 5% of eligible female physicians refused to participate as compared with 21% of men. Medical specialty did not have a significant impact participation in this study.
Discussion
Results of the multi-faceted recruitment approach used in the Physicians Counseling Smokers project demonstrate that it is feasible to enroll a population-based sample of primary care physicians into a dissemination trial. We were successful at recruiting a representative sample of community-based physicians. It was our goal to saturate our target geographic area to obtain a truly population based sample. We succeeded in achieving this, recruiting 81% of eligible physicians. It is noteworthy that we were able to retain 88% of enrolled physicians at the end of the 3-year study period. This reinforces that physicians were willing and able to keep their minimal commitment to complete the annual assessments. The most common reason for drop out was leaving the practice/moving out of state.
Recruiting physicians and practices into community-based trials is a challenging process, and several investigators have examined the effectiveness of different recruitment strategies. Recruitment efforts have evolved from a single mailing method to a multi-stepped process. Kottke and colleagues13 assessed and compared mailed recruitment methods for primary care physicians in Minnesota for a 1-month office-based smoking intervention. Eligible family medicine physicians (n=1100) were mailed a brochure alone or a brochure with an explanatory letter signed by one of the investigators on university letterhead or by an investigator on a state Academy of Family Physicians letterhead. Ten percent of eligible physicians responded and no difference between brochure alone or brochure plus letter groups. In a second study, the brochure only mailing strategy was used again to recruit 1108 general internists and cardiologists on the mailing list of a state Medical Association into a one-year trial. Five percent responded and 2.7% participated. Dietrich and colleagues14 used a multi-faceted approach to recruit community-based physicians into a randomized trial to increase cancer prevention practices. Of 628 eligible family physicians and internists in Vermont and New Hampshire, 234 physicians (37%) agreed to participate. Physicians with name recognition in their communities assisted with recruitment Table 2.
Since PCS was conducted, recruitment strategies targeting community-based individual physicians and practices for cancer prevention studies have evolved from single mailing techniques to more common use of multi-step approaches, including face-to-face visits, advisory boards, and physician phone calls Table 3. Participation incentives including honorarium, office staff trainings, and patient materials are often included to enhance recruitment rates,25,26 but even substantial physician incentives do not guaranteed high participation rates.10
In reviewing these studies, it is difficult to assess the impact of each specific recruitment strategy used. However, the in-person appearance of the principal investigator, a physician, appeared to have a major impact on physician enrollment. Earlier studies7,13 producing lower recruitment rates did not involve this in-person meeting component, and Asch’s review of physician recruitment studies supports the importance of personal contact. Two recent community-based physician office recruitment trials included in-person office visits.25,26 In addition to office and clinic visits, in PCS the principal investigator was also present at hospital departmental meetings and gave grand rounds at these hospitals.
Another successful strategy demonstrated in PCS was involvement of the principal investigator in calling physicians who were difficult to recruit. Although nonphysician PCS research staff made concerted efforts to assist with recruitment, their access to the physician by phone was often limited by gatekeepers within the office. PCS demonstrated that, although time intensive and costly, the use of a physician recruiter may be necessary to recruit a representative sample, for example, with at least 75% of eligible physicians, into a dissemination trial. Although difficult to assess the impact of the impact of these preliminary phases, it was also evident that the work completed in Phases 1 and 2 created familiarity and laid the groundwork for the Phase 3 calls.
