OBJECTIVE A high quality screening mammography program should find breast cancer when it exists, when it’s small, and ensure that suspicious findings receive prompt follow-up. The Mammography Quality Standards Act (MQSA) guidelines related to tracking outcomes are insufficient for assessing quality of care. We used data from a quality improvement project to determine whether mammography screening facilities could show that they met certain quality benchmarks beyond those required by MQSA. METHODS Participating facilities (N=52) provided aggregate data on screening mammograms conducted in calendar year 2009 and corresponding diagnostic follow-up, including lost to follow-up and timing of diagnostic imaging and biopsy, cancer detection rates, and the proportion of cancers detected as minimal and early stage tumors. RESULTS The percentage of institutions meeting each benchmark varied from 27% to 83%. Facilities with American College of Surgeons or National Comprehensive Cancer Network designation were more likely to meet benchmarks pertaining to cancer detection and early detection, and Disproportionate Share facilities were less likely to meet benchmarks pertaining to timeliness of care. CONCLUSIONS Results suggest a combination of care quality issues and incomplete tracking of patients. To accurately measure quality of the breast cancer screening process, it is critical that there be complete tracking of patients with abnormal screening mammograms so that results can be interpreted solely in terms of quality of care. The Mammography Quality Standards Act guidelines for tracking outcomes and measuring quality indicators should be strengthened to better assess quality of care.
Black women present with later stage breast cancers compared to white women, and their cancers are more likely to be larger, receptor negative, and undifferentiated. This study evaluated black:white differences in the stage and biology of breast cancer among women who had a screening mammogram at one of two Chicago academic medical centers within two years of the breast cancer diagnosis (regularly screened) and compared them to the black:white differences in the stage and biology of breast cancer in women who had not received mammographic screening within two years of a breast cancer diagnosis (irregularly screened.) There were no significant black:white differences in the proportion of early breast cancers (black = 74 %; white = 69 %, p = NS) in the regularly screened population or in the irregularly screened group (black = 60 %; white = 68 %, p = NS.) The regularly screened population received significantly more mammograms (58 % ≥4 mammograms) compared to the irregularly screened population (41 % ≥4 mammograms.) Black women in the regularly screened population were less likely than irregularly screened black women to have estrogen negative breast cancers (26 vs. 36 %, p < .05), progesterone negative breast cancers (35 vs. 46 %, p < .05), and poorly differentiated breast cancers (39 vs. 53 %, p < .05.) White women in the irregularly screened population also had worse prognostic factors than white women in the regularly screened population, though these were not statistically significant. Regular mammographic screening can contribute to the narrowing of black:white differences in presentation of breast cancer.
6120 Background: Chicago Black women are 62% more likely to die from breast (BC) cancer than White women. Previous data from 39 Chicago hospitals suggested significant quality deficits in breast cancer screening and treatment (Chicago Breast Cancer Quality Consortium, 2010). Patient tracking, follow up and referral practices may influence quality of care for minority women (Mojica et al, Cancer Control, 2007). Our goal is to evaluate tracking, follow up and referral practices during screening, diagnosis and treatment of BC at Chicago hospitals servicing Black women. Methods: Using the framework approach of qualitative research, we conducted interviews with providers of BC screening and care from 20 Chicago institutions with Black patients averaging 50% of patient base (15 community, 3 academic and 2 public hospitals). Informants included surgeons, medical oncologists, radiologists, mammography technicians, internists, nurses, administrators, and patient navigators. Interviews were transcribed, and thematic and statistical analyses were performed (simple frequencies and Fisher's exact test). Results: Six of the 20 sites (30%) follow up with patients who did not show for a scheduled mammography visit. Five of these sites (83%, 5/6) have a low “no-show” rate (below 20%), compared to 4 sites (29%, 4/14) with low “no-show” rates among the 14 sites without follow-up (p=0.05). Seven of the 20 sites (25%) direct diagnosed patients to their next step in care by providing referrals and guidance, while other 13 sites rely on a primary care physician or leave the patient without a clear care plan. BC patients at 6 of the 7 sites directing care (83%, 5/6) are referred to a mid- or high-volume surgeon (3+ BC surgeries / month), compared to patients from only 1 of the 13 sites not directing care (p=0.001). Nine of the 20 sites track diagnosed BC patients through their care. Five of them (56%, 5/9) also track survivors, compared to none (0%, 0/11) of the 11 sites who do not track patients (p=0.008). Conclusions: Poor tracking, follow up and referral practices for breast cancer screening and treatment are associated with suboptimal care and may contribute to outcome disparities for Black women in Chicago.
Background: The death rate from breast cancer for black women in Chicago, Illinois is 62% higher than for white women, and is much higher than the U.S. disparity of 41% and the New York City disparity of 27% (Sinai Urban Health Institute, 2010). The Chicago Breast Cancer Quality Consortium, funded by Susan G. Komen for the Cure Foundation, previously collected data from 43 Chicago hospitals identifying significant quality deficits in breast cancer screening and treatment (Chicago Breast Cancer Quality Consortium, 2010). Women with a BRCA1/2 mutation have a significantly higher risk for breast and ovarian cancer. While most primary care physicians are aware of BRCA testing, only a minority follow guidelines for BRCA evaluation (Bellcross CA, et al 2011). Our aim was to examine the collection of personal and family cancer history during breast cancer imaging and the resulting referrals to genetic counseling/testing that are or are not initiated from the breast imaging care process. Methods: We conducted 113 semi-structured interviews with cross-discipline providers involved in breast cancer screening and care. These interviews were across 26 institutions including 18 community, 4 academic, and 4 public hospitals in the Chicago metro area. Participating institutions provide care to diverse populations. For 22 institution's, African American and Hispanic women comprised more than 50% and for the other 4 institution's more than 30% of the patient population. 10 of the participating community hospitals are classified as low resource. Interviewees included: radiologists, mammography technologists, nurses, surgeons, medical oncologists, internists, administrators, registrars and patient navigators. Interviews were transcribed, thematic analysis was conducted following the framework approach, and statistical analysis was performed using simple frequencies and Fisher's exact test. Results: All (26/26) institutions ask patients at breast cancer screening about their personal and family breast cancer history. One (1/26) institution had a process to refer breast screening patients with a personal or family history to genetic counseling. 10 institutions (38%) had access to genetic counseling within their organizations. Of institutions with internal access to genetic counseling, 80% (8 of 10) referred diagnosed breast cancer patients with familial or personal history to genetic counseling/testing as compared to 31% (5/16) of institutions that do not have internal access to genetic counseling (p=0.0414). Conclusions: While all institutions collected personal and family history of breast cancer, only one institution had a process for and regularly referred appropriate high risk breast screening patients to genetic counseling/testing. Several of the breast imaging centers are now considering methods to implement genetic counseling referrals in their screening protocols. The biggest challenge the institutions noted was not having a clear place to send the patients for genetic counseling. Further research is needed to investigate factors of access to genetic counseling and testing for low resource hospitals serving diverse populations, as well as to develop the needed services and care processes for all institutions participating in our Consortium. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A38.
Background: In Chicago Black women are 62% more likely to die from breast cancer than White women. Previous data from 39 Chicago hospitals suggested the existence of significant variation in mammography quality across facilities (Chicago Breast Cancer Quality Consortium, 2010). We developed process improvement recommendations for sites that participated in our care process assessment (Weldon CB, et al, ASCO-Abstract-6120-2012). This study was funded through a generous grant from the Susan G. Komen for the Cure Foundation. Appointment reminder calls and follow-up calls to patients that do not attend their appointments are effective in increasing breast cancer screening and diagnosis completion rates of (Goel A, et al, JHCPU 2008). We provided technical assistance to implement breast imaging care process improvements and compared pre and post process improvement appointment no-show rates and follow-up call rates at 14 sites. Procedures: Using Deming's PDCA cycle for continuous improvement, we created care process improvement recommendations for 27 Chicago institutions with the patient base averaging more than 50% medically underserved patients (22 community, 3 academic and 2 public hospitals), 17 of the sites are safety net institutions. Recommendations were based on analysis across sites, literature, and input from institution staff. We provided 14 of the sites with technical assistance to implement “rapid cycle” care process improvements (RCI sites). Sites were selected for technical assistance based on their need and their commitment to improving breast imaging care processes. Thematic and statistical analyses were performed using simple frequencies, and McNemar's test. Summary of Results: Detailed results are shown in the table below. Technical assistance was utilized by 14 of 17 safety net sites (RCI sites) to which it was offered. 10 sites adjusted their processes to conduct appointment reminder calls to patients. 12 sites implemented processes to conduct follow up phone calls with patients who missed an appointment, with a focus on answering patient questions and to schedule a new appointment. 6 sites adjusted their processes to conduct phone calls to inform patients of abnormal breast screening results (BIRADS 0, 4, 5) in addition to sending each patient a letter (MQSA requires at least a letter). Working with the 14 sites resulted in an improvement in no-show rates from 29% to 21%. Appointment reminder call: baseline 48% (13/27) all sites, 21% (3/14) RCI sites post-improvement 85% (23/27) all sites, 93% (13/14) RCI sites pvalue = 0.0044, Chi squared: 8.100 w 1 degree of freedom Call no-show patients : baseline 19% (5/27) all sites, 0% (0/14) RCI sites post-improvement 63% (17/27) all sites, 86% (12/14) RCI sites pvalue = 0.0015, Chi squared: 10.083 w 1 degree of freedom Call to follow up with patients who have abnormal results: baseline 56% (15/27) all sites, 50% (7/14) RCI sites post-improvement 78% (21/27) all sites, 93% (13/14) RCI sites pvalue = 0.0412, Chi squared: 4.167 w 1 degree of freedom No show rate for screening mammograms baseline 22% all sites, 29% RCI sites : post-improvement 18% all sites, 21% RCI sites Conclusions: Conducting phone calls to remind patients about appointments improves no-show rates at sites that care for the medically underserved. Further analysis may show a reduction in loss-to-follow-up for sites that implement follow up phone calls to patients who miss appointments and to patients who need additional diagnostic assessment. Findings from this study have generalizable application to health facilities beyond breast imaging sites. Given persistent and growing disparities in health outcomes for vulnerable populations and the limited resource availability; these findings suggest that implementation of basic patient tracking strategies have substantial benefit to improve patient outcomes and health care quality. Citation Format: Christine B. Weldon, Teena L. Francois, Julia R. Trosman, Betty Roggenkamp, Danielle M. Dupuy, Jimmie T. Knight, David A. Ansell, Anne Marie Murphy. Do patient follow-up improvements, at hospitals caring for medically underserved patients, impact no-show rates. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A84. doi:10.1158/1538-7755.DISP13-A84
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