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This study demonstrates that post-intervention, both African American and Caucasian study participants showed a decrease in emergency department visits and an increase in asthma self-management. This finding is especially important for African Americans, who face increasing asthma mortality and morbidity.

OBJECTIVE:To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN:A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING:Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS:A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION:Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS:Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50-75) or 2 years (if age 40-49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-todate with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI ؊ 5%, 7%) in one of the control clinics and ؊ 2% (95% CI ؊ 3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-todate with mammography increased over time and was consistent with a linear trend ( p ‫؍‬ .004). CONCLUSIONS:Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians' usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures. here is ample evidence that mammography is effective in detecting asymptomatic breast cancer and in decreasing mortality from this disease, 1-7 which will affect approximately 184,000 women in the United States. 8 Although population-based surveys have found that the proportion of women who have ever had a screening mammogram has been increasing, 9,10 a national survey in 1992 found that on average, only 45% of women over 50 had received a mammogram in the past year, 10 and approximately one third of women received regular screening. 10 These estimates are far below the goal for the year 2000 set by the United States Public Health Service. 11 Furthermore, managed care organizations and individual physicians are increasingly being evaluated by their adherence rates to practice g...

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