Black women die of breast cancer at a much higher rate than white women. Recent studies have suggested that this racial disparity might be even greater in Chicago than the country as a whole. When data describing this racial disparity are presented they are sometimes attributed in part to racial differences in tumor biology. Vital records data were employed to calculate age-adjusted breast cancer mortality rates for women in Chicago, New York City and the United States from 1980-2005. Race-specific rate ratios were used to measure the disparity in breast cancer mortality. Breast cancer mortality rates by race are the main outcome. In all three geographies the rate ratios were approximately equal in 1980 and stayed that way until the early 1990s, when the white rates started to decline while the black rates remained rather constant. By 2005 the black:white rate ratio was 1.36 in NYC, 1.38 in the US, and 1.98 in Chicago. In any number of ways these data are inconsistent with the notion that the disparity in black:white breast cancer mortality rates is a function of differential biology. Three societal hypotheses are posited that may explain this disparity. All three are actionable, beginning today.
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
Background: Insufficient access to mammography and early detection are contributing factors to the racial disparity in breast cancer mortality in Chicago (Chicago Breast Cancer Quality Consortium, 2010). Patient navigators provide information, support, and guidance that can help remove barriers to care and improve the quality of disease management for underserved patients (Vargas et al, 2008). The Metropolitan Chicago Breast Cancer Task Force developed a patient navigation program called Beyond October to provide free mammograms to uninsured and underserved women throughout Metropolitan Chicago. Our goal is to develop a replicable and effective means for patient navigation across multiple sites. Through navigation from Task Force staff, these women received timely and managed care through the screening, and if necessary, diagnostic and treatment processes. Methods: Nine facilities in various locations throughout Chicago donated free mammograms in order to meet our program's goal of 800 mammograms completed from November 1, 2012 to October 31, 2013. Participants were identified through community events, online applications, personal referrals, and referrals from other hospitals and organizations. To be eligible participants were over 40 years of age, uninsured and without symptoms. Eligible participants received culturally sensitive navigation throughout the screening and, if needed, diagnostic process from bilingual staff navigators. A staff navigator (4 navigators in total) verified the patient's eligibility prior to the patient completing intake and HIPAA authorization forms necessary to receive an appointment. Participants were navigated to a facility that was most convenient to their home address and received a packet of site-specific forms, as well as a voucher, to take to their appointment. Each patient received reminder and follow-up calls to assure appointment attendance. If the initial appointment was missed, a patient would receive one more attempt at attending the appointment. Navigators ensured appointments were scheduled, prior mammogram films were requested and obtained. After the appointment, results were communicated effectively and the necessary follow-up imaging and procedures were scheduled. Any patients requiring follow-up imaging and/or biopsies who did not receive their initial mammogram at a site that donated diagnostic mammograms, were referred to an IBCCP (state funded) facility. Women diagnosed with breast cancer received free treatment through the Treatment Act. Results: Based on preliminary data, a total of 662 mammograms were completed across nine Chicago facilities. From this pilot, successful outcomes were observed in the areas of client recruitment, communication of results, and care management for each woman. The program identified economic, language, and administrative /health system barriers as the main challenges faced by women. These barriers were addressed by: 1) providing access to free screening and diagnostic breast health care, 2) providing translation assistance for Spanish speaking clients, and 3) obtaining PCP orders and prior medical information to reduce health system barriers. Developing site specific protocols, providing patients with site specific forms, and having designated facility contacts decreased scheduling times and increased the rate of completion of the specific care plan for each participant. Delays occurred when medical information had to be sent across multiple sites, requests for prior medical history were not properly documented, and patients had a high number of forms to complete. Conclusion: A multi-site, culturally sensitive navigation program that takes into account both patient and facility needs can reduce screening barriers and increase access to quality breast health care for uninsured women. Citation Format: Jimmie Knight, III, Teena L. Francois. Beyond October: A multisite breast care patient navigation program. [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 B82. doi:10.1158/1538-7755.DISP13-B82
45 Background: Chicago black women are 62% more likely to die from breast cancer than white women. Previous data from 39 Chicago hospitals suggested significant variation in mammography quality (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. We compared improvement needs between high and low patient volume institutions. Methods: Using Deming’s PDCA cycle for continuous improvement, we created care process improvement recommendations for 25 Chicago institutions with the patient base averaging more than 50% minority patients (20 community, 3 academic and 2 public hospitals). Low mammography volume (< 5,000 mammograms/ year) was reported by 12 of the 25 sites. Recommendations are based on analysis across sites, literature, and input from institution staff. Thematic and statistical analyses were performed using simple frequencies and Fisher's exact test. Results: Improvement recommendations are classified into nine areas (see Table). We found that 100% (12/12) of low mammography volume institutions have specific improvement needs in 6 or more process improvement areas, as compared to 23% (3/13) of the high mammography volume institutions (p value > 0.0001). Conclusions: Lower volume mammography sites have a larger need for breast cancer care process improvements. [Table: see text]
Introduction: Screening mammography for early detection of breast cancer is subject to both false positive and false negative results. False positive mammograms subject women to unnecessary diagnostic imaging and biopsies that create a burden to the patient and costs to the health care system. False negative mammograms, on the other hand, result in the diagnosis of an “interval” cancer following symptoms and typically at a later stage than if discovered on the prior screen. Prior studies conducted in metropolitan Chicago suggested that differences in both mammogram image quality and quality of the interpretation of the mammogram might contribute to higher false negative rates (FNR) and higher false positive rates (FPR) for ethnic minority patients. We sought to examine predictors of FNR and FPR, and whether ethnic disparities might exist in these outcomes within a single, large healthcare organization. Methods: Screening mammograms during 2001-2009 were linked to incident breast cancer cases for the period 2001-2010 from the Illinois State Cancer Registry (ISCR) using probabilistic linkage methods. Screening mammograms were scored by the interpreting radiologist using the American College of Radiology Breast Imaging Reporting and Data System (BIRADS) and each mammogram was defined as negative (BIRADS 1,2) or positive (BIRADS 0,4,5); BIRADS 3 mammograms were excluded from these analyses. A false positive (FP) mammogram was defined as a screening mammogram with an abnormal interpretation which nonetheless did not result in a breast cancer diagnosis in the subsequent 12 months. A false negative (FN) mammogram was defined as a screening mammogram with a normal interpretation in a woman who nonetheless was diagnosed with breast cancer (“interval cancer”) in the subsequent 12 months. We examined patient factors (race/ethnicity, age at diagnosis, and breast density) and tumor characteristics including hormone (estrogen and progesterone) receptor (ER/PR) status, tumor grade, and behavior (in-situ vs. malignant) and their association with FNR and FPR. Results: A total of 669,222 screens were included in this analysis and 4,058 breast cancer cases were diagnosed in the 12 months subsequent to each screening mammogram (3,071 screen-detected and 988 interval cancers). Overall, the false negative rate was 24.3%. As expected, the FNR decreased with increasing age, and increased with increasing breast density. Also as expected, FNR was higher for ER-/PR- breast cancer than other forms (31% vs. 25%, p=0.01), was higher for high grade/undifferentiated tumors and was higher for malignant than in situ tumors (27% vs. 19%, p <0.001). Contrary to expectation, however, FNR was higher in White than African Americans patients (26% vs. 20%, p<0.001); and FNR was higher for digital than analog mammograms (27% vs. 23%, p=0.001). With regards to false positive rate (FPR), FPR was 12.6% overall. As hypothesized, FPR was slightly higher in African Americans compared to Whites (14% vs. 11%, p=0.014), and higher for mammograms performed on women with heterogeneously/extremely dense versus less dense breasts (14% vs. 11%, p<0.0001). Conclusion: Contrary to expectation, we did not find a racial disparity in the probability of a false negative mammogram, though we did find a modestly increased false positive rate in ethnic minorities. Radiologists in this organization are provided feedback on the quality of their screening interpretations on a regular basis, and this quality control program may be responsible for leveling the quality of screening mammography by race/ethnicity. Citation Format: Firas M. Dabbous, Garth Rauscher, Terry Macarol, Jenna Khan, Therese Dolecek, Sally Friedewald, Teena Francois, Tom Summerfelt. Examining racial/ethnic disparities in mammography screening performance in a single, large healthcare organization. [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 B74. doi:10.1158/1538-7755.DISP13-B74
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