Redesigning Primary Care Processes to Improve the Offering of Mammography The Use of Clinic Protocols by Nonphysicians

McCarthy, Bruce D.; Yood, Marianne Ulcickas; Bolton, Mary Beth; Boohaker, Emily A.; MacWilliam, Cynthia H.; Young, Mark

doi:10.1046/j.1525-1497.1997.00060.x

Cited by 18 publications

(14 citation statements)

References 38 publications

(42 reference statements)

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“…One trial used chart reminders and controlled for insurance status (Chambers et al 1989), one used a chart flow sheet that required physician response but did not control for insurance status (Litzelman et al 1993), and one provided administrative assistance in completing radiology requisition forms for patients who were due for screening mammography (McCarthy et al 1997). In the latter study, the patient insurance profiles were similar at the intervention and control clinics.…”

Section: Screening Mammographymentioning

confidence: 99%

Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women

2007

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The authors conduct a systematic review of the literature to identify interventions designed to enhance breast cancer screening, diagnosis, and treatment among minority women. Most trials in this area have focused on breast cancer screening, while relatively few have addressed diagnostic testing or breast cancer treatment. Among patient-targeted screening interventions, those that are culturally tailored or addressed financial or logistical barriers are generally more effective than reminder-based interventions, especially among women with fewer financial resources and those without previous mammography. Chart-based reminders increase physician adherence to mammography guidelines but are less effective at increasing clinical breast examination. Several trials demonstrate that case management is an effective strategy for expediting diagnostic testing after screening abnormalities have been found. Additional support for these and other proven health care organization-based interventions appears justified and may be necessary to eliminate racial and ethnic breast cancer disparities. Keywords breast cancer; screening; diagnosis; treatment; race; ethnicity; interventionBreast cancer is the most common noncutaneous malignancy and the second most common cause of cancer death among U.S. women (Ries et al. 2005). With over 200,000 cases diagnosed each year, the lifetime risk of breast cancer among U.S. women is 1 in 8 (American Cancer Society 2005). Although breast cancer mortality declined by 2.3% per year between 1990 and 2002, racial and ethnic disparities increased during that time, primarily due to a greater decline in breast cancer mortality among white women compared to minority women (Jemal et al. 2004;Ries et al. 2005). Five-year female breast cancer survival is currently 87.5% among whites, 75.0% among blacks, 83.0% among Hispanics/Latinos, 89.4% among Asians/Pacific Islanders, and 79.6% among American Indians/Alaska Natives (Jemal et al. 2004).Disparities in breast cancer survival may be related to racial and ethnic differences at each stage of detection and management, including screening, timeliness of diagnostic testing after abnormal screening, quality of care during breast cancer treatment, and follow-up upon completion of breast cancer therapy (Aziz and Rowland 2002;McWhorter and Mayer 1987). No single element of care explains all of the mortality disparities. For example, breast cancer mortality remains higher among black women compared to white women despite evidence that screening mammography rates have been similar in these two groups since about 1993 ( Figure 1). In addition, compared to white women, Hispanic/Latino women have lower mammography rates and lower 5-year breast cancer survival, while Asian/Pacific Islander women have lower mammography rates and higher 5-year breast cancer survival (National Center for Health Statistics 2005;Jemal et al. 2004 (McPhee et al. 2002), these results suggest that screening mammography is only one of several factors important to racial/ethnic differen...

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Section: Screening Mammographymentioning

confidence: 99%

Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women

2007

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“…This approach has been successful in primary care settings, [14][15][16][17] and in a public hospital emergency department. 18 Some studies have used nurses to deliver screening recommendations; however, several studies involving minority populations have employed culturally sensitive lay health advisers in medical settings 19 and in the community.…”

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confidence: 99%

Increasing breast and cervical cancer screening in low-income women

et al. 1998

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OBJECTIVE:To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital.PARTICIPANTS: Women aged 40 years and over attending appointments in several non-primary-care outpatient clinics. INTERVENTIONS:Lay health advisers assessed the participants' breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS:Screening rates at baseline and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group ( p ‫؍‬ .009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group ( p ‫؍‬ .02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group ( p ‫؍‬ .006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group ( p ‫؍‬ .002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS:Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening.KEY WORDS: mass screening; vaginal smears; mammography; nurse practitioners; community health aides. J GEN INTERN MED 1998;13:515-521.S creening mammography and Pap smears have been shown convincingly to decrease breast and cervical cancer mortality. 1,2 Recent population-based surveys suggest progress toward the year 2000 goals in the general population for both breast and cervical cancer screening. 3,4 However, nonwhite women, older women, and those with lower incomes and less education generally have lower screening rates. [4][5][6] Strategies to improve screening rates in these groups are needed.Hennepin County Medical Center, the urban county teaching hospital in Minneapolis, serves many women from groups that are less likely to receive breast and cervical cancer screening. Preliminary reviews of the charts of women attending appointments in the general medicine clinic, medical subspecialty clinics, and surgical clinics, showed the lowest screening rates in women attending surgical clinics (K.L. Margolis, unpublished data). Primary care physicians have been urged to "put prevention into practice" with each patient contact, 7 but few specialists are prepared to utilize each patient contact this way. Physicianoriented interventions such as education, 8 feedback of screening rates, 9 checklists, 10,11 nurse-generated reminders, 12 and computer-generated reminders 9,13 have been modestly successful in increasing cancer screening in primary care setting...

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“…MAs spend considerable time with patients, averaging about one-half as much time with them as physicians do. 13,14 And MAs have successfully participated in other prevention programs, including mammography referral, 15 tobacco cessation, 16,17 and screening for domestic violence. 18 Recent proposals to transform primary care highlight the crucial importance of redefi ning practice roles to optimize teamwork and appropriate application of skills.…”

Section: Pro Gr a M To Pro M Ot E He A Lt Hy Behav Ior Smentioning

confidence: 99%

“…44 In the next iteration, considerably more resources will need to be devoted to MA training, fostering collaboration between MA-physician dyads 45 to support the referral program, and nurturing a group process for problem solving. 46,47 MA roles have been redesigned for many purposes, 15,48 but smoking cessation has been a frequent focus, most commonly by having MAs record smoking status as a vital sign. 49 A few trials have gone further, with MAs effectively delivering brief counseling messages.…”

Section: Pro Gr a M To Pro M Ot E He A Lt Hy Behav Ior Smentioning

confidence: 99%

A Medical Assistant-Based Program to Promote Healthy Behaviors in Primary Care

Ferrer¹,

Mody-Bailey²,

Jaén³

et al. 2009

The Annals of Family Medicine

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PURPOSE Most primary care patients have at least 1 major behavioral risk: smoking, risky drinking, low physical activity, or unhealthy diet. We studied the effectiveness of a medical assistant-based program to identify and refer patients with risk behaviors to appropriate interventions. METHODSWe undertook a randomized control trial in a practice-based research network. The trial included 864 adult patients from 6 primary care practices. Medical assistants screened patients for 4 risk behaviors and applied behaviorspecifi c algorithms to link patients with interventions. Primary outcomes were improved risk behaviors on standardized assessments. Secondary outcomes included participation in a behavioral intervention and the program's effect on the medical assistants' workfl ow and job satisfaction.RESULTS Follow-up data were available for 55% of participants at a mean of 12 months. The medical assistant referral arm referred a greater proportion of patients than did usual care (67.4 vs 21.8%; P <.001) but did not achieve a higher success rate for improved behavioral outcomes (21.7 vs 16.9%; P = 0.19). Qualitative interviews found both individual medical assistant and organizational effects on program adoption.CONCLUSION Engaging more primary care team members to address risk behaviors improved referral rates. More extensive medical assistant training, changes in practice culture, and sustained behavioral interventions will be necessary to improve risk behavior outcomes. INTRODUCTIONS moking, risky drinking, physical inactivity, and unhealthy diet are pervasive challenges to health across the world. 1,2 With its high population contact rate, 3,4 primary care is well-positioned to address unhealthy behaviors, but its historical development as a physician-centered acute care delivery system has hampered its ability to manage the large burden of unhealthy behaviors and the chronic diseases that follow. 5 Most practices confront behavioral risks with a very limited response set-physician assessment and management-creating a bottleneck limited by the fl ow of physician workload. 6,7 Better outcomes call for a model of primary care that manages population risk at the necessary scale. 8 Such management requires engaging other members of the primary care team and forging linkages with community resources that can amplify the practice's impact. 9 A framework for managing behavioral risks in primary care emerges from the concept of multiscale complexity. 10 Organizations that address complicated problems must perform an array of tasks that vary in complexity and scale. Complexity measures the degree to which tasks require independent judgment and customization to produce a good outcome. Scale quantifi es the number of tasks to be performed. An important principle in optimizing effi ciency, therefore, is to correctly design a system that can respond to its environment with both low-variety and low-complexity tasks delivered on a 505 PRO GR A M TO PRO M OT E HE A LT HY BEHAV IOR Slarge scale, and high-variety and hig...

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Redesigning Primary Care Processes to Improve the Offering of Mammography The Use of Clinic Protocols by Nonphysicians

Cited by 18 publications

References 38 publications

Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women

Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women

Increasing breast and cervical cancer screening in low-income women

A Medical Assistant-Based Program to Promote Healthy Behaviors in Primary Care

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