BREAST CANCER SCREENING

Raising Member and Physician Awareness

When baseline measurements indicate a severe problem, many health plans immediately focus on improving their performance. But when baseline data indicate that performance is already average or above, they are often less interested. This health plan did not focus its efforts in an area where performance was unusually poor. It focused on an area where performance was unusually important.

By 1994, the plan's staff and practitioners had already become concerned about an increasing number of breast biopsies and cases of breast cancer. Some of these cases might have been treated more successfully if they had been identified earlier. Death from breast cancer can be significantly reduced by identifying and treating the cancer as soon as possible. Breast cancer is the most common cause of death from cancer for women aged 40 to 50 years. It accounts for 46,000 deaths each year in the U.S. With these statistics in mind, the plan set out to improve its performance in breast cancer screening.

The plan used HEDIS methodology throughout this activity. It used the mammography screening (later called the breast cancer screening) measure. It targeted its commercial population, looking at the percentage of women aged 52 to 64 years who received a mammogram in the last two years.

Baseline data from 1993 revealed that 65.4% of the selected women had received a mammogram in the past two years. The plan's performance already exceeded the Healthy People 2000 goal of a 60% screening rate. For a benchmark, the plan chose 77%, the grand mean for plans participating in NCQA's 1993 Report Card Pilot Project. The quality improvement team, which included 12 physicians, chose a performance goal of 75%.

In 1994, the plan began its initiative with interventions devoted to raising member awareness of the importance of breast cancer screening. During Breast Cancer Awareness Month, the plan placed focused articles in the member newsletter, supported community activities, and provided member educational materials, which included a list of its mammography facilities with its business hours.

The plan introduced a number of interventions that remained constant throughout the years of the activity:

• educational articles in newsletters for practitioners, providers, and members
• community-wide efforts to encourage women to have mammograms
• distribution of preventive health guidelines to members and practitioners
• reminder cards for women

MISSED-OPPORTUNITY LISTS One of the strongest interventions taken by this plan was its use of missed-opportunity lists. Responses from physicians showed that many took action by contacting members, either by scheduling appointments or encouraging their patients to make appointments as soon as possible. Some physicians even wrote letters to the quality improvement team, sharing their opinions, ideas, and suggestions for promoting women's preventive health activities.

Data from 1994 showed statistically significant increase in breast cancer screening rates to 70.1%. This result encouraged the plan to continue its interventions. It targeted the population of women identified as not having been screened for breast cancer.

In December 1995, the plan initiated the distribution of missed-opportunity lists for primary care physicians (PCPs) and gynecologists. The plan sent PCPs and gynecologists lists of all their patients who were identified as not having had a screening mammogram within the past two years. Each physician was first asked to determine the accuracy of the list. Where the plan's data appeared to be correct, physicians were asked to contact the members and encourage them to come in for mammography. Sending lists to both PCPs and gynecologists made it harder for women to evade or ignore promptings from their physicians.

Data from 1995 showed a breast cancer screening rate of 70%, not a statistically significant change from the previous year.

In late 1996, the plan revised its reminder cards. Realizing the importance of eye-catching, timely, and personalized attention, it began sending attractive, colorful birthday greeting cards in envelopes - with enclosed reminders to make an appointment for a mammogram. These cards also contained shower hangers that described how to perform a breast self-exam, and lists of mammography facilities, along with their business hours.

The plan's staff continued its educational interventions with member newsletter articles. It revised the plan's preventive health services guidelines and mailed these to the appropriate practitioners.

FUNDING Much of this program cost very little to implement. The newsletter articles required no new expenditures. Similarly, the postcards, greeting cards, and the missed-opportunity reports were low-cost items. The direct cost was less than $0.75 per birthday mailing. Although most of the human resources were in place prior to the interventions, some additional clerical help was needed to handle the mailing of cards, lists, newsletters, and letters.

Data from 1996 were run with both HEDIS 3.0 criteria and HEDIS 2.5 criteria. HEDIS 2.5 allowed the plan to compare its results to 1995 data, while HEDIS 3.0 allowed it to compare its 1996 results with other plans.

The 1996 breast cancer screening rate, using HEDIS 2.5 specifications, was 72.8%. This represented a statistically significant increase.

The plan's staff continued with most of the previous interventions, including the Breast Cancer Awareness Month activities, the distribution of missed-opportunity lists, and the birthday greeting card mailings. The main addition to the program in 1997 was the distribution of preventive health guidelines to all members and in all reenrollment packets.

The plan's 1997 data, using HEDIS 3.0 specifications, demonstrated a breast cancer screening rate of 75.3%, an increase of almost ten percentage points from the baseline.

The 1997 data also revealed a new area for improvement in the Medicare population, where the breast cancer screening rate was only 61.3%.

This plan's future challenges are to sustain the improvements made in the commercial population and to find ways to achieve the same high rates for their new Medicare and Medicaid members. These groups may present new and different reactions to preventive health screening.