BREAST CANCER SCREENING

Hitting the Road With Screening Programs

Despite recommendations from physicians, public health officials, and the media, many women still don't receive screening mammograms. Besides implementing reminder and education programs, this plan implemented mobile mammography screening. If women weren't coming in for mammography, the plan decided that it would just have to take the service out to them.

Breast cancer is the second most common type of cancer among American women. Approximately 180,000 new cases are reported each year. Women who have their breast cancer detected early have more treatment choices and a better chance for survival. Recognizing the importance of early detection, this plan began an aggressive program to remove barriers to screening.

The plan used HEDIS 2.5 (and 3.0) methodology throughout the activity. The targeted population consisted of women between the ages of 52 and 64 (it expanded in 1996 to include women up to 69 years of age). The measure used was the percentage of women who had received at least one mammogram during the preceding two years. Baseline measurement from 1993 showed that only 61.5% of women received a screening mammogram.

The plan initially chose a benchmark of 83%, the highest reported rate of the 21 plans participating in the NCQA Report Card Pilot Project. The plan's quality improvement committee (QIC) established a performance goal of 75%.

The plan began its initiative with careful research. In 1994, it convened focus groups to determine why women were reluctant to have mammograms. The barriers most cited by the women were fear of the procedure and inconvenient access. The awareness of these barriers subsequently determined the course of the overall initiative.

The plan's initial efforts addressed awareness and education. The plan:

• placed articles in member and provider newsletters to promote awareness
• offered a CME program on improving the quality of physician communication with female patients
• mailed shower cards that outlined how to perform a breast self-exam to the targeted population

The first remeasurement, based on 1994 data, showed a breast cancer screening rate of 60.6%. This rate was statistically no different from the baseline value. The QIC was not surprised by the lack of improvement; it felt that the interventions had not been in place long enough.

CYCLE TIME Although HEDIS measures are reported yearly, meaningful improvement can take longer than a single year. A thorough barrier analysis can help reassure a plan that it is heading in the right direction. Knowledge that interventions need time to work can help prevent tampering with efforts that ultimately yield success.

To further understand barriers to improvement, the plan conducted a survey of members who did not receive mammograms. With a response rate of 12%, the results revealed the top five reasons for noncompliance:

• no history of breast cancer in family
• the procedure is painful
• not aware that the plan benefits covered the cost of mammograms
• did not have time
• did not know how to obtain a referral

Using this information, the plan established a QI work team to develop an improvement plan. The result was an aggressive intervention effort that addressed the access issue. The plan began to provide mobile mammography services at the work sites and offices of major employer groups. It gave information on the mobile mammography services to employers and encouraged them to make arrangements for work-site mammography services.

VALUE Purchasers of health care are searching for value. Although this health plan initially had to bear the cost of the mobile mammography effort, the popularity of the program demonstrated its value to employers. Ultimately, it was able to share the cost of the service with employer groups.

The plan also mailed birthday card reminders to women emphasizing the importance of mammography screening. These reminders included:

• a list of participating mammography locations
• suggestions that women seek an annual clinical breast examination
• a recommendation for monthly self-examinations
• a bilingual hanging shower card describing how to perform breast self-examination
• information about how to access plan services
• information dealing with possible fears

The plan also sent a mailing to primary care physicians (PCPs). These mailings included:

• individual mammography screening results from the prior year
• a list of their members who had not obtained a mammogram
• a template letter, which the PCPs were encouraged to use for notifying members of the need for a mammogram
• chart labels to remind PCPs to schedule mammograms

The second remeasurement, based on 1995 data, revealed a screening rate of 64.4%. This was a statistically significant increase over the prior year and the baseline year.

NETWORK COMMUNICATION Throughout this initiative, the plan informed its providers of interventions. They found it prudent to send copies and explanations of member mailings to clinicians prior to mailing the information to the members. In the case of the coupons, the plan notified both the PCPs and the radiology centers of the mailing, and the radiology centers agreed to accept the coupon in lieu of a referral. The radiology centers were able to adjust staffing to handle the increase in appointment requests, and the PCPs were prepared for members calling for their results and follow-up visits.

The QIC decided to continue the present interventions, with one change. The birthday card reminders were replaced with a coupon ''good for one screening mammogram.'' These coupons, which substituted for referrals, were sent to women who had not had mammograms in the previous 20 months. Accompanying the coupon was a list of sites where mammograms were performed. The plan notified the PCPs and radiology providers of this mailing so they could prepare for the increase in appointment requests.

With these interventions firmly in place, the plan saw another increase in its screening mammography rates. Using 1996 data and HEDIS 2.5 methodology, it calculated the rate to be 69.2%, another statistically significant improvement. In order to facilitate comparisons in the future, the plan also recalculated its rate using HEDIS 3.0 methodology.

The plan maintained all of its previous interventions, plus it mailed report cards to PCPs, providing them with a comparison of their individual rate to the plan-wide performance goal.

In 1997, the plan decided to reevaluate its benchmarks. It used two health plans as benchmarks; one was a group model (benchmark = 81.2%) and the other an IPA (benchmark = 78.5%). Both plan benchmarks were obtained from the 1997 NCQA Quality Compass.

The remeasurement using 1997 data indicated a rate of 67.9%, statistically no different from the previous year's measurement. Based on this result, the plan's staff decided to take additional steps to determine why some women continue to decline mammography screening. At the end of 1998, members who consistently did not receive a mammogram were mailed a barrier analysis survey. The plan intends to use the results of this survey to develop additional interventions specifically aimed at encouraging this group of women to seek care.

The plan intends to continue to pursue its goal, utilizing this additional data analysis to determine why some women are unwilling to have a mammography screening. The plan's strategy is to identify those women and to develop appropriate interventions to address their concerns.