BREAST CANCER SCREENING

Improving Access and Awareness

In 1996, 184,300 new cases of breast cancer, and 44,300 deaths, were projected among women in the United States. [1] Screening reduces mortality from breast cancer by at least 30 percent among women age 50 and older. [2] Unfortunately, more than 30 percent of malignant tumors present in advanced stages, reducing the effectiveness of even the most aggressive treatment regimens. [3]

With 14.5 percent of female members in the age range recommended for screening mammography, the plan felt that breast cancer was not only a high-risk diagnosis, but one of importance to a significant portion of its population. Plan-specific data showing 631 members with a diagnosis of breast cancer reinforced the desire to improve secondary prevention efforts. The plan hoped to reduce the number of tumors presenting in advanced stages, as well as breast cancer mortality rates, by increasing the number of women receiving regular mammograms.

The plan used HEDIS criteria to identify women in the target population for screening mammograms. At first, this included women age 52 to 64, continuously enrolled with the health plan for two years. In 1996, the measure changed to include all women age 52 to 69, continuously enrolled with no greater than a 45-day break in enrollment.

The performance measure, using HEDIS specifications, was the percentage of women who had received a screening mammogram in the last two years.

The plan used a hybrid system of data collection, using administrative and medical records data to determine a rate for a simple random sample. Baseline data, from a two-year period encompassing 1993 to 1994, showed a mammography rate of 62.1 percent.

The plan cited a benchmark from the 1996 edition of NCQA's Quality Compass. It used the combined average regional rate of 70.2 percent. The plan defined its goal as statistically significant improvement towards the Healthy People2000 goal of 80 percent.

The plan identified a number of barriers to women obtaining a mammogram screening. These included:

• Embarrassment: women must get undressed from the waist up, and are self-conscious
• Fear: women fear the test results, stating that they would rather not know
• Discomfort: the procedure is uncomfortable; some women report significant pain
• Lack of knowledge: women may not be aware that the test is covered by the plan
• Physician oversight: physicians may not recommend the test
• Access/convenience: access to facilities that offer mammograms may be limited or at inconvenient locations

CORPORATE RESOURCES As a member plan of a large national managed care organization, this plan made use of a corporate research group. During its activities, the research arm uncovered information on barriers to screening mammography. It communicated these findings to the regional plan.

The plan continued a number of ongoing interventions, as well as implementing new ones designed to address the identified barriers.

Birthday reminder cards were sent to women age 50 and older in two of the five market areas. Reminder calls to women over 50 were placed during the evenings and on weekends in one market area. These calls were followed up with a letter to the member from the medical director. (Sample script for calls is included in QP Tool ; sample letter from medical director is included in QP Tool .)

Revised preventive health guidelines were published in member newsletters and sent to all providers.

One market area set up six mobile mammography sessions at several large companies with a high number of female employees.

The first remeasurement, based on data from 1994 to 1995, documented a rate of 66.1 percent, an increase of four percentage points, and a statistically significant improvement.

The plan felt that the increase showed that it was possible to improve rates. However, it felt that the access barrier might have been stronger than originally anticipated. It took additional steps to increase the numbers of mobile mammography sites and access to gynecological services.

The plan held a number of worksite mammography screenings at three large employers. It recruited and credentialed a total of 96 new gynecology practitioners and increased the numbers of preferred mammography sites.

Targeted reminder mailings and phone calls continued. The plan developed an "on hold" telephone message about the need for screening mammograms.

The second remeasurement, based on 1995 to 1996 data, showed a 68.3 percent screening mammography rate, according to HEDIS 3.0 methodology (which equated to a 68.9 percent rate according to the HEDIS 2.5 methodology used in previous years).

This represented a statistically significant improvement over both the previous year and the baseline measurement.

The plan sought additional knowledge about why some women failed to get mammograms. It performed a brief survey of its members (included in QP Tool ). Results showed that women were leading busy lives. In a time crunch, one of the things they failed to do was get around to having a mammogram. This caused the plan to continue its focus on access issues. It opened direct access to OB/GYN practitioners in two market areas. Letters to members informed them of the need for a mammogram and that they did not need a referral (included in QP Tool ).

It added an additional 223 gynecologists plan-wide. Letters from the medical director to all providers stressed revised guidelines for mammography screening (included in QP Tool ).

The plan began focusing mobile mammography services on a target list of clients with 50 or more female employees over the age of 35.

The third remeasurement, based on 1996 to 1997 data, showed a mammography screening rate of 70.6 percent. This rate exceeded the plan's benchmark and represented a statistically significant improvement over the baseline measurement. Improvement over the previous year approached, but did not reach a level of statistical significance.

The plan has continued its efforts to maintain and increase mammography screening. The entire region adopted a policy of not requiring a referral to visit a gynecologic provider. The plan continued its reminder programs and mobile mammography screenings. It maintained its expanded network of gynecologists. The plan looks forward to 2000 data showing sustained improvement.

[1] - Department of Health and Human Services, Centers for Disease Control and Prevention, "Breast Cancer Incidence and Mortality-United States 1992," Morbidity and Mortality Weekly Report, 45 no. 39 (Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, August 22, 1997), 835-837.

[2] - "Cancer Facts and Figures,"In Cancer Facts and Figures [page on website of the American Cancer Society]. Atlanta, GA 1998 [cited January 30, 2001]. Available from www.cancer.org; INTERNET.

[3] - "Breast Cancer Reducing Mortality Through Early Detection," In Medscape.com [online database]. Hillsboro, OR 1996 [cited January 30, 2001]. Available from www.medscape.com; INTERNET.