Outreach team builds system to head off screening cancellations
Phone calls alone didn’t significantly reduce screening mammography cancellations among underserved urban patient populations in a recent pilot project.
However, expanding available hours on top of calling with reminders did the equity-focused job with encouraging effectiveness.
So report Harvard researchers in a case study published online Sept. 14 in JACR [1].
Using an established QI methodology called Plan-Do-Study-Act (PDSA), radiologists Nita Amornsiripanitch, MD, of Brigham and Women’s Hospital, Adrian Jaramillo-Cardoso, MD, of Massachusetts General and colleagues began by convening a multidisciplinary team of radiology professionals.
Along with radiologists, technologists and a senior patient experience manager, the group’s roster included a patient service coordinator, a population health coordinator and a mobile mammography program manager.
The input of the latter two would be critical since a pre-project survey showed the highest rates of screening mammography cancellations in the Mass General Brigham system were at a mobile mammography unit and a community health center.
Both these sites serve high percentages of Medicaid beneficiaries, racial/ethnic minorities and women with limited English proficiency, the authors note.
Found and (Getting) Fixed: Language Barriers, Wrong Numbers, Integration Fails
Groundwork laid, Amornsiripanitch and colleagues turned to constructing a detailed plan for reducing screening mammography cancellations.
The case study breaks the plan into four action items. Stated as imperatives, these are:
1. Create a screening mammography process map. During the planning phase, this provided a visual aid for understanding the factors that contribute to a patient’s completing or cancelling a scheduled screening mammography appointment, the authors state. More:
The map prompted dialogue among team members, allowing the team to gain the patient’s perspective. This dialogue led to several important discoveries, including the lack of communication between EMR software used by radiology versus one used by community health centers.”
2. Use a ‘driver diagram’ to organize screening-mammography barriers into primary drivers of cancellation while fostering a group discussion about secondary drivers. Here the team identified five primary factors contributing to appointment completion or cancellation: patients’ knowledge about breast cancer screening, the appointment reminder process, cost, transportation and appointment availability.
The discussion of patients’ knowledge led the team to discover secondary drivers such as anxiety about breast cancer diagnosis and radiation concern. Similarly, discussion of appointment reminder process yielded discovery of secondary drivers such as language barriers and incorrect phone numbers in the medical record.”
3. Survey patients to validate previously identified barriers and understand each from a patient’s point of view. Project leaders administered the survey to 27 patients who called to reschedule over a two-week period. They found transportation led the list, followed by work schedule and not remembering the appointment date and/or time.
Of those who responded to the open-ended question ‘How can we improve your access to screening mammograms?’ some 74% (14 of 19) recommended increasing appointment flexibility with evening and weekend hours.”
4. Prioritize the most impactful test of change vis-à-vis effort and resources available. Given the frequency with which patients named transportation and work schedule conflicts as barriers to appointment completion, “expansion of [a] rideshare program and increasing screening mammography schedule flexibility were high priorities,” the authors write. The problem there: Implementing these solutions “would require additional IT infrastructure and staff recruitment (high impact/high effort).”
However, the second most common barrier, ‘not remembering appointment date/time,’ could be addressed by improving the appointment reminder process and readily implemented without significant resource constraints (high impact/low effort).”
Stacking Expanded Hours atop Unabated Reminders
After describing details of two key interventions, Amornsiripanitch and co-authors report the results.
- Over the first three weeks after introducing the first intervention—improving the phone reminder methodology by setting up radiology administrators with community health center EMR access—phone number accuracy increased from 58% to 94%.
- Successful appointment reminders—i.e., calls made, received and understood—increased from 21% to 59%.
- Improving telephone reminders alone did not significantly improve screening mammography cancellation rates over the first five months of observation (189 of 366, 51.6% per- vs. 1,200 of 2,182, 55.0% post-intervention), the authors report. All the same, they add, this intervention remained in routine clinical use “as a building block toward future improvement of the reminder system.”
- The second intervention—expanding appointment availability by offering screening mammography on weekends—demonstrated lower mean cancellation rate on piloted Saturdays (4 of 29, 14%) compared to that of weekdays (117 of 229, 59.2%), with zero cancellations on the last piloted Saturday. These results “validate the diagnostic data that patients desire more flexible screening mammography appointment hours,” the authors comment.
Planning for the long term, the team has begun creating digital communications that will combine appointment reminders with multilingual and “culturally concordant” educational information emphasizing the importance of screening mammography, the authors write.
‘Scalable Across the Health System and Beyond Radiology’
In their discussion Amornsiripanitch et al. acknowledge as a limitation their concentration on appointment cancellations and exclusion of unscheduled patients, “which is another area of missed care opportunity in need of attention.”
Also, they note, QI methodology relies on data from patients actively receiving care, “which limits the ability to capture data for an extended period or from large populations like in traditional research constructs.”
Nevertheless, the authors conclude, QI frameworks “provide opportunities for incremental changes and a rigorous evaluation process that is adaptable to work in health equity,” the authors state. “This experience provided radiology leadership with a framework to develop and expand programs to improve equitable breast imaging care delivery that is scalable across the integrated health system and other cancer screening modalities beyond radiology.”
JACR has published the paper in full for free (PDF).
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.