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The American Journal of Managed Care December 2012
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Population-Based Breast Cancer Screening in a Primary Care Network

Steven J. Atlas, MD, MPH; Jeffrey M. Ashburner, MPH; Yuchiao Chang, PhD; William T. Lester, MD, MS; Michael J. Barry, MD; and Richard W. Grant, MD, MPH
A health information technology system designed to facilitate population-based breast cancer screening increased mammography rates in overdue women beyond rates achieved with office-based reminders alone.
Objectives: To assess the ability of a health information technology system to facilitate population- based breast cancer screening.

Study Design: Cohort study with 2-year follow-up after a 1-year cluster randomized trial.

Methods: Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years.

Results: Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052).

Conclusions: Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.

(Am J Manag Care. 2012;18(12):821-829)
A health information technology system was designed to facilitate population-based breast cancer screening among overdue women in a primary care network.

  •  Among overdue patients at the start of the study, mammography completion rates were higher among intervention patients (adjusted 3-year rates 51.7% vs 45.8%; P = .002).

  •  Among patients who became overdue during the study, a similar increase in mammography completion rates was seen (adjusted 2-year rates 53.8% vs 48.7%; P = .052).

  • Population-based screening that supplements office-based reminders can increase mammography rates in overdue women.
The US healthcare system is dramatically expanding the use of health information technology as a way to improve the quality and efficiency of care.1,2 In primary care networks, population- based surveillance is being used to identify specific individuals for prevention or disease management interventions. To date most interventions have focused on the use of electronic health records to facilitate care during office-based visits or inpatient hospital admissions.3-5

A novel informatics system to facilitate population-based preventive cancer screening was developed and implemented within a large primary care network.6 Breast cancer screening was chosen because it is the most common cancer in women and the second-most-common cause of cancer-related death,7 because there is scientific evidence supporting screening to decrease breast cancer mortality,8,9 and because many women are not being regularly screened despite broad consensus about the value of screening, especially for postmenopausal women.10,11 The study’s goal was to increase breast cancer screening rates by identifying eligible women overdue for a mammogram and allowing primary care providers to use an informatics tool to quickly review overdue patients and initiate outreach for those selected for contact. The system then automatically mailed reminder letters to the selected patients, tracked mammogram ordering and completion, and facilitated the scheduling of reminder phone calls by practice delegates for women remaining unscreened.

Previous results demonstrate that among women overdue for screening at the start of the study period (prevalent cohort), this system increased breast cancer screening rates over 1 year of follow-up.12 Outcomes for women who became overdue during the 1-year intervention period (incident cohort), representing those just becoming overdue after prior testing or newly eligible for screening based on age criteria, have not been previously reported. Because this incident cohort represents the ongoing population for reminder systems, the current report compares results in incident and prevalent cohorts and assesses the durability of the 1-time intervention benefit over a 3-year period.


Study Design and Randomization

The informatics system used in this study, the controlled, cluster randomized trial method, and the primary outcome results over 1 year among individuals who were overdue for screening at the study start are described elsewhere.6,12 A total of 12 primary care practices were allocated to intervention (n = 6) or usual care (n = 6) control groups after stratifying by practice type, the number of eligible patients, baseline mammography rates, and unaffiliated outside facility screening rates. Providers could not be blinded to group assignment. The study was approved by the institutional review board at Massachusetts General Hospital (MGH).

Setting and Participants

The study population consisted of 163,028 individuals seen in the Massachusetts General Primary Care Practice- Based Research Network during the 3 years ending December 31, 2006. All patients were linked to either a specific primary care physician (PCP) or (for patients who could not be linked to a specific physician) to the primary care practice where they received most of their care, using a previously validated algorithm.13,14 This linking ensured that the review of women overdue for breast cancer screening was by the PCPs or practices most directly responsible for each patient’s care.

Eligible study subjects were women 42 to 69 years of age who had no record of mammography in the prior 2 years. This group included women who were overdue as of the intervention start date (March 20, 2007; prevalent cohort) or became overdue during the first year of follow-up (March 20, 2007-March 19, 2008; incident cohort). Patients were excluded if their listed PCP was outside of the MGH network, they had previously undergone bilateral mastectomy, or they had died. All practices used electronic health records that provided visit-based cancer screening reminders.

Study Intervention

The informatics tool was implemented in the 6 intervention practices on March 20, 2007, and remained available to providers through March 19, 2010. During the intervention year (through March 19, 2008), providers received reminders to use the tool. After this 1-year period, providers could still use the tool, but they received no additional reminders and the original patient registry was not updated. For intervention providers, the informatics tool consisted of a web page listing their eligible patients linked to the network’s electronic health record.

Physician and Population Manager Role. Separate list views were visible for PCPs for their own patients and for practice-designated population managers (nurses, medical assistants, or nonclinical staff) for patients in each practice not linked to a specific PCP. Physicians and population managers received 3 e-mail reminders (start date, 3 months, 8 months) with a direct link to the population screening web page during the intervention year. A mailed reminder with step-by-step instructions was sent to physicians not yet using the system after 2 months. The web page could also be accessed directly from the hospital’s intranet and included (1) a list of overdue patients, (2) clinically relevant decision support information to help determine whether or not to initiate patient contact, (3) an actionable component to initiate or defer the mammography screening process. If a provider initiated patient contact, a centralized process was started with a letter. Providers could also defer screening (eg, if the patient had previously declined screening after a discussion or had screening done elsewhere) and remove a patient from their list for the remainder of the study. Electronically signed patient letters were sent centrally and included information about the value of screening and how to schedule a mammogram.

Practice Delegate Role. Physicians and population managers were linked with a practice-specific delegate (nonclinical staff or medical assistant) who used his or her own version of the informatics tool to facilitate tracking and scheduling of patients needing contact. Practice delegates were responsible for contacting patients who did not schedule screening on their own. When speaking with patients, delegates could schedule a mammogram by directly accessing the hospital’s radiology ordering system using the informatics tool.

Outcome Assessment

Patient characteristics, mammography reports, and dates of completion were obtained from an electronic clinical and billing data repository.15 Physician characteristics were obtained from the hospital registrar.

The primary outcome was mammography completion rates among patients overdue for screening at the start of the study (prevalent cohort) and among women newly overdue for mammography (incident cohort) during the first study year, comparing intervention and control practices.12 The maximum length of follow-up was 3 years for those in the prevadlent cohort and at least 2 years among those in the incident cohort.

A mammogram was considered to have been completed if there was an electronic report for an imaging test at a network-affiliated institution or if a mammogram was listed in billing data for the patient. Secondary outcomes included time to mammography completion among all overdue patients (prevalent and incident cohorts), censored by cancer diagnosis, death, or end of follow-up. New cancer diagnoses using Partners Healthcare. Cancer Registry data were compared among intervention and control groups.

Statistical Analyses

Baseline patient and physician/practice characteristics were compared between intervention and control groups and between prevalent and incident cohorts using 2-sample t tests or x2 tests, as appropriate. For the primary outcome, adjusted mammography completion rates and 95% confidence intervals were calculated for both the prevalent and incident cohorts at 1, 2, and 3 years of follow-up using Cox proportional hazard models with the robust sandwich covariance matrix estimate to account for clustering while adjusting for potential confounders (PROC PHREG in SAS version 9.2; SAS Institute Inc, Cary, North Carolina). In these models, physicians were considered as the unit of cluster for physician-connected patients and the population manager was considered the unit of cluster for practice-connected patients. To control for differences in patient and practice characteristics among intervention and control practices, patient age, race/ethnicity, insurance status, English language proficiency, practice type (health center vs non–health center), and number of months since last practice visit were included in the models as covariates. All adjusted rates were calculated by holding these covariates at the population mean levels. Unadjusted time to screening completion survival distributions were depicted with Kaplan-Meier curves and compared using a log-rank test. Adjusted hazard ratios comparing intervention with control practices for the entire follow-up period were also reported from the Cox proportional hazards models. The percentages of patients with new cancer diagnoses were compared between intervention and control groups using x2 tests.


There were 64 eligible physicians and 6 practice population managers in the 6 intervention practices and 74 eligible physicians in the 6 control practices. Among intervention providers, 65 of 70 (92.9%) used the system. There were no significant differences between intervention and control practice physicians with regard to age (47.4 vs 46.9 years; P = .78), years since medical school graduation (19.9 vs 19.2; P = .67), or sex (48.4% vs 51.4% were women; P = .86). Two practices in each arm were community health centers. Screening rates at baseline were similar in intervention and control practice groups (79.5% vs 79.3%; P = .73). Figure 1 depicts practice randomization and follow-up.

Among 32,688 eligible women, 9795 (30%) were overdue for screening during the 1-year study period, including 4487 patients in intervention practices and 5308 patients in control practices (Table 1). Intervention and control patients were equally likely to be connected to a specific physician (58.9% vs 58.8%) and overdue for screening at the start of the study (prevalent cohort, 67.9% vs 68.8%). Intervention patients were slightly younger, and more likely to speak English, to be non-Hispanic white, to have health insurance, and to have their last clinic visit further in the past than control patients. Compared with patients who were overdue at the start of the study (prevalent cohort), patients who became overdue during 1-year follow-up (incident cohort) were more likely to be connected to a physician (67.6% vs 54.8%; P <.001), to have commercial health insurance (70.9% vs 61.9%; P <.001), and to have been seen more recently for a practice visit (mean 8.6 [8.6 standard deviation (SD)] months vs 13.8 [8.1 SD] months; P <.001).

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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