Measurable impact of the Program is reflected in the mammography screening rates (aged 52-69 years) based on HEDIS specifications: 1996 = 73.8%, 1997 = 74.5%, 1998 = 80.6%, 1999 = 84.3%. The observed improvement in mammography screening rates for the period 1996-99 was statistically significant (p < 0.0001). The Georgia Region's 1997 performance for HEDIS breast cancer screening measure was the second lowest in the Program. Its 1998 performance was among the top four KP Regions, and for 1999 was again among the top 10%. The interventions employed in this Program are common in many KP Regions but with varying degrees of success. For example, in the Georgia Region, Call Center telephone outreach to contact women aged 52-69 years who are past due for a mammogram was one of the most successful outreach methods, whereas the mobile mammography van outreach was the least successful activity. Our practice results are transferable among KP Regions but could show varying results depending on how implemented.

Introduction
The Kaiser Permanente (KP) Georgia Region, which includes The Southeast Permanente Medical Group (TSPMG) and Kaiser Foundation Health Plan (KFHP) of Georgia implemented its Breast Health and Cancer Detection Program in November of 1994, when the organization's Interdisciplinary Prevention Committee (IPC) prevention priority was set as breast cancer screening.

Background
The IPC was initiated as a part of the Quality Forum (the KP Georgia Region Quality Improvement Committee) in late 1994. A charge of IPC was to identify priorities for quality improvement in preventive health services. The IPC conducted a review of scientific literature and considered both national and state health initiatives in considering what services to establish as priorities. The IPC also considered areas where low-cost interventions might achieve KP Regional goals to enable the Georgia Region to become a leader in delivery of medical care as measured by HEDIS effectiveness-of-care measures.

Breast cancer screening was selected as a top-ten priority for guideline development and for additional intervention. Breast cancer will develop in one of every eight American women in her lifetime. Breast cancer is the leading cause of cancer deaths in women aged 15 to 64 years. Forty-eight percent of new breast cancer cases and 56% of all breast cancer deaths occur in women aged 65 years and older. Breast cancer is most treatable and curable when it is found early, and the key to early detection is screening.

The national HEDIS result of 71%, reported in May 1995, provided our baseline performance measurement. This result fell short of our goal of being in the 90^th percentile of performance on this and several other HEDIS effectiveness-of-care measures.

In August 1995, the Quality Forum accepted the IPC recommendations, endorsed by the Department of Medicine, which emphasized the importance of annual clinical breast examination and mammography for women of targeted age groups. In November 1997, a new Excellence in Quality (EIQ) HEDIS Improvement Team began work. Its charge was to undertake analyses of underlying causes of reduced performance and to develop additional steps to impact yearend 1997 performance and for incorporation into care delivery processes in 1998. In March 1998, the Quality Forum Executive Committee designated breast cancer screening one of the six organizational quality priorities for 1998 and designated "owners" who would be accountable for this performance--the Chief of Radiology and the Director of Radiology. At that time, the KP Georgia Region's Clinical Affairs Division designated mammography as one of four priorities for improvement by the local Implementation Team--a collaborative effort with KP's Care Management Institute.

Program Objectives
One objective of the Breast Health and Cancer Detection Program has been to assist our members and practitioners with information and treatment to facilitate adherence to practices that promote early detection of potential breast cancer. The second objective of the Program has been to sustain measurable improvement in the screening rates to a level that meets or exceeds the 90^th percentile of HEDIS breast cancer screening rates as reported in Quality Compass.¹

Program activities were implemented in 1997. The 1996 screening rate therefore served as a baseline rate. If the program activities were efficacious in increasing and sustaining the screening rate, then the 1999 rate could be expected to be much greater than the 1996 rate; and the screening rates should exhibit a trend of increasing rates from 1996 through 1999. On the basis of the current screening rates, we expected to meet or exceed projected rates.

For the sample size used to calculate each year's mammography screening rate, we used administrative data only to calculate the screening rate. We did not select samples: thus, 100% of the eligible population was used to calculate rates.

Thus, the 1999 predicted rate was developed by using a simple linear projection from historical rates (Table 2). Yearend 1999 actual data showed a mammography screening rate of 84.3% (confirming the predicted rate; not a statistically significant difference from 1998).

Program Description
The EIQ's designated Breast Cancer Screening Work Group, in cooperation with the IPC, the Implementation Team, and under the general direction of the Quality Forum, have implemented a broad array of activities to improve breast cancer screening rates. These activities have been intended to improve member access to screening services, member and practitioner awareness for timely screening, and practitioner adherence to screening guidelines.

Improving Member Access
Access was considered on the basis of 1996 HEDIS results to be a key barrier to improved performance. The IPC Continuous Quality Improvement team (IPC/CQI) was convened in May 1997 to discuss ways to increase access to mammography. Saturday hours and mobile mammography were identified as potential activities to overcome access barriers.

A mobile mammography pilot study was conducted in December 1997. Although 60 women were screened and two previously undetected cancers were found, the mobile mammography program was discontinued because of mammogram quality problems that led to increased patient callbacks.

In November 1997, the EIQ recommended analysis of scheduling backlogs greater than three months that began the same month. Call Center staff examined wait lists, and primary care operations began to provide backfill staffing to allow practitioners with the longest wait lists to provide examinations, including clinical breast examination and referral to mammography.

Unique aspects of the solutions developed that year and in 1998 included the following:

• Use of Saturday sessions with van transportation from other nearby centers that don't have mammography services (and offering Pap smears at the same time);
• Developing mechanisms for self-referral by members for mammograms, including walk-in capability; and
• Ensuring appropriate capacity at high-use facilities by adding second mammography units at the Southwood and Gwinnett Medical Offices.

Improving Member and Practitioner Awareness
Throughout 1997, the EIQ recommended implementation of a broad array of low-cost ways of improving member and practitioner awareness of the need for timely screening.

• Fuchsia-colored chart reminders were placed in the charts of women aged 50 years and over not screened by mammography for two years. This reminder was easily recognized by practitioners during the visit of a woman overdue for a mammogram recommended by the Breast Cancer Screening Prevention Guideline.²
• Recommended Screening Preventive Services for Adults wall charts³ were placed in all adult exam rooms to remind practitioners and members about important preventive services.
• In 1997, the Georgia Region initiated a mammography tracking system based in the Radiology Department to monitor patients with abnormal clinical breast examinations or mammograms. Patients with an abnormality are contacted by phone or letter through the ordering physician to notify them of results and needed follow-up appointments.
• Health care team (HCT) and Call Center staff began to call members in the target group missing mammograms that year. Mammography Reminder Cards, entitled "You Oughta Be in Pictures"⁴ also were mailed to members who had missed mammograms. Adult Health Preventive Services Guidelines brochures⁵ were mailed to all member households.

Improving Practitioner Adherence

• Beginning in 1995, the Georgia Region began redesign of primary care delivery--shifting emphasis in accountability of service and clinical care quality from individual primary care physicians to HCTs. That accountability has been linked to financial incentives for improvement in selected areas of care.
• In August 1995, early detection and screening of breast cancer was identified as one of the preventive service priorities for which HCTs would be held accountable. To motivate improved screening rates, each HCT received an inservice presentation on the Breast Cancer Screening Prevention Guideline² and mechanisms to implement it during any clinical encounter. TSPMG began to motivate its practitioners to improve breast cancer screening rates as one of two clinically significant measures of quality performance for adjustment of each HCT's incentive reward. By Fall 1998, HCT-specific screening rates were reported on a quarterly basis--making HCTs aware of their relative performance and potential relative financial benefit.

System and process interventions made since inception of the KP Georgia Region's Breast Health and Cancer Detection Program are shown in (Table 3).

Program Impact
Program performance is currently measured by the HEDIS (version 3.0) breast cancer screening rate measure. This measure captures the screening rate of all women aged 52-69 years who have been continuously enrolled for two years preceding the reporting year. The possible confounding variables might include women who have had radical bilateral mastectomies and women with long breaks in enrollment.

The number of women defined by this measure has increased from 7017 in 1996 to 10,515 in 1999. The population targeted by this program is all women aged 50 years and older in the Georgia Region. Because the population in the measure specification covers most ages of women in the target population, we presume that program impact is accurately represented by the HEDIS rates.

Table 4 shows statistical significance of the observed improvement in mammography screening rate from 1996 to 1999. The observed improvement from 1996-1999 was statistically significant (p < 0.0001).

Figure 1 illustrates the screening rate for 1996 through 1999. The 1999 rate was projected using the year-to-date screening rate. Analyses were retrospective and were conducted using EPI-INFO 6.02. The screening rate increased from 73.8% in 1996 to 84.3% in 1999 (c² = 271.03, p < 0.01, df = 1). During the period 1996-1999, the screening rate increased at approximately 3% per year (absolute). This change represents a sustained, linear trend (c² = 337.87, p < 0.01, df = 3).

Comment
Program Evaluation
The Breast Health and Cancer Detection Program has achieved demonstrable results. In 1997 and 1998, the IPC/CQI team (and in 1999, the EIQ Breast Cancer Work Group) systematically identified issues impeding performance improvement and have recommended innovations to motivate and accelerate improvement in breast cancer screening.

The program has achieved its objectives. The breast cancer screening rate for women rose from 74% in 1996 to 84% for all insurance product lines in 1999. National benchmarks for 1998 were 81% (90th percentile for commercial members) and 84% (90th percentile for Medicare-eligible members). Our 84.3% screening rate thus apparently makes the Georgia Region a KP national leader and puts the Georgia Region in the top 10% of all health plans in the country.

The program has achieved these results with a broad array of activities: Saturday hours, mobile mammography, medical record reminders, patient and physician reminders, Call Center outreach, practitioner feedback on performance, and practitioner financial incentives. Some of these activities are relatively low in cost (eg, the fuchsia inserts in medical records). Several other innovations demonstrate the ability to integrate improved care management into evolving service delivery within KP--such as use of Call Center technology and redesign of Primary Care delivery. Although we cannot point to any one of these innovations as a key driver of improvement, implementing this cluster of innovations can substantially improve care delivery.

In particular, the Call Center outreach was one of the most successful methods implemented by the Georgia Region. The purpose of this outreach tool was to call women aged 52-69 years who were past due for a mammogram and to schedule an appointment for them. In some instances, the Call Center was not able to reach the patient; if that were the case, those names and phone numbers were forwarded to the HCT for follow-up. At least three attempts at calling the patient were made before involving the HCT. This activity should be increased to maximize future return on these efforts.

The least successful activity was the mobile mammography van outreach. Although the mobile mammography van did not have the turnout in numbers that we had anticipated, two women were found in the early stages of cancer. The purpose of this outreach effort was to provide mammography services at sites without mammography equipment. This intervention was directed at women who needed transportation to a medical center to get a mammogram. The protocol for this intervention was to process the films at the end of the day. A problem occurred in some cases where incomplete views of the breast were taken, making the films inadequate. Forty (65%) of the women had to return for repeat views. No additional mobile mammography interventions have been implemented. However, one initiative that came out of this outreach was the Mammography Days event, in which vans are used to transport women to medical offices with onsite mammography equipment. Mammography Days occurs on a quarterly basis and has been successful. Plans to use the mobile mammography van are uncertain. But the initiative to provide van transportation should be increased as a feasible alternative to the mobile mammography van outreach.

The impact of improved mammography screening access on the rate of breast cancer diagnosis and breast cancer stage at diagnosis were not available when this article was prepared. The Georgia Region began developing a Breast Cancer Registry with stage-at-diagnosis information in 1996. The 1996 and 1997 data showed results comparable with other KP Regions. The 1998 and most recent data are currently undergoing data integrity checks related to our recently required state reporting and are not available at this time.

Cost-effectiveness
Data from the Centers for Disease Control and Prevention²⁷ suggest that screening women aged 50-69 years for breast cancer every one to two years can lead to a 20% to 30% reduction in breast cancer mortality. One study²⁸ indicated that the combination of a clinical breast examination and an annual mammogram prevents premature death at a cost of $22,000 to $84,000 per life-year gained in women aged 55 to 65 years, depending on the effectiveness of screening. Our Georgia Region's data on the evaluation of cost-effectiveness of the described interventions are forthcoming. In the meantime, our annual budget for the KP-Georgia Breast Health and Cancer Detection Program is $71,000, a modest investment to achieve these substantial gains.

Implications
The following activities have already become the normal practice for breast cancer screening outreach and are embedded in our ongoing processes of care. We therefore expect to sustain the gains made and possibly even improve our results.

• Each summer, the Call Center phones women aged 52-69 years who have not been screened for two or more years.
• Each May, the Prevention and Health Promotion Department will mail the "Mammography Reminder Card: You Oughta Be in Pictures"⁴ or the "Mammograms: Not Just Once, But For A Lifetime"²⁴ brochure to women aged 50 years and older.
• During the second quarter of each year, the Prevention and Health Promotion Department will place colorful "chart reminders" with the Breast Cancer Screening Prevention Guidelines² on them in the medical records charts of women aged 50 years and older who have not had a mammogram in two or more years.
• The breast health posters with the Breast Cancer Screening Prevention Guidelines² will be revised and placed in the bathrooms during the second quarter of each year by the Prevention and Health Promotion Department as needed.
• The "Recommended Screenings and Preventive Services for Adults"³ wall chart that is placed in all medical center exam rooms is revised every two years by the IPC and the Prevention and Health Promotion Department. The wall chart is sent to the network practitioners.
• The Radiology Department will continue to offer Saturday appointments that support routine mammograms and "Well Women" examinations and will provide transportation to the medical centers for women who need it.

Transferability
None of our changes in process of care (with the possible exception of HCT incentives) are intrinsic to the Georgia Region. Some of the project processes, tools, and practices (eg, Saturday hours, self-referral, walk-in appointments, reminders) are common practice in many KP Regions.

The Georgia Region's Prevention and Health Promotion Department is dedicated to providing high-quality care to the members. In order to do this, this Department practices networking with other KP Regions and gleans from them initiatives that have proved successful. Some of the initiatives that KP Georgia uses for breast awareness were adapted from the KP Northwest Region. Specifically, the KP Northwest Region's EpicCare Health Maintenance Reminder became our paper version chart reminder; the Northern California Region's Clinic Visit Summary form to alert clinicians became our exam room wall chart, and the letter outreach became our "Mammography Reminder Card: You Oughta be in Pictures"⁴ and "Mammograms: Not Just Once, But For A Lifetime"²⁴ brochure mailer; and the KP Northwest Region's Women's Safety Net gave us the idea to select a particular population to target.

The nature of the innovations we used in the Georgia Region make this Program a model of care both for other medical conditions and for other KP Regions. In the absence of an electronic medical record, medical record inserts are a low-cost method for prompting behavior on the part of patient and practitioner whenever a visit occurs. This simple activity can be used for promoting adherence to clinical practice guidelines for other diseases, such as asthma and diabetes. We have also focused recent efforts to develop a registry for our prostate and colorectal cancers and melanomas similar to our Breast Cancer Screening Registry. In addition, the Georgia Region mailed the large-print edition of the "Mammograms: Not Just Once, But For A Lifetime"²⁴ brochure to women aged 70 years and older. Dr Adrienne Mims and Kecia Leatherwood presented our results at the Kaiser Permanente Third Prevention & Self-Care Symposium in December 1999 with an exhibit called "Implementation of a Breast Health Screening Program for the Hard-to-Reach Woman."²⁸

Conclusion
In conclusion, although we have no specific feedback information yet from other KP Regions that have adopted aspects of our Georgia Region project (either regarding their experience or with respect to quality improvement results with the inreach and outreach activities and educational programs), we believe that any KP Region can apply a similar cluster of interventions to achieve measurable, sustainable quality improvement.

The breast cancer screening rate for women rose from 74% in 1996 to 84% for all insurance product lines in 1999.

 

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