Breast Cancer Screening

Part 1: Introduction

Part 2: Characteristics for Success: Breast Cancer Screening

Part 3: Implementation of Quality Measure: Breast Cancer Screening

Part 4: Improvement Strategies: Breast Cancer Screening

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 3: Implementation of Quality Measure: Breast Cancer Screening 

Before following the steps in Part 3, an organization should first make a commitment to increase the rate of breast cancer screening with mammography and complete the initial steps outlined in the previous section that include:

• Developing an aim statement
• Creating an infrastructure for improvement
• Obtaining commitment from leadership

Performance on this measure indicates how effectively all the steps of the processes used to deliver care work together so that breast cancer screening with mammography is optimized. Because there are so many factors that can have an impact on whether patients receive screening mammography, it helps to visualize how these steps are mapped. The next section defines Critical Pathway and illustrates the application of this concept to test improvements to improve breast cancer screening in female patients.

The case study continues....

The Case Study: The Approach

A critical pathway, also known as a clinical pathway, is a visual depiction of the process steps that result in a particular service or care. The sequence and relationship among the steps are displayed, which reveals a map of the care process. Additional information, including tools and resources regarding the mapping of care processes, can be found in the Redesigning a System of Care to Promote QI module. In an ideal world, the care process is reflective of evidence-based medical guidelines. Evidence-based medicine aims to apply the best available evidence gained from the scientific method for medical decision making. (34) There are a number of evidence-based recommendations for Breast Cancer Screening, including those listed and referenced earlier in this module.

A map of the care process steps that incorporates all of the known evidence and follows respected evidence-based medical guidelines can be considered the idealized critical pathway. While the guidelines for Breast Cancer Screening do not completely align, there are recommended steps with shared decision making that incorporate individual risk, including age, known family history, individual risk factors along with patient preferences. The purpose of listing these steps is to reflect current best practices for breast cancer screening and to form a systematic method to consider the systems of care that underpin appropriate screening. It is important to emphasize that clinical evidence and guidelines will evolve as knowledge progresses; therefore, the idealized critical pathway may evolve over time and not meet the needs of every individual.

In Figure 3.1, the schematic for Critical Pathway for Breast Cancer Screening incorporates available evidence and represents an idealized critical pathway for care to optimize breast cancer screening. The boxes represent typical steps in care delivery. If these steps happen reliably and well, effective screening is accomplished.

Walkthrough of the Idealized Critical Pathway

The steps illustrated in the schematic reflect a system for breast cancer screening that is working well. This pathway extends beyond the boundaries of what is assessed with the Breast Cancer Screening clinical quality measure as important aspects of care for women of high risk precede the age range targeted in the measure. These steps are pertinent to effective breast cancer screening in general and encompass breast cancer screening for patients of average risk:

1. All female patients should have readily available information about breast cancer and other age-appropriate screening. Family and personal medical histories should be obtained for all patients.

2. Prescreening and education using the recommended clinical guidelines that are tailored toward the patient's risk serve as opportunities for prevention. Female patients in their twenties should be assessed specifically for risk factors for breast disease and offered a clinical breast exam at least every three years until age 39, and annually thereafter. ⁽³⁵⁾ Patients at high risk, especially those with genetic factors, such as, breast cancer susceptibility or BCRA gene mutations, should be managed according to prevailing guidelines for these high risk patients. A risking tool, such as the Gail Model, takes into account race and ethnicity and is available on the National Cancer Institute's website.

3. A patient-provider partnership is needed to ensure that decisions made respect patients' wants, needs, and preferences, and those patients have the education and support they require to make informed decisions and participate in their own care. ⁽³⁶⁾ Patients aged 40 years and older with average risk for breast cancer should discuss the pros and cons of screening mammography with their care providers. Patients aged 50 years and older with average risk for breast cancer should be strongly encouraged to complete screening mammography.

4. Through the screening and risk assessment step, the provider determines with the patient that screening mammography should be ordered.

4a. If the patient does not meet the screening guidelines, she is not screened. Interim and follow-up care is then discussed to ensure that the patient understands the risks for breast cancer and what can be done to mitigate those risks. Guidelines are emphasized so the patient understands the benefits and limitations of breast self exams and appropriate follow-up if risk factors change. Appropriate follow-up screening occurs in a timely manner and the cycle repeats. In addition, patients may choose to decline screening even if strongly encouraged by the health care team. Patients should be periodically re-assessed and supported to complete screenings as per current guidelines.

4b. Ensuring that breast cancer screening has been completed is essential for preventive care. Mammography is often not done on site and simply ordering a mammogram does not mean it will be completed. Care teams should invite a conversation about any barriers – real or perceived – to completing the mammography and work together with patients to mitigate those barriers.

5. Establishing a process to retrieve and review mammography results is important for tracking the number of completed screenings and patient's adherence to recommended guidelines. Internal systems should clearly define who reviews the results of both positive and negative screenings.

6. Patient notification of the results provides an opportunity to involve the patient in her care plan and educate her about healthy behaviors to minimize breast cancer risks. Appropriate follow-up to the screening is important and, regardless of the result, should include timely notification to the patient.

6a. Negative screening results should prompt interval screening recommendations per the adopted guidelines.

6b. Positive results should be communicated to the patient in a culturally-sensitive manner. Treatment information and advice should be provided to the patient with an appropriate referral for additional diagnostic testing or treatment.

The cycle repeats with appropriate interval screening, including outreach to patients as needed.

A quality improvement team benefits from mapping out how care is actually provided. Once it is able to evaluate where there are potential opportunities for improvement, it can use some of the improvement ideas that have worked for others, as outlined in Table 4.2: Sample Changes That Work.

A couple of important notes:

• An organization may adopt additional guidelines that include other important preventive care parameters for women or focus on other cancer screening recommendations. The USPTF has recommendations for evidence-based screening based on age.
• A critical pathway can also be constructed to illustrate how care is currently provided within an organization (the existing pathway). Understanding the gap between an organization's existing critical pathway (how you provide care now), and the idealized critical pathway (how to provide reliable, evidence-based care aligned with current guidelines), forms the basis for improvement efforts.

In addition to understanding the steps for Breast Cancer Screening, factors that interfere with optimal care should be understood. As there may be several of these factors, a QI team may find it helpful to focus its attention on factors that interfere with ideal outcomes. This becomes especially useful as plans are developed to mitigate these factors.

Factors that have an impact on Breast Cancer Screening can be organized into those that are patient-related, relative to the care team, and a result of the health system. Overlaps exist in these categorizations, but it is useful to consider factors that have an impact on care processes from each perspective to avoid overlooking important ones.

Patient factors are characteristics that patients possess, or have control over, that have an impact on care. Examples of patient factors are age, race, diet, and lifestyle choices. Common patient factors may need to be addressed more systematically, such as, a targeted approach to address low health literacy, or a systematic approach to educate staff on the cultural norms of a new refugee population. Examples of how patient factors may influence breast cancer screening include:

• Age-the incidence of breast cancer increases with age
• Cultural differences-cultural norms about weight vary, family planning choices, and perceptions of mammography may vary
• Health literacy-creates barriers in understanding and following a care plan
• Work status-may create care access issues; shift work may influence care plan
• Co-morbid diagnosis-may create barriers to screening
• Socioeconomic status-may have an impact on access to affordable screening
• Urban versus rural-access to screening may be limited in rural areas (as highlighted in a recent publication) ⁽³⁷⁾

Care team factors are controlled by the care team. These types of factors may include care processes, workflows, how staff follows procedures, and how effectively the team works together. Care team factors that may influence Breast Cancer Screening include:

• Processes staff use to outreach to or educate patients to ensure periodic care based on level of risk
• Procedures that provide culturally-competent care to address the patient's cultural norms about cancer screening and mammography
• Processes that provide comprehensive care for patients who are seen regardless of reason for visit
• Providers who may dislike doing breast cancer screenings

Health system factors are controlled at the high level of an organization and often involve finance and operational issues. Health system factors that may influence Breast Cancer Screening include:

• Cost-co-pays and availability of subsidies for mammography
• Scheduling systems-availability of evening and weekend appointments and wait time may have an impact on access
• Location-no transportation or unsafe location may present barriers to keeping appointments

These factors, when added to the critical pathway, create another dimension to the map as shown in Figure 3.2:

Example 3.1: A Team’s Brainstorming Session

The team did some quick checking and found that patients would often state that mammography had been completed but results were not available and no follow-up had been initiated. Using this information, the team brainstormed on factors that would likely have an impact on the arrow (or opportunity) between Steps 4b and 5 of the critical pathway for Breast Cancer Screening.

Factor Category	Factors pertinent to our organization - Steps
Patient	Patients live in a geographically diverse area and go to one of four imaging centers.
Care Team	Staff writes orders for "screening mammography" on a prescription pad but does not record which imaging center the patient plans to visit. That means the clinic does not know who to contact for results and the imaging center cannot assist by reporting no-shows. There is no expected screening date and no prompt for staff to follow up following the screening. There are no systems to outreach to patients who are beyond the expected interval period for mammography screening.
Health Systems	"No news is good news" policy about test results so patients cannot prompt to learn results; two imaging centers use a mobile unit which is available only one day per week; there are no formalized relationships between the clinic and the imaging centers that might facilitate communication about results.
Now that the team has thought through some of the challenges, it is able to focus its improvement efforts for this particular part of the care system.

The team continues to look at different parts of the pathway to identify relevant impacts for each part. Once it is able to evaluate where there are potential opportunities for improvement, it can use this information to target its efforts. Additional examples of strategies to improve care for the Breast Cancer Screening, measure are described in the Improvement Strategies section of this module.

Once the team visualizes the pathway and identifies opportunities for improved care, the next step is to collect and track data to test and document them. First, a QI team needs to determine how to collect data to support its improvement work. This step is essential for understanding the performance of its current care processes, before improvements are applied, and then monitoring its performance over time.

There are three major purposes for maintaining a data infrastructure for quality improvement work:

• To know the starting baseline
• To track and monitor performance as changes are implemented
• To perform systematic analysis and interpretation of data in preparation for action

The first step to creating a data infrastructure for monitoring the performance measure is to determine the baseline. A baseline is the calculation of a measure before a quality improvement project is initiated. It is later used as the basis for comparison as changes are made throughout the improvement process. For the Breast Cancer Screening measure, an organization can determine the percentage of patients aged 40 to 69 years who have had a mammogram during the last two years. Performance reflects the current organizational infrastructure and the patient's interactions with existing care processes and the care team.

Baseline data is compared to subsequent data calculated similarly to monitor the impact of quality improvement efforts. The details of how to calculate the data must be determined to ensure that the calculation is accurate and reproducible. The difference between how an organization provides care now (baseline) and how it wants to provide care (aim) is the gap that must be closed by the improvement work.

The next step of data infrastructure development involves a process in place to calculate the measure over time as improvements are tested. A QI team's work is to make changes, and it is prudent to monitor that those changes result in achieving the stated aim. This involves deciding how often to calculate the measure and adhering to the calculation methodology.

Finally, an organization's data infrastructure must include systematic processes that allow analysis, interpretation, and action on the data collected. Knowledge of performance is insufficient for improvement. It is important for an organization to understand why performance is measured and to predict which changes will increase breast cancer screening rates with mammography based on an organization's specific situation. Collecting data related to specific changes and overall progress related to achieving an organization's specified aim are important to improvement work. The next section describes in more detail how to develop a data infrastructure to support improvement.

This section explores each step to create the data infrastructure used to improve performance on the measure, Breast Cancer Screening.

Description: Percentage of women aged 40 to 69 years who had a mammogram.

Rationale/Purpose: Breast cancer continues to be a leading cause of morbidity and mortality in the U.S. female adult population. The goal is to further reduce the morbidity and mortality associated with breast cancer. Regular mammograms for women aged 50 to 69 years can reduce breast cancer mortality by up to 35 percent through early detection, and a mammogram can detect breast cancer one to four years before a woman can feel the lump. Mammography can also detect 80 to 90 percent of breast cancers in women without symptoms.

Numerator/Denominator:
Numerator: Women in the denominator who received one or more mammograms during the measurement year or the year prior to the measurement year.
Denominator: All women patients aged 42 to 69 years during the measurement year or year prior to the measurement year.

Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusion: Women who had a bilateral mastectomy and for whom administrative data does not indicate that a mammogram was performed; the bilateral mastectomy must have occurred by December 31 of the measurement year.

Numerator/Exclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documentation in the medical record must include: a note indicating the date the test was performed and the result of the finding (or a copy of a mammogram result), or a note that documents the date and results from a test ordered by another provider.

1. Step 1 - Determine and Evaluate the Baseline

   As previously discussed, a baseline for improvement is a calculation that provides a snapshot of the performance of the systems of care for a measure before improvements are applied. The baseline is determined by calculating the measure and collecting the information for the numerator and denominator.

   Determination of a baseline is accomplished by actually calculating the measure and requires that the information for the numerator and denominator be collected. There are several methods to collect this information. While electronic methods are more efficient once established, manual chart audits using random sampling techniques are equally valid.

   Consistent data collection sources and methodologies are critical to ensure reliable data. Please note that the tables referenced in this section are from the NQF-Endorsed National Voluntary Consensus Standards for Physician-Focused Ambulatory Care Appendix A- NCQA Measure Technical Specifications. [PDF | 56KB]

   The following tables depict a decision algorithm for the measure, Breast Cancer Screening. The algorithm outlines the steps that an organization follows to determine its baseline and monitor improvements for Breast Cancer Screening.
   

   Identify the Denominator
   The denominator for this measure is all women patients aged 42 to 69 years of age during the measurement year or year prior to the measurement year.
   a. Use a two-year date range: the measurement year and the year prior to the measurement year. [See choosing a date range to audit]
   b. Choose a selection method	Use date of birth or age from EHR or Practice Management System to identify women who are aged 42 to 69 as of December 31 of the measurement year
   c. Exclude women who had a bilateral mastectomy and for whom administrative data does not indicate that a mammogram was performed; the bilateral mastectomy must have occurred by December 31 of the measurement year	Use these codes or operative reports to verify bilateral mastectomy: Bilateral mastectomy CPT Codes: 19180, 19200, 19220, 19240, 19303- 19307 WITH Modifier .50 or modifier code 09950* ICD-9-CM Procedure: 85.42, 85.44, 85.46, 85.48 Unilateral mastectomy (must have 2 separate occurrences on 2 different dates of service) CPT Codes: 19180, 19200, 19220, 19240, 19303-19307 ICD-9-CM Procedure: 85.41, 85.43, 85.45, 85.47 *50 or 09950 modifier codes indicate the procedure was bilateral and performed during the same operative session.

   
   

   Identify the Numerator
   Based on an organization's systems, evaluate all of the individuals who remain in the denominator and choose a method to determine those who should be included in the numerator--women in the denominator who received one or more mammograms during the measurement year or the year prior to the measurement year.
   a. Administrative Method: Audit all submitted claims or encounters for patients in the denominator and include those with the following codes: CPT: 76083, 76090-76092, 77055 – 66057, or HCPCS: G0202, G0204, G0206, or ICD-9-CM Diagnosis: V76.11, V76.12, or ICD-9-CM Procedure: 87.36, 87.37, or UB Revenue: 0401, 0403
   b. Medical Record Audit: Audit all patients in the denominator or use valid sampling methodology. The records audited may be electronic or paper. Include the patient in the numerator if the documentation in the medical record includes: a note indicating the date the test was performed and the result of the finding, or a copy of a mammogram result, or a note that documents the date and results from a test ordered by another provider

   
   

   Calculate the Measure
   Divide the numerator by the denominator and multiply by 100 to get the percentage of women who received mammograms between the ages of 40 to 69 years.

   Compare an organization's performance to national benchmarks and other available data. The NCQA Web site updates national and State performance on this measure on an annual basis. Note that there is considerable variation among practices reporting. Other opportunities for comparison data are from payers, State cancer control programs, State and regional quality improvement organizations, as well as aggregate reports for specific HRSA-funded programs.

   Decide if the performance is satisfactory based on available data from reliable sources. It is important to consider the organizational capacity and constraints, but it is recommended that an organization's aim is high. An organization with a low performance may want to allow a longer time to achieve excellence, but striving to reach screening rate greater than 75 percent is feasible for most. If the performance is satisfactory, an organization may wish to choose another measure and focus on other systems of care.
   If the performance is unsatisfactory, consider adopting the measure and using it to monitor improvements to the care delivery system. An organization should understand that if a measure is adopted for improvement, ongoing and regular measurement is necessary to reach and sustain its organizational goals. More information regarding measurement can be found within the Managing Data for Performance Improvement module.

   Evaluate the baseline. Initially, a team compares its baseline to the performance it hopes to achieve. It is important to remember this gap in performance is defined as the difference between how the care processes work now (baseline) and how an organization wants them to work (aim). An organization may often modify its aim or timeline after analyzing its baseline measurement and considering the patient population and organizational constraints.

   As an organization moves forward, the baseline is used to monitor and compare improvements in care over time. While it is important for an organization to stay focused on its aim, it is equally significant to periodically celebrate the interim successes.

2. Step 2 - Create a reliable way to monitor performance over time as improvements are tested.

   An organization should standardize its processes and workflows to ensure the team collects and calculates performance data the same way over time. An organization should

   1. Document exactly how the data is captured so staff turnover does not interfere with the methodology.
   2. Determine the frequency that performance will be calculated. Frequent data collection is often associated with higher levels of improvement. Monthly measurement is recommended, if feasible, as it is associated with a higher level of team engagement and success. If it is infeasible, quarterly measurements may be obtained. Less frequent performance measurements are adequate for reporting purposes, but do not adequately support improvement efforts. An advanced discussion can be found in the Managing Data for Performance Improvement module.
   3. Chart and display results. A simple chart audit form is appropriate for manual audits and can be repeated frequently as desired. Results of multiple audits can be presented in a graphic format to demonstrate trends.
      

   Note: The frequency of team meetings is not necessarily prescribed for success. Many successful teams meet once a week while others may meet bi-weekly when focusing their improvement efforts on any given measure. Success of these meetings is rather the output of the team members' active engagement in the meeting and being prepared to report on recent improvement findings. More information, including resources and tools for developing and implementing effective team meetings can be found in the Improvement Teams module.

3. Step 3 - Create systematic processes that allow an organization to analyze, interpret, and act on the data collected.

   Having the data is not enough. Improvement work involves thinking about the data and deciding what to do based on that analysis. A QI team needs to put processes in place – team meetings, scheduled reports, and periodic meetings with senior leaders, to use the data tracked. This section describes how a QI team may accomplish the work of creating actionable plans based on the data collected. In Example 3.2: QI at Team Pathways Health, the hypothetical scenario illustrates how a fictional team may use these concepts to act on its data.

   1. Analyze: What are the data trends? Tracking performance over time for the measure, Breast Cancer Screening, is critical to successful improvement, but calculation of performance is not enough. It is important for a team to meet to analyze the data on a regular basis. QI teams that are experienced in looking at data recognize these common patterns:
      • Performance is improving
      • Performance is decreasing
      • Performance is flat
      • Performance has no recognizable pattern
      Additional examples of common data patterns are provided with further explanation in the Managing Data for Performance Improvement module. It is typical for a team to see little movement in its data over the first several months. If a team has chosen to monitor an associated process measure, such as, the percent of no-show patients who are rescheduled for breast cancer screening, performance improvement may be evident more quickly. Regardless, it is important that a QI team review performance progress regularly. A QI team that meets regularly and calculates performance monthly should spend part of one meeting each month reviewing its progress to date.
   2. Interpret: What do these data trends mean? A QI team needs to then interpret what these data trends mean within the context of its own organization. If performance is increasing, but has not yet reached the numerical aim, perhaps the changes in place are having the desired effect and the aim will be reached over time. If performance is decreasing, what has changed? Are there new care process changes, a failure of registry data input, or a large increase in those patients included in the registry? If performance is flat, did the organization maximize the benefits from changes implemented or was there some regression to the former way of doing things? Improvement trends that have reached a plateau may indicate that an organization needs to think differently about future changes. A few suggestions that an organization may consider when experiencing a plateau in performance improvement are listed below:
      1. i. Consider looking at outliers to determine barriers to patient access to mammography, for example, lack of insurance, transportation, or language and cultural differences
      2. ii. Consider changes in a different part of the framework to get improvement back on track. If using a critical pathway approach, an organization may look at the steps prior to where the problem seems to be. If a Care Model approach is used and the team worked hard on delivery system design issues, opportunities to better leverage the clinical information systems or engage the community may be considered.
      Interpretation of data over time is critical in determining where a team will target its efforts. Additional tools that can assist a team in understanding underlying causes for data trends are beyond the scope of this manual but are discussed in detail in a monograph that was published by the NQC, A Modern Paradigm for Improving Healthcare Quality.
   3. Act: Make decisions based on data. Once a QI team has a better understanding of what the data means, efforts should be targeted to further advance the performance toward the aim. Often the decisions are made at the team level about what to tackle first. Then small tests of change can be accomplished to determine what improvements could be implemented to enhance performance. The practice of using small tests of change actually allows multiple changes to be tested simultaneously.