1. Barriers to Screening Mammography in an Urban Family Medicine Residency Clinic Bonnie H. Kwok, MPH, MD (c) University of Wisconsin School of Medicine and Public Health Wisconsin Health Improvement and Research Partnerships Forum September 15, 2011

2. Topics to be Covered Purpose Background Literature Review Methods Results Discussion Next Steps

3. Research Goals 1) To evaluate the barriers to breast cancer screening by mammography 2) To measure the effectiveness of an outreach program for breast cancer screening at Wingra clinic 3) To identify missed opportunities for screening patients at Wingra clinic

4. Background Breast Cancer Rank: 2 nd leading cause of cancer death in US women Incidence: 230,480 (2011)¹ Deaths: 40,970 (2007)² Recent changes: screening mammogram every 2 years for women ages 50-74 National screening rate: 71% (2008)³ ¹ National Cancer Institute at NIH, ² CDC, ³ CDC

5. Wingra Clinic Urban family medicine residency clinic FQHC in South Madison Diverse patient population Ethnically 22.6% Hispanic/Latino 22.1% African-American/Black 6% Asian Geographically Background

6. Breast Cancer Screening in 2009 Percentage screened Screening test

7. Literature review Literature search Papers published in PubMed from 2006-2010 Search terms (MeSH and Keywords): mammography, mammogram, delivery of healthcare, quality improvement, preventive health services, barriers, and screening Significant barriers at the patient, provider and structural levels

8. Patient Barriers to Screening Mammography Variables Race/ethnicity Language Insurance BMI Age Family history of breast cancer Smoking

9. Provider Barriers Provider barriers Lack of time, training, skill, and awareness Lack of continuity with patient Financial barriers Cultural barriers Assignment of higher priority to other health concerns/competing demands Physician fatigue Negative attitude about breast cancer screening and mammography

10. Structural and Mammography-related Barriers Structural barriers Cost or lack of insurance Failure to recall that patient is due for exam/lack of reminders Poor documentation and charting within office Lack of follow-up Barriers related to mammography Patient reluctance/fear/anxiety Challenges/delays to scheduling mammogram Preparation by patients for procedure/adherence Unpleasantness of procedure Referrals (additional consultation) Lack of direct access to mammography

11. Hypotheses We hypothesize that: 1) Several demographic factors are associated with failure to receive services: Black, Hispanic, and Asian race/ethnicity Primary language other than English Insurance type (public and uninsured) 2) Outreach Those who receive outreach services are more likely to be screened 3) Missed opportunities The likelihood of having a screening mammogram ordered is increased if: Seeing ones own PCP Provider receives a staff reminder in EMR Health maintenance visit

12. Methods ~10,000 Wingra patients in UW HealthLink Inclusion criteria 947 1)Female 2)Ages 50-74 3)Active Wingra patients 4)Have a Wingra PCP 4 1)Breast cancer 2)Double mastectomy 3)Hospice 4)Diagnostic mammography 5)Deceased 35 no longer Wingra patients 912 eligible patients Overdue Not due or Due soon 512 (56.1%) Screened 400 (43.9%) Unscreened Excluded

13. Results

15. Percentage screened Insurance type

16. Outreach and Missed Opportunities Telephone outreach to overdue and due soon patients 3 rounds of calls + 1 mailed letter Interpreter services available Missed opportunities: Chart review of patient visits between May 9 – June 21, 2011 Visits n=142, Patients n=96 Primary Care Physician Staff reminder Health maintenance visit

17. Limitations and Challenges Quality of data Small sample size for Other race/ethnicity (Asian, American Indian, Alaska Native, Native Hawaiian and other Pacific Islander) (n=65 screened, n=37 unscreened) Loss to follow-up Recent implementation of electronic ordering Limited time and support from research staff Only 1 staff member to conduct all outreach calls Residency clinic

18. Discussion Key Points: Barriers – patient, provider, structural Insurance – having no insurance or public insurance Race/ethnicity – minorities What I learned: Evidence-based guidelines for cancer screening EMR data Clinical duties vs. research responsibilities Family medicine

19. Keep Calm and Carry On Analyze data from first round of outreach Analyze Missed Opportunities data Continue outreach Begin patient focus groups Agree to getting a mammogram Mammogram scheduled No show

20. Acknowledgements Kirsten Rindfleisch, MD Jon Temte, MD, PhD Wingra clinic staff Shereen Vakili UWSMPH Department of Family Medicine Ron Prince Patrick Kwok, MFSA

21. Questions? Who ever thought up the word mammogram? Every time I hear it, I think Im supposed to put my breast in an envelope and send it to someone. Jan King Bonnie H. Kwok, MPH, MD (c) University of Wisconsin School of Medicine and Public Health bkwok@wisc.edu