Retrospective Study of the Mammogram 1
Retrospective Study of the Mammogram Health Maintenance Reminder at the
Guthrie Clinic
Luke Dombert
Research Department
Laura Fitzgerald and Dr. David Channin
One Guthrie Square
Retrospective Study of the Mammogram 2
Sayre, PA 18840
Introduction
The American Cancer Society currently suggests that mammography screening for
breast cancer should be done annually for women 40-49 years of age in patients of average
risk. Many other health organizations have differing guidelines which can be seen in the
table below.
Per 1,000 mammograms in women in this group there are 97.8 false positive results, 9.3
biopsies, and 2.6 screening-detected cancers (invasive or ductal carcinoma in situ)
observed. From this data, informed consent is recommended for screening mammography
Retrospective Study of the Mammogram 3
as the benefits to harm ratio are finely balanced. Once over the age of 50, benefits
outweigh the harms. Deaths per 1000 are 0.5, 2, 3, and 2 fewer for women age groups 40,
50, 60, and 70 respectively over 10 years (Barratt & Howard et al., 2005). In the Guthrie
report area there is higher prevalence of breast cancer, an annual incidence rate of 123.60
(Per 100,000 Pop.), compared to a national annual incidence rate of 119.70, with one
county obtaining an annual incidence rate of
145.10 (Data source: State Cancer Profiles:
2005-10. Source geography: County), which
can be seen in the map to the left, Guthrie
locations are black stars. However, the
higher incidence rates in the northeast
maybe attributed to higher medical
availability.
With the obvious benefits associated with screening mammography, several health
organizations have implemented strategies to increase compliance and awareness. One of
these institutes, the Kaiser Permanente, has developed postcard, automated voicemails,
and personal call reminders to patients in their Electronic Health Record who were soon
due for a mammogram. This increased mammograms in the 50-69 age group by 17%
(from 63%-80%) by the second year of the study. The Kaiser Permanente system oversees
roughly 35,000 patients the largest of such three pronged studies. (Kaiser Permanente’s
Center for Health Research, 2009)
Retrospective Study of the Mammogram 4
Other studies have developed flow sheets on which support staff such as LPNs and
medical assistants would offer a mammogram if a patient did not fit a preset guideline.
Henry Ford Hospital in Detroit partook in a study based on the flow chart provided below.
In the study clinic mammograms over a 15 month period the screening rate of those in the
risk group increased 9% (68% to 77%) compared to a 1% in one of the four control clinics.
(Mccarthy & Yood et al., 1997)
The Guthrie Medical Group has implemented a prompt in their Electronic Medical
Record that notifies a physician when viewing a patient’s chart if they are currently in the
predetermined group that is in recommended to get screening mammography. In this
Retrospective Study of the Mammogram 5
situation the EHR automatically follows a similar path to a flow chart based of the patients
medical record.
Objectives/Purpose
To identify the primary source of guidelines utilized by providers within the Guthrie
System to aide in their determination of screen eligibility. Additionally, evaluate the
effectiveness of the integrated EPIC Health Maintenance Reminder for women seen within
the Guthrie System. This will be measured by comparing screening rates prior to the
initiation of the prompt and after the prompt was activated.
Inclusion/Exclusion
A total of 70,000-75,000 women aged 40-69 making who made a visit to one of the Guthrie
clinics during the study period, January 1, 2012 through December 31, 2013, the period of
which the EPIC reminder has been implemented and a baseline year.
Methodology
This study was conducted in the Guthrie Medical Group in 23 primary sites through
upstate New York and Northern Pennsylvania, a rural healthcare area. Descriptive
statistics will be used to determine the percentage of women getting screened compared to
the number of alerts, the number of women 40-69 who were alerted during visits
compared to the total number of mammograms, and the percentage of women in need of
mammograms before the prompt compared those after. The change in rate will also be
stratified by the age interval and in need status, as well as screened at Guthrie compared to
age interval.
Retrospective Study of the Mammogram 6
These data will be processed on encrypted computers within the research
department. The project was approved by the Internal Review Board at the Guthrie Clinic.
All data will be non-identified.
Results
The Health Maintenance Reminder, shown in Figure1, has three buttons:
contraindicated which turns off the reminder for 8760 hours (~one year), Patient declines
which turns off the reminder for 720 hours (~30 days), and financial limitations which
turns off the reminder for only the current visit. The reminder appears for women 40-69
years old who do not have a history of cancer or have had a mammogram within the past
year. A history of breast cancer is determined by looking for one of many cancer codes in
the patient’s electronic health record. Screening is determined by looking for one of the
many mammogram codes can be seen in Figure 2 within the electronic health record in the
past year.
In doing the query of the health records it was determined that the codes used by
the Health Maintenance Reminder were insufficient. Therefore, we incorporated more
codes for both Guthrie screened (mammogram codes) and non-candidates (cancer history
codes).
The graph shown in Figure 3: Percent Women In Need Of Mammograms, shows an
increase in mammogram rates after the initiation of Health Maintenance Reminder on
January 1, 2013. The percent of women without mammograms within the past year and
without breast cancer history declined between the two years. The difference was
statistically importance via a Chi-squared test.
Retrospective Study of the Mammogram 7
To further characterize the change between the two years a pie chart was made of
the women who visited the Guthrie Clinic in each year, 36,556 and 37,547 women
respectively for 2012 and 2013 and graphed in a pie charts shown in Figure 4. The “noncandidate” group is women that had cancer histories. The “other non-candidate” group
was women that had cancer history codes that where not picked up by the health
maintenance reminder. The “Guthrie screened” group was women that had mammograms
done at the Guthrie Clinic. The “Done outside” group was women who indicated that they
had a mammogram at another location. The “Multiple” group was a women who fit into
more than one group. The significant results are that the in need group diminished by
about 5% between the two years and that the Guthrie screened group increased by roughly
10% in 2013.
Further characterization of the in need group was done to determine if a certain age
group was more likely to miss mammogram screening. Appearing Figure 5, it was
determined that in 2012 women from 60-69were more likely to miss screening than
women from other age groups. However this trend appears to have corrected in 2013.
Age interval was also graphed against women screened at Guthrie in Figure 6 to
determine if the decreased screening rates in 2012 were because of Guthrie screening
rates. In 2012 in was determined that a diminished amount of women were screen from
the 60-65 age groups, and that zero women were screened in the 65-69 age group.
Discussion
The main result of this project was proving a statistical significant drop in women in
need of mammograms from 2012 to 2013 after the implementation of the Health
Retrospective Study of the Mammogram 8
Maintenance Reminder’s implementation. The statistical significance was based largely off
the shear sample size used. The correlation with the increase in mammogram rates and
the increase of individuals screened at Guthrie leads one to believe that the increase in
mammogram rates may be a result of the Health Maintenance Reminder; however, in this
study it is impossible to rule out many outside factors.
Many outside factors that could have played a role in changing mammogram rates
between the two years mainly based on public awareness. For example, breast cancer
awareness walks, and even commercials have an effect of the public’s level of awareness. I
have also noticed that Guthrie commonly has advertisements for procedures such as
annual screening. Specifically the Guthrie pink perks program gives women who get
screened at Guthrie discounts at local businesses.
Further research could be done to determine at risk patients. The American cancer
society has determined two at risk groups based on insurance status and education level.
They determined that there is about a 20% decrease between college educated women and
high school educated. There is a 30% difference between women who have insurance
compared to women who do not have insurance (American Cancer Society). It would be
interesting to see if these correlations translate to the patients at Guthrie. Also as time goes
on more data will become available and subsequent years would provide information on
the long term effect of the Health Maintenance Reminder.
The results of this study suggest that a multifaceted approach could be a more
effective way for further improving mammogram rates. Using the method of reminding
women who come into the Guthrie Clinic in a given year is missing a large portion of the
Retrospective Study of the Mammogram 9
patient pool that doing out-reach method such as text messages, emails, personal calls, and
postcards could. These out-reach methods could substantially increase the compliance
rates. Similar to the way the Kaiser Permanente approach increase mammogram rates by
17% in a little more than two years.
A study by Yabroff, O’Malley, Mangan, and Mendelblatt characterized methods for
reaching patients to determine the most effective. The looked at total of 95 studies over a
decade. They determine that the difference between in-reach (during clinic encounters)
and out-reach increased rates by 14% and 18.7% respectively. However, the most
conclusive part of their study was that theory based educational strategies proved to be the
most effect method of increasing in-reach by 14% and out-reach 27%.
Acknowledgements
I would like to thank Dr. David Channin, the Chairman of the Radiology Department
at Robert Packer Hospital, for his mentorship and providing me with the data that I used
for this research project.
I would also like to thank Mrs. Laura Fitzgerald, the Research Director, for her help
in providing a research topic, arrange meetings, and guidance throughout the semester.
Retrospective Study of the Mammogram 10
Works Cited
Aspy, C. B., Enright, M., Halstead, L. & Mold, J. W. (2008). Improving mammography
screening
using best practices and practice enhancement assistants: an Oklahoma
physicians
resource/research network (okprn) study. The Journal Of The American
Board Of
Family Medicine, 21 (4), pp. 326--333.
Barratt, A., Howard, K., Irwig, L., Salkeld, G. & Houssami, N. (2005). Model of outcomes of
screening mammography: information to support informed choices. BMJ: British
Medical Journal, 330 (7497), p. 936.
Retrospective Study of the Mammogram 11
Breast Cancer. (2014, April 23). Centers for Disease Control and Prevention. Retrieved April 23,
2014, from http://www.cdc.gov\
Fletcher, S. W. (n.d.). Screening for breast cancer: Strategies and recommendations. UpToDate.
Retrieved April 23, 2014, from http://www.uptodate.com/home
Kaiser Permanente’s Center for Health Research. (2009). Reminder program dramatically
increases mammography rates, kaiser permanente study finds. [online] Retrieved
from: http://www.kpchr.org/research/public/News.aspx?NewsID=38 [Accessed:
17 Feb 2014].
Mccarthy, B. D., Yood, M. U., Bolton, M. B., Boohaker, E. A., Macwilliam, C. H. & Young, M.
J.
(1997). Redesigning primary care processes to improve the offering of
mammography: the use of clinic protocols by nonphysicians. Journal Of General
Internal Medicine, 12 (6), pp. 357--363.
Text Alternative for Breast Cancer: Mammography Statistics (2013). (n.d.). American Cancer
Society. Retrieved April 23, 2014, from
http://www.cancer.org/research/infographicgallery/mammography-statistics-textalternative
Yabroff, K. R., A. O'Malley, P. Mangan, and J. Mendelblatt. "Inreach and Outreach Interventions to
Improve Mammography Use." J Am Med Womens Assoc 56.4 (2001): 166-73.
Pubmed. Web. 5 May 2014. <http://www.ncbi.nlm.nih.gov/pubmed/11759785>.
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Figure 1
Figure 4
Figure 3
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Figure 4
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Figure 5: Women In-Need by Age Interval
5000
Number of Women In-Need
4500
4000
3500
2012
3000
2013
2500
2000
1500
40-45
45-50
50-55
55-60
60-65
65-70
Age Range
Number of Women Screened at Guthrie
Figure 6: Guthrie Screened vs. Age Range
3500
3000
2500
2000
2012
1500
2013
1000
500
0
40-45
45-50
50-55
55-60
Age Range
60-65
65-70
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Figure 1: Figure 1 shows a screenshot of the Health Maintenance Reminder that a
physician would see on an electronic Medical Chart of a woman eligible for mammogram
screening.
Figure 2: Figure 2 two shows a variety of codes and a brief description of what those codes
are that exclude women from having the Health Maintenance Reminder appear with a year
of that code.
Figure 3: The differences in mammogram screening rates are shown between 2012, the
baseline year, and 2013, experimental year.
Figure 4: The two pie charts show how eligible women were split up between not
candidates for screening, in-need patients, or screened.
Figure 5: The relationship between age interval and in-need of mammogram screening was
graphed.
Figure 6: The relationship was graphed between women screened at Guthrie and age
interval.