Betty Roggenkamp

Do hospitals in a large metropolitan area utilize published breast cancer care practices and guidelines

151 Background: Insufficient utilization of guideline and evidence based care practices contribute to the cancer crisis (IOM 2013). We examined utilization of published breast cancer (BC) care practices and guidelines at hospitals in a large metropolitan area. METHODS IRB approved web survey of all 35 hospitals in a large metro area that provide BC treatment. Using guidelines/recommendations (NCCN, NAPBC, ADA, IOM) and peer-reviewed literature (62 studies) we developed a survey on BC care practices. Results analyzed by simple frequencies and Fishers exact test. RESULTS Response rate: 91% (32/35 sites). Care practices, included in the table, are utilized by < 50% of sites. Radiation oncologist preoperative consults (53%, 8/15) and offering indicated pre-operative chemo* (67%, 10/15) are associated with 15 sites that have high volume (67+/year, Chen CS 2008) BC surgeons, compared to 17 sites without high volume BC surgeons (12%, 2/17) and (24%, 4/17) respectively, p=0.02, p=0.03. Indicated supportive services, such as a dental checkups (ADA 2008), are more likely at sites with patient-centered written treatment plans (IOM 2011) (58%, 7/12) than at sites without written treatment plans (10%, 2/20), p=0.006. CONCLUSIONS Low utilization of published care practices and guidelines is concerning and requires attention. Other metro areas and regions should be examined as our findings indicate that patients may have limited local choices of care that is up-to-date on published guidelines and practices. [Table: see text].

Process improvement in breast cancer care: Is mammography volume associated with a greater need for process improvement?

45 Background: Chicago black women are 62% more likely to die from breast cancer than white women. Previous data from 39 Chicago hospitals suggested significant variation in mammography quality (Chicago Breast Cancer Quality Consortium, 2010). We developed process improvement recommendations for sites that participated in our care process assessment (Weldon CB, et al, ASCO-Abstract-6120-2012). This study was funded through a generous grant from the Susan G. Komen for the Cure Foundation. We compared improvement needs between high and low patient volume institutions. METHODS Using Demings PDCA cycle for continuous improvement, we created care process improvement recommendations for 25 Chicago institutions with the patient base averaging more than 50% minority patients (20 community, 3 academic and 2 public hospitals). Low mammography volume (< 5,000 mammograms/ year) was reported by 12 of the 25 sites. Recommendations are based on analysis across sites, literature, and input from institution staff. Thematic and statistical analyses were performed using simple frequencies and Fishers exact test. RESULTS Improvement recommendations are classified into nine areas (see Table). We found that 100% (12/12) of low mammography volume institutions have specific improvement needs in 6 or more process improvement areas, as compared to 23% (3/13) of the high mammography volume institutions (p value > 0.0001). CONCLUSIONS Lower volume mammography sites have a larger need for breast cancer care process improvements. [Table: see text].

Abstract A38: Are breast cancer screening patients with family cancer history directed to genetic counseling/testing?

Background: The death rate from breast cancer for black women in Chicago, Illinois is 62% higher than for white women, and is much higher than the U.S. disparity of 41% and the New York City disparity of 27% (Sinai Urban Health Institute, 2010). The Chicago Breast Cancer Quality Consortium, funded by Susan G. Komen for the Cure Foundation, previously collected data from 43 Chicago hospitals identifying significant quality deficits in breast cancer screening and treatment (Chicago Breast Cancer Quality Consortium, 2010). Women with a BRCA1/2 mutation have a significantly higher risk for breast and ovarian cancer. While most primary care physicians are aware of BRCA testing, only a minority follow guidelines for BRCA evaluation (Bellcross CA, et al 2011). Our aim was to examine the collection of personal and family cancer history during breast cancer imaging and the resulting referrals to genetic counseling/testing that are or are not initiated from the breast imaging care process. Methods: We conducted 113 semi-structured interviews with cross-discipline providers involved in breast cancer screening and care. These interviews were across 26 institutions including 18 community, 4 academic, and 4 public hospitals in the Chicago metro area. Participating institutions provide care to diverse populations. For 22 institution9s, African American and Hispanic women comprised more than 50% and for the other 4 institution9s more than 30% of the patient population. 10 of the participating community hospitals are classified as low resource. Interviewees included: radiologists, mammography technologists, nurses, surgeons, medical oncologists, internists, administrators, registrars and patient navigators. Interviews were transcribed, thematic analysis was conducted following the framework approach, and statistical analysis was performed using simple frequencies and Fisher9s exact test. Results: All (26/26) institutions ask patients at breast cancer screening about their personal and family breast cancer history. One (1/26) institution had a process to refer breast screening patients with a personal or family history to genetic counseling. 10 institutions (38%) had access to genetic counseling within their organizations. Of institutions with internal access to genetic counseling, 80% (8 of 10) referred diagnosed breast cancer patients with familial or personal history to genetic counseling/testing as compared to 31% (5/16) of institutions that do not have internal access to genetic counseling (p=0.0414). Conclusions: While all institutions collected personal and family history of breast cancer, only one institution had a process for and regularly referred appropriate high risk breast screening patients to genetic counseling/testing. Several of the breast imaging centers are now considering methods to implement genetic counseling referrals in their screening protocols. The biggest challenge the institutions noted was not having a clear place to send the patients for genetic counseling. Further research is needed to investigate factors of access to genetic counseling and testing for low resource hospitals serving diverse populations, as well as to develop the needed services and care processes for all institutions participating in our Consortium. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A38.

Supportive Oncology Collaborative: Initial impact of supportive oncology screening and care.

180 Background: The Institute of Medicine (IOM) 2013 report recommends supportive oncology care from diagnosis through survivorship, to end of life. The Coleman Supportive Oncology Collaborative (CSOC) developed a city-wide plan to improve supportive oncology. Metrics derived from the Commission on Cancer (CoC), ASCO Quality Oncology Practice Initiative (ASCO-QOPI) and National Quality Forum (NQF) were used to assess the CSOC impact. METHODS Medical records of consecutive cancer patients from 6 practice improvement cancer centers in Chicago (3 academic, 2 safety-net, 1 public) were reviewed for 2 periods: 2014 (n = 843) and Q1 of 2015 (n = 313). Descriptive statistics assessed differences in quality metrics. RESULTS Significant improvement was achieved in 6 of 8 core supportive oncology metrics (see table). CONCLUSIONS Consolidated metrics are feasible to assess supportive oncology quality. Early data indicate improvement and effectiveness of the collaborative approach. [Table: see text].

Do breast cancer treatment and imaging providers follow hereditary breast and ovarian cancer risk screening guidelines

207 Background: Women with personal or family history suggestive of susceptibility to hereditary breast or ovarian cancer (HBOC) should be referred to genetic assessment (USPSTF, Ann Intern Med. 2005). Women with HBOC have a 50-85% lifetime risk of breast cancer, 30-50% of breast cancer before 50 years old,15-50% lifetime risk of ovarian cancer, and 40-60% chance of developing a second breast cancer (ASCO Cancer.net HBOC 8/2013). Our goal is to examine if this almost decade old guideline is followed in breast cancer treatment and breast cancer imaging centers in a large metropolitan area. METHODS We conducted an IRB approved web survey of all 35 breast cancer treatment sites (5 academic, 21 community, 9 public or safety net) and 58 breast imaging sites (5 academic, 27 community, 26 public or safety net) in Chicago. Results were analyzed using simple frequencies and Fishers exact test. RESULTS We achieved a response rate of 91% (32/35 treatment sites, 53/58 imaging sites). We found that 56% (18/32) of treatment sites have a hereditary cancer syndrome (HBOC) screening process for newly diagnosed breast cancer patients. Most of these sites, 83% (15/18), always use genetic test results in surgical decisions, as compared to 21% (3/14) of sites that do not have an HBOC screening process, p=0.0009. Only 8% (4/53) of breast imaging sites have an HBOC screening process and provide indicated patients genetic assessment information and/or referrals. While 38% (20/53) of imaging sites conduct daily internal staff discussions of hereditary risk, only 15% of them (3/20) provide genetic assessment information to indicated patients. We found no statistically significant difference between practices of academic, community, public and safety net sites. CONCLUSIONS Breast cancer treatment sites have partial adherence to HBOC risk screening guidelines; while breast imaging sites rarely adhere to HBOC risk assessment guidelines. Consistent HBOC risk screening protocols are needed in breast cancer treatment and breast cancer imaging sites that include providing indicated patients information about, and access to, genetic assessment.

Abstract A84: Do patient follow-up improvements, at hospitals caring for medically underserved patients, impact no-show rates

Background: In Chicago Black women are 62% more likely to die from breast cancer than White women. Previous data from 39 Chicago hospitals suggested the existence of significant variation in mammography quality across facilities (Chicago Breast Cancer Quality Consortium, 2010). We developed process improvement recommendations for sites that participated in our care process assessment (Weldon CB, et al, ASCO-Abstract-6120-2012). This study was funded through a generous grant from the Susan G. Komen for the Cure Foundation. Appointment reminder calls and follow-up calls to patients that do not attend their appointments are effective in increasing breast cancer screening and diagnosis completion rates of (Goel A, et al, JHCPU 2008). We provided technical assistance to implement breast imaging care process improvements and compared pre and post process improvement appointment no-show rates and follow-up call rates at 14 sites. Procedures: Using Deming9s PDCA cycle for continuous improvement, we created care process improvement recommendations for 27 Chicago institutions with the patient base averaging more than 50% medically underserved patients (22 community, 3 academic and 2 public hospitals), 17 of the sites are safety net institutions. Recommendations were based on analysis across sites, literature, and input from institution staff. We provided 14 of the sites with technical assistance to implement “rapid cycle” care process improvements (RCI sites). Sites were selected for technical assistance based on their need and their commitment to improving breast imaging care processes. Thematic and statistical analyses were performed using simple frequencies, and McNemar9s test. Summary of Results: Detailed results are shown in the table below. Technical assistance was utilized by 14 of 17 safety net sites (RCI sites) to which it was offered. 10 sites adjusted their processes to conduct appointment reminder calls to patients. 12 sites implemented processes to conduct follow up phone calls with patients who missed an appointment, with a focus on answering patient questions and to schedule a new appointment. 6 sites adjusted their processes to conduct phone calls to inform patients of abnormal breast screening results (BIRADS 0, 4, 5) in addition to sending each patient a letter (MQSA requires at least a letter). Working with the 14 sites resulted in an improvement in no-show rates from 29% to 21%. Appointment reminder call: baseline 48% (13/27) all sites, 21% (3/14) RCI sites post-improvement 85% (23/27) all sites, 93% (13/14) RCI sites pvalue = 0.0044, Chi squared: 8.100 w 1 degree of freedom Call no-show patients : baseline 19% (5/27) all sites, 0% (0/14) RCI sites post-improvement 63% (17/27) all sites, 86% (12/14) RCI sites pvalue = 0.0015, Chi squared: 10.083 w 1 degree of freedom Call to follow up with patients who have abnormal results: baseline 56% (15/27) all sites, 50% (7/14) RCI sites post-improvement 78% (21/27) all sites, 93% (13/14) RCI sites pvalue = 0.0412, Chi squared: 4.167 w 1 degree of freedom No show rate for screening mammograms baseline 22% all sites, 29% RCI sites : post-improvement 18% all sites, 21% RCI sites Conclusions: Conducting phone calls to remind patients about appointments improves no-show rates at sites that care for the medically underserved. Further analysis may show a reduction in loss-to-follow-up for sites that implement follow up phone calls to patients who miss appointments and to patients who need additional diagnostic assessment. Findings from this study have generalizable application to health facilities beyond breast imaging sites. Given persistent and growing disparities in health outcomes for vulnerable populations and the limited resource availability; these findings suggest that implementation of basic patient tracking strategies have substantial benefit to improve patient outcomes and health care quality. Citation Format: Christine B. Weldon, Teena L. Francois, Julia R. Trosman, Betty Roggenkamp, Danielle M. Dupuy, Jimmie T. Knight, David A. Ansell, Anne Marie Murphy. Do patient follow-up improvements, at hospitals caring for medically underserved patients, impact no-show rates. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A84. doi:10.1158/1538-7755.DISP13-A84