A recent Harvard study, published September 14 in JACR, helps pinpoint ways to prevent cancellations of screening mammography appointments. The research team, led by radiologists Nita Amornsiripanitch, MD, of Brigham and Women’s Hospital, and Adrian Jaramillo-Cardoso, MD, of Massachusetts General, utilized QI methodology (PDSA – Plan-Do-Study-Act)for their study.
The team’s composition was critical — besides radiologists, technologists, and a senior patient experience manager, the study members included a patient service coordinator, a population health coordinator, and a mobile mammography program manager. Including the last two researchers provided essential input because the highest rates of mammography cancellations were for the community health center and the mobile mammography unit. These two sites offer care for larger percentages of racial and ethnic minorities, Medicaid recipients, and women whose native language is not English.
The study was partitioned into 4 actionable priorities.
Understand the screening mammography process. The researchers created a visual aid that helped them identify the factors that patients faced that influenced their completing or canceling their mammography appointment.
The map allowed the team to look at the process from the patient’s perspective. The researchers discovered a lack of communication between the radiologists’ EMR software and the one used by the community health center.
Divide the drivers of mammography cancellation into primary and secondary factors.
The patients’ primary driving factors for cancellation included insufficient knowledge about breast cancer screening, inadequate understanding of the appointment reminder process, cost, transportation, and availability of appointments. Secondary factors included anxiety if diagnosed with breast cancer, radiation concerns, language barriers, and incorrect phone numbers in the patient’s records.
Survey patients to ensure the patients’ points of view and validate identified drivers.
Project leaders interviewed 27 patients who called to reschedule their appointments over a two-week period. Transportation was the primary factor, followed by their work schedule or forgetting their appointment date/time. When researchers asked how they help their access to screening mammograms, almost three-quarters of those who answered replied, “Increase appointment flexibility by offering evening and weekend appointments.”
Balance resources with potential impacts.
Although transportation and more flexible scheduling were high priorities, neither of these were feasible due to additional staff needs and extra IT infrastructure. But the next most common reason of forgetting their appointment date and/or time was a problem that could be easily addressed by improving appointment reminder procedures without incurring significant costs or staff.
Implementing Simple Changes — the Results
- The researchers’ first step was to allow radiology administrators access to community health center EMR. Phone number accuracy soared from 58% to 94%.
- Completed call reminders, i.e., where patients received and comprehended their reminders, increased from 21% to 59%.
- However, the increased appointment reminders only decreased cancellations by about 4%.
- The second solution of increasing availability demonstrated that offering Saturday appointments was validated with the pilot project — over the Saturdays scheduled, only 14% canceled compared to the 59% canceled on weekdays. The last pilot Saturday had zero cancellations.
In the future, researchers plan to create digital communications that will include “multilingual and culturally concordant” messages to stress the importance of screening for breast cancer. These researchers suggest that their results “provide opportunities for incremental changes and a rigorous evaluation process adaptable to work in health equity. This approach can be scalable across the integrated health system and other cancer screening modalities beyond radiology.”