Organisational efforts to improve quality while reducing healthcare disparities: the case of breast cancer screening among Arab women in Israel

Abstract

Objectives: (1) To improve quality and equity by increasing utilisation of mammography screening among Israeli Arab women. (2) To explore effectiveness of designing interventions with a combined top-down and bottom-up approach.

Design: Retrospective study at two periods of time: 2004--intervention's preliminary stages; 2005--intervention's implementation.

Setting: Maccabi Healthcare Services (MHS), an Israeli health plan serving 1.7 million members at study period; 7% of them are Arabs by 139 branches, 13 of which serve Arabs exclusively. MACRO-ORGANISATIONAL INTERVENTION (TOP DOWN): Development of a computerised Mammography Promotion System, phone contacts with non-respondents and intraorganisational reporting of screening rates. INTENSIVE INTERVENTION (BOTTOM UP): A local analysis of barriers to care and implementation of tailored solutions. This intervention was initiated and documented in three Arab branches, with spillover to the entire Arab sector. MEASURE DEFINITION: Biennial breast cancer (BC) screening of eligible women. Improvement measures Changes in BC screening rates in Arabs and comparisons with overall MHS BC screening rates for 2004 and 2005.

Results: In 2005, average BC screening rates in Arab branches increased from 26.7% to 46.2% (73% improvement), while overall MHS screening rates increased from 49.0% to 63.1% (29% improvement). Analysis of the relative differences between 2004 and 2005 BC screening rates indicated statistically significant differences (p<0.006) in rates between the Arab and other branches. These results did not change after adjustment for branch size, region and branch average age.

Conclusions: Combined top-down interventions and bottom-up initiatives are effective for formulating programmes to reduce inequality.