Population-based breast cancer screening in a primary care network

Abstract

Objectives: To assess the ability of a health information technology system to facilitate population- based breast cancer screening.

Study design: Cohort study with 2-year follow-up after a 1-year cluster randomized trial.

Methods: Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years.

Results: Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052).

Conclusions: Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.

Trial registration: ClinicalTrials.gov NCT00462891.

Figure 1

Diagram depicting the flow of study practice clusters and patients through randomization, intervention, and outcome analysis.

Figure 2

Percent completing mammography during 3-years of follow-up in intervention and control practices among, A. women overdue at the start of follow-up (prevalent cohort) and B. women becoming overdue during the first year of follow-up (incident cohort). Figure 2A: Percent of women overdue for mammography at the start of follow-up (prevalent cohort) in intervention and control groups who completed screening in each year of follow-up. Figure 2B: Percent of women becoming overdue for mammography during the first year of follow-up (incident cohort) in intervention and control groups who completed screening in each year of follow-up.

Figure 3

Kaplan-Meier curves of time to mammography completion during 3 years of follow-up among, A. women overdue at the start of follow-up (prevalent overdue) and B. women becoming overdue during the first year of follow-up (incident overdue) in intervention and control practices. Shaded area around each line represents the 95% confidence interval for that Kaplan-Meier curve.