January / February 2006
Breast Health Services
Improving Access and Quality for Breast Health Services
In response to an overwhelming community need, Staten Island University Hospital in New York decided to develop a “breast center” approach to the provision of breast health services. Quality improvement is a core element of the hospital’s mission and is integrated into our planning process, so outcome measures were an integral part of this initiative. The goals of the initiative were threefold:
- To reduce wait times for the complete spectrum of breast imaging services.
- To improve the quality of care.
- To improve the patient’s overall experience.
Opportunity for Improvement
Problems with access to screening mammography in our community reached a critical point in 2001. Multiple sites, previously available for screening had closed their doors, pushing wait times to more than 8 months. Waiting time for diagnostic imaging was 3 weeks and image-guided biopsy over 4 weeks. A study conducted by a local congressman revealed that 55 facilities stopped providing mammography services between 1999 and 2002 (Brice, 2004, p. 28). Further, the number of MQSA-certified facilities has declined by 10% in the same period (Brice, p. 27). The implications for both access and quality of care were negative.
The root causes impacting this phenomenon included malpractice liability concerns, insurance restrictions, a scarcity of fellowship-trained mammographers, and a negative reimbursement methodology that discouraged support for breast health programs. On the malpractice front, the Physician Insurers Association of America reports that delay in diagnosis of breast cancer is the leading cause of malpractice claims in studies in 1995 and 2002. It is no surprise, then, that in June 2003, the journal Radiologyreported that 64% of residents surveyed (135 of 211 surveyed) would not consider a fellowship in breast imaging if offered, the most common reasons given were fear of lawsuits and that the specialty is too stressful (Bassett, 2003).
The implications for women’s health were severe. In 2004, biostatistics from the Centers for Disease Control and Prevention (CDC) revealed that 215,990 new cases of invasive breast cancer were diagnosed, and more than 40,000 women died from the disease. The CDC concluded, “Timely mammography screening among women 40 years or older could reduce mortality by approximately 16%.” New York state has the second highest rate of breast cancer in the country (HANYS, 2005). In our community, the prevalence of breast cancer was 135 per 100,000 population based on the 1998-2000 data from the State Cancer Profile of the National Cancer Institute.
Staten Island University Hospital is a tertiary care center with 780 beds at two acute-care facilities in Richmond County, New York; and a member of the North Shore-Long Island Jewish Health System. The hospital provides services throughout Staten Island, Brooklyn, and the New York metropolitan area and is a major affiliate of the Medical School at the State University of New York (SUNY) Downstate Center in Brooklyn.
Prior to the program, breast imaging services were performed at three sites. Each site performed some combination of screening, diagnostic work-up, and image-guided biopsies, but the availability of services at each site was limited by equipment and staffing issues. There were as many as 10 radiologists providing services, all with different levels of training; no radiologist spent more than 50% of his or her time doing breast imaging, which was identified as a key area for improvement.
Early in the project, the hospital designated a physician champion to lead the design, implementation, and execution of the breast center strategy. The clinical services involved are radiology, oncology, surgery, radiation oncology, and patient care services. The hospital identified specially trained and credentialed staff members to participate and chose a setting for the new center that was contiguous to the hospital but discrete in its identity. Plans for the space evolved after we interviewed focus groups of patients and physicians and visited imaging centers with patient-friendly settings and a focus on privacy, technology, effective workflow, patient satisfaction, and economy of scale.
Following multiple site visits, a full-service breast-imaging center was designed and built in a location adjacent to a newly opened ambulatory surgery center. The center’s design minimizes stress for the patients while providing an efficient workflow for the staff. In order to attract imagers with a high level of expertise and dedication, the positions were removed from the responsibility of general radiology and on-call rotations. We hired three radiologists, two of whom have breast imaging fellowships and 8 years of practice experience and one with more than 15 years of dedicated mammography experience.
The new center includes seven mammography rooms, two ultrasound rooms, and a stereotactic room. We incorporated equipment from the three existing sites into the new center and purchased two ultrasound units. In February 2004, the first digital mammography unit went into operation, and a second unit was installed in December 2005. A substantial portion of the funding for digital mammography equipment was obtained through City Councilman, James Oddo.
By early 2003, wait times for all breast imaging services had decreased dramatically. The gain was further improved on in 2004. We measured outcomes against the following criteria:
- Decreasing wait time for screening mammography to 4 to 6 weeks or less.
- Decreasing wait time for diagnostic imaging to less than 10 days.
- Decreasing wait time for image guided biopsy to less than 10 days.
- Increasing cancer detection rate to greater than 3.5 per 1,000 patients screened.
- Consolidating services to a patient-friendly care center with high satisfaction rates.
The two core measurements were mammography waiting time and cancer detection rates. Both measurements demonstrated rapid and sustained improvement. Waiting times for screening mammography declined from an average of 30 weeks in 2002, to 5 weeks in 2003, and to 3.5 weeks in 2004. That is significantly better than the outcomes reported from a random sample of 40 hospitals throughout the New York metropolitan area, which showed a range of waiting times from 5 to 28 weeks in a survey conducted in March 2003 (NYC Council Staff Report, p. 7).
Screening rates of cancer detection increased from 3.2 per 1,000 patients in 2002, to 5.2 per 1,000 patients in 2003, and to 6.3 per 1,000 patients in 2004. This is an overall increase in detection rate of 97% when comparing performance in 2004 and 2002. Those measures compare favorably with benchmark data from studies done nationally (Yankaskas, et al., 2005). We estimate that 91 lives will be saved as a result of the improvements from the first 2 years of the project. This estimate is based on improved detection rates and prompt biopsies and treatments. In each successive year, patients with an initial staging of minimal cancer were 86% and 85% respectively. Conversely, patients with lymph node positive staging were less than 12%.
Other important outcome measures that we had previously identified were wait times for diagnostic studies and biopsy appointment. These two measures are quality indicators and patient satisfaction issues. Initially, patients with a suspicious finding on mammogram had to wait 2 to 3 weeks for a diagnostic study appointment and 3 to 4 weeks for an appointment for image-guided biopsy. In 2003, those times improved to 2 to 5 days for both indicators — a significant improvement. Furthermore, the statistics for 2004 remained consistently within this range. Patient volume for all modalities combined increased from 18,000 in 2002, to more than 30,000 in each successive year.
We measured patient satisfaction by evaluating wait time, courtesy of staff, explanation of care, appearance of facility, and overall care. The results were overwhelmingly positive, with satisfaction rates of over 95% documented by questionnaire.
Additionally, collaboration between the imaging director of the breast center and medical leadership has been instrumental in effecting change in practice. The formation of a weekly multidisciplinary breast tumor board attended by surgeons, oncologists, radiation therapists, pathologists, and radiologists has been a vehicle for medical staff performance improvement. Examples of process improvement include protocol for performance of image-guided versus open biopsy of non-palpable breast lesions, monthly follow-up to ensure breast-conserving therapy, and reconstruction offered to every patient when indicated.
Increased volume in breast imaging services can be achieved with improved detection rates and earlier diagnosis, which translates into lives saved.
Barriers to high-quality breast healthcare include: demand in excess of capacity, inadequate reimbursement, scarcity of trained personnel, and liability concerns. Despite these substantial obstacles, improvement can be achieved with coordination of services, focus on quality outcomes, outreach for government resources, and development of well-trained and dedicated staff. Furthermore, these improvements can be achieved without excessive financial burden to the organization.
Technology must be used to leverage capacity in order to meet volume demand. External funding is available for high profile community health issues and must be capitalized on to control cost and improve service access. Recruitment, retention, and development of qualified staff can be achieved when mission-driven service delivery is included in the process. The intangible concept of mission in meeting a community need can be a powerful motivating force for staff and leadership.
Joseph Conte (firstname.lastname@example.org) is chief quality officer at Staten Island University Hospital (SIUH), responsible for the departments of quality and risk management, internal review board, patient representation, safety services, and medical staff services. Under his leadership, SIUH has won the Pinnacle Award for Quality Improvement in 2003 from the Hospital Association of New York State (HANYS) and the Codman Award from JCAHO in 2004. Conte holds a master’s degree in public administration from New York University and is pursuing a doctoral degree in health professions leadership at Seton Hall University.
Carolyn Raiais the medical director of the Breast Imaging Center at Staten Island University Hospital. She is a board-certified, fellowship-trained radiologist.
Shalom Buchbinderis chairman of radiology at Staten Island University Hospital. He is an associate professor of clinical radiology at the Albert Einstein College of Medicine. Buchbinder has published and lectured extensively on the topic of breast cancer detection and is a Fellow in the Society of Breast Imaging.
Bassett, L. W., et al. (2003, June). Survey of radiology residents: Breast imaging training and attitudes. Radiology,227(3), 862-869.
Brice, J. (2004, September). Closing doors in mammography threaten continued access to care. Diagnostic Imaging.p. 28.
Centers for Disease Control (CDC). (2004-2005). The National Breast and Cervical Cancer Early Detection Program: Saving lives through screening.p. 1.
HANYS Breast Cancer Demonstration Project Information. Accessed December 20, 2005, at http://www.hanys.org/bcdp/breast_cancer_project.cfm
NYC Council Staff Report: Committee on Oversight and Investigation. (2003, May). An updated report on mammogram wait times in New York City. Accessed December 20, 2005, at http://www.nyccouncil.info/pdf_files/reports/mammogramupdate.pdf
Physician Insurers Association of America. (1995, 2003). Breast cancer study.Rockville, MD: author.
Yankaskas, B. C., et al. (2005, February). Association between mammography timing and measures of screening performance in the United States. Radiology, 234(2), 363-373.