What Women Want: Real Time Results for Screening Mammography in the Era of Value-Based Care | A Single Institution Experience During the COVID-19 SARS-COV2 Pandemic

Megan Kalambo; Toma S Omofoye; Ethan Cohen; Jessica W T Leung; Thu Nghiem

doi:10.36502/2023/ASJBCCR.6309

Asploro Journal of Biomedical and Clinical Case Reports
ISSN: 2582-0370
Article Type: Original Research
DOI: 10.36502/2023/ASJBCCR.6309
Asp Biomed Clin Case Rep. 2023 Jul 01;6(2):161-67

Abstract

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What Women Want: Real Time Results for Screening Mammography in the Era of Value-Based Care | A Single Institution Experience During the COVID-19 SARS-COV2 Pandemic

Megan Kalambo^1ID*, Toma S Omofoye^1ID, Ethan Cohen^1ID, Jessica W T Leung¹, Thu Nghiem¹
¹Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

Corresponding Author: Megan Kalambo, MD ^{ORCID iD}
Address: Associate Professor, Department of Breast Imaging, Clinical Medical Director, Breast Imaging Houston Area Locations, The University of Texas MD Anderson Cancer Center, 1155 Pressler, Unit 1350, Houston, TX 77030, USA.
Received date: 05 June 2023; Accepted date: 24 June 2023; Published date: 01 July 2023

Citation: Kalambo M, Omofoye TS, Cohen E, Leung JWT, Nghiem T. What Women Want: Real Time Results for Screening Mammography in the Era of Value-Based Care | A Single Institution Experience During the COVID-19 SARS-COV2 Pandemic. Asp Biomed Clin Case Rep. 2023 Jul 01;6(2):161-67.

Copyright © 2023 Kalambo M, Omofoye TS, Cohen E, Leung JWT, Nghiem T. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Screening Mammogram Results, Patient Communication, Patient Survey, Quality Practice Improvement

Abstract

Objective: Direct radiologist to patient communication has been linked to higher levels of patient satisfaction, compliance, and overall treatment outcomes. Recent studies examining patient expectations in breast imaging indicate that 90% of women prefer result communication and review of imaging directly from their radiologist. Though the primary components of diagnostic breast imaging are patient centered, supplemental data suggests that screening mammography result consultation may represent an additional opportunity for engagement in the new era of patient-experience driven care. The primary aim of our study was to examine patient preferences for receiving real time screening mammography result communication (RTRC) and characteristics that may influence their willingness to participate.
Material and Methods: This quality-improvement based, IRB-approved, study was performed at three community-based academic breast radiology centers in a large metropolitan area between October 5, 2020, and January 2, 2021. Female patients presenting for screening mammography were invited to opt in for RTRC and/or participate in an electronic, HIPAA-compliant, simple survey that could be completed on the personal subject’s phone or tablet. Subjects opting in for RTRC were invited to wait in a consultation room during staff radiologist review. Once interpreted, the radiologist would discuss the results and next step recommendations with the patient. Self-reported patient demographic characteristics and RTRC preferences by age, race, ethnicity, level of education, household income, prior personal or family history of breast cancer, active (non-breast) cancer history and prior history of abnormal mammogram were assessed by categorical variable analysis using Chi-squared tests. A p-value <0.05 was determined to be statistically significant.
Results: 1714 screening mammograms were performed across our three community-based breast imaging centers and 11% (186/1714) of women completed the survey during the study timeframe. White women (92%) were statistically more likely to opt in for RTRC when compared with non-white (80%) counterparts (p=.026). Patients with a personal history (p=0.001) or family history (p=0.006) of breast cancer were statistically more likely to opt in for RTRC when compared with other cohorts. A positive correlation was observed between prior history of abnormal mammogram and preference for receiving RTRC (93%) but did not achieve statistical significance (p=.082). There was no correlation observed between RTRC preference and an active (non-breast) cancer diagnosis (p=0.415).
Conclusion: Our study confirms previous data suggesting that patients vastly prefer direct verbal communication ahead of written letter result notification. Our study also suggests that screening mammography RTRC may be of particular interest in patients with higher (personal or familial) risk for developing breast cancer. While this service may operationally add demand on radiologist-patient face time and cost to care delivery, an awareness of patient preferences and cohorts that may find value in this service option can be prioritized to optimize both patient experience and clinical workflow. Additional studies are warranted to further validate which practice models would achieve most benefit from this tailored service offering.

Introduction

The emergence of community based academic radiology (CBAR) practice [1] has paved the way for institutions to offer improved access to subspecialized radiology services in the community with the goal of improving disease outcomes through earlier stage detection and treatment [2]. The strategy for gaining and maintaining community market share has become largely patient driven, challenging health systems to adapt to the changing needs of the patient-consumer [2,3]. The primary objectives of US health care reform in tandem with ACR’s Imaging 3.0 initiative have provided breast imagers with a unique opportunity to set best practices in radiology for routine communication [4,5].

Mammography remains the gold standard for breast cancer screening, helping to reduce breast cancer mortality in the United States by nearly 40% since 1990 [6-8]. The American College of Radiology and Society of Breast Imaging continue to recommend annual screening mammography starting at 40 years of age for average risk women [8]. Patients undergoing routine annual screening mammography have traditionally had the examination performed without any direct radiologist interaction. The Mammography Quality Standards Act (MQSA) requires communication of the results directly to the patient using lay language within 30 days of the examination [9]. Patients may also be contacted by their referring provider with the results which may contribute to delays in communication and increased anxiety or stress to the patient [10,11].

Recent studies examining patient expectations in breast imaging indicate that 90% prefer communication of breast imaging results and review of imaging directly from their radiologist [10,12-15]. Though the primary components of diagnostic breast imaging are patient centered, supplemental data suggests that screening mammography result consultation may represent an additional opportunity for engagement in the era of patient-experience driven care [4,12,14]. While some studies have examined direct patient communication of radiology results, patient characteristics that may influence expectations for receiving immediate results has not gained considerable attention. The primary aim of our study was to examine patient preferences for receiving real time screening mammography result communication (RTRC) and characteristics that may influence their willingness to participate. This new concierge-based service offering can also serve as a tool for practice building, market differentiation and optimization of patient experience in community-based breast imaging practices.

Methods

This quality-improvement based, institutional review board exempt pilot study was performed at three community-based academic breast radiology centers in a large metropolitan area between October 5, 2020, and January 2, 2021. Female patients presenting for screening mammography were invited to opt in for RTRC and participate in an electronic, HIPAA-compliant, simple survey that could be completed on the personal subject’s phone or tablet. Instructions for completion of the online questionnaire were provided on a flyer with a QR code available at the check-in desk and in the imaging suite. Informed consent was obtained electronically at opt-in. Surveys could be completed on the subject’s personal smart phone or tablet. The questions were designed at a 9th grade reading level and made available in English. Opting in for real-time result communication was not a prerequisite for survey completion (Fig-1). Subjects opting in for RTRC were invited to wait in a consultation room during staff radiologist review. Once interpreted, the radiologist discussed the results and next step recommendations with the patient (Fig-2 and Fig-3).

Fig-1: Materials used for Real Time Result Consultation Survey Participation

What Women Want: Real Time Results for Screening Mammography in the Era of Value-Based Care | A Single Institution Experience During the COVID-19 SARS-COV2 Pandemic

Fig-2: A Pictorial Illustration of the steps involved in a Real Time Result Consultation Workflow

Fig-3: A process map outlining steps involved in a Real Time Result Consultation Workflow

RTRC preferences by age, race, ethnicity, level of education, household income, prior personal or family history of breast cancer, active (non-breast) cancer history and prior history of abnormal mammogram were assessed by categorical variable analysis using Chi-squared tests. Demographic data was collapsed into binominal variables to obtain aggregate data points: age < or > 60 years, race as white and non-white, household income less than or greater than 50k, and education greater than or less than a high school degree. A p-value <0.05 was determined to be statistically significant. Additional questions involving preference for receipt of results, willingness to wait for real time results and actual wait time, were also obtained.

Results

During the survey period, a total of 1714 screening mammograms were performed across our three community-based breast imaging centers and 11% (186/1714) of women completed the survey. 89% (166/186) of respondents opted in for RTRC with 93% reporting a wait time under 10 minutes. Self-reported demographic data including age, race, ethnicity, level of education, household income, prior personal or family history of breast cancer, active (non-breast) cancer history and prior history of having an abnormal mammogram are presented in Table-1.

Table-1: Patient Characteristics & Preferences for Real Time Result Communication Opt-in

Patient preference for receipt of screening mammogram results: Of the 186 survey respondents, 172(92%) indicated they would like to preferentially receive the imaging results in person at the time of their appointment, 7 (4%) preferred receiving results via the electronic medical record, 4 (2%) from their referring physician and 2 (1%) via postal mail.

Opting in or out of Real-Time Results: 166 patients (89%) completing the survey opted to receive real-time results while 20 patients (10%) opted out. Of the 20 patients opting out, 4/20 (20%) indicated an unwillingness to wait, 2/20 were too nervous to wait, and 14/20(70%) selected other undisclosed reasons.

Willingness to wait: 38% (70) of patients willing to wait for real-time results indicated they would wait up to 20 minutes, 50 (27%) up to 10 minutes, 5 patients (24%) up to 30 minutes, and 17 (9%) up to 45 minutes. Of the patients who waited to receive real-time results, 81 (44%) self-reported a wait time of 0-5 minutes, 91 (49%) self-reported 5 to 10 minutes and 13 (7%) more than 15 minutes (Fig-4).

Fig-4: RTRC Patient Wait Time Expectation compared to Actual Wait Time for Result Consultation

Patient Demographics and RTRC Participation: White women (92%) were statistically more likely to opt in for RTRC when compared with non-white (80%) counterparts (p=.026). A positive correlation was observed between Hispanic ethnicity (92%) and preference for RTRC compared to the non-Hispanic cohort (88%) but did not achieve statistical significance (p=0.431). There was no correlation observed in RTRC across the remaining reported demographic categories of age (p=0.674), household income (p=0.286), and level of education (p=0.712).

History of cancer or abnormal imaging and RTRC Participation: Patients with a personal history (p=0.001) or family history (p=0.006) of breast cancer were statistically more likely to opt in for RTRC when compared with other cohorts. A positive correlation was observed between prior history of abnormal mammogram and preference for receiving RTRC (93%) but did not achieve statistical significance (p=.082). There was no correlation observed between RTRC preference and an active (non-breast) cancer diagnosis (p=0.415).

Conclusion

Direct communication of screening mammography results by the radiologist aligns with the provision of patient-centered care which has also been linked to higher treatment adherence and compliance [5]. Our study suggests that RTRC reporting may be of particular benefit to patients undergoing baseline imaging, patients with inconsistent (non-annual) screening patterns, history of abnormal mammogram, and/or in patients with higher (personal or familial) risk for development of breast cancer. While this service may operationally add demand on radiologist-patient face time and cost [13], an awareness of patient preferences and particular sub-populations that may benefit from this workflow may be prioritized to maximize cost-effectiveness.

Our pilot study confirms previous data suggesting that patients vastly prefer direct verbal communication ahead of written letter result notification via patient portal [14]. Advantages of direct result communication include faster communication, decrease in potential miscommunication of findings through a referring provider, the ability to ask direct follow-up or clarifying questions, and reduction in time to scheduling follow up imaging appointments [11,12,14,15]. In addition to improved patient experience, effective patient physician communication has been identified as an important factor in avoiding litigation [16].

This voluntary survey took place during the first year of the COVID-19 pandemic when two out of the three involved breast centers were new to the community marketplace, screening volumes were low and survey recruitment was dependent on technologist and radiologist staffing limitations across the three imaging centers. Though established COVID-19 masking and shielding protocols were in place, some patients also preferred to minimize the amount of face-to-face interaction while in the office and opted out of RTRC and/or survey participation [17-19]. For these reasons, while not all patients were offered real time results, we were unable to generate a definitive response rate as the total number of electronic surveys distributed during the survey period was not proactively tracked.

Lastly, this study did not examine radiologist attitudes towards this program. Both clinical workload and radiologist workspace may impact radiologist buy-in, and engagement needed to establish a successful real time result program. While the majority (83%) of our patients waited 0-10 minutes for result reporting, daily workflow and workload factors can impact result reporting times and could potentially adversely affect patient experience. Additionally, the immediate release of results may lead to requests for same day diagnostic workup with possible biopsies, which can only be accommodated with the appropriate staffing and schedule template availability.

The development of standardized protocols and IT infrastructure to support a RTRC service with established pathways for communication, notification, and prioritization of patients in queue is essential to RTRC programmatic success [20,21]. Optimization of the RTRC program requires the delineation of clear radiologist coverage roles and personnel for timely result reporting in addition to configuration of reading workstations in proximity to the consultation room. Through thoughtful consideration and incorporation of innovative approaches to patient-centered care activity, optimization of patient experience may be achieved.

Though RTRC may not be practical in all breast imaging centers due to varying radiologist staffing models and patient volumes, our data confirm that patients prefer and expect prompt results. The RTRC model may also serve as a strategic component of growth strategy in new community-based breast imaging practices in an effort to increase market share through the offering of unique patient-centered services, improved patient access and reducing wait and turnaround times for additional appointment scheduling. Additional studies are warranted to further validate which practice models and subsets of patients would benefit most from this new service offering.