Communication problems after mammographic screening

Medical imaging call centre: a communication success story

AIM

To evaluate utilisation of a medical imaging call centre (MICC) at a multi-site, academic radiology department, focusing on communication of critical, urgent, or significant unexpected findings.

MATERIALS AND METHODS

Institutional research ethics board approval was obtained. All calls made to MICC from 1 January to 31 December 2019 were reviewed retrospectively. The total number of calls, date, and reason of each call, level of report alert, and turnaround time (TAT) were recorded. Level 1, 2, and 3 alerts were defined as "potentially life-threatening new/unexpected findings", "could result in morbidity/mortality", or "not immediately life-threatening or urgent", respectively. TAT was defined as the time from alert request received by the MICC until acknowledgement of receipt by the referring physician, with a desired TAT of 60 min, 3 h, and 3 days for each level, respectively.

RESULTS

The MICC received 29,799 calls in 2019, on average 2,483 (range 1,989-3,098) calls per month. The most common indications for contacting the MICC were to request imaging reports to be expedited (14,916 calls, 50%) and issuing report alerts to communicate unexpected or urgent findings (7,060 calls, 24%). Average number and range of calls for Level 1, 2, and 3 alerts were 57 (39-80), 345 (307-388), and 187 (127-215) per month, respectively. Average TAT for Level 1, 2, and 3 report alerts were 59 min, 2 h 26 min, and 19 h 39 min, respectively.

CONCLUSION

The MICC received a large volume of calls and was a successful method for timely communication of unexpected or urgent imaging findings using a three-tiered alert system.

Who You Gonna Call? Automatically Connecting Radiologists to the Right Clinician

Contacting clinicians to convey critical results is a critical part of radiology workflow, but many obstacles prevent easy and timely communication. Integration of radiology applications and workflow with an EHR-based patient coverage database demonstrated subjective and objective improvement in radiologist workflow and satisfaction.

Reviewing imaging examination results with a radiologist immediately after study completion: patient preferences and assessment of feasibility in an academic department

OBJECTIVE

The purpose of this study was to assess patient preferences about receiving radiology results and reviewing the images and findings directly with a radiologist after completion of an examination.

SUBJECTS AND METHODS

A prospective survey of English-speaking outpatients undergoing either nononcologic CT of the chest, abdomen, and pelvis or nonobstetric ultrasound examinations was completed between December 2010 and June 2011. Responses to survey items such as preferences regarding communication of results, knowledge of a radiologist, and anxiety level before and after radiologist-patient consultation were recorded. The average wait time between the end of the imaging examination and the consultation and the duration of consultation were documented.

RESULTS

Eighty-six patients (43 men, 43 women; mean age, 52 years) underwent 37 CT and 49 ultrasound examinations). Forty-eight patients (56%) identified a radiologist as a physician who interprets images. Before imaging, 70 patients (81%) preferred hearing results from both the ordering provider and the radiologist. This percentage increased to 78 (91%) after consultation (p=0.03). Before consultation, 84 of the 86 patients (98%) indicated they would be comfortable hearing normal results or abnormal results from the person interpreting the examination; the number increased to 85 (99%) after consultation. Eighty-five patients (99%) agreed or strongly agreed that reviewing their examination findings with a radiologist was helpful. Eighty-four patients (98%) indicated they wanted the option of reviewing or always wanted to review future examination findings with a radiologist. After consultation, anxiety decreased in 41 patients (48%), increased in 13 (15%), and was unchanged in 32 (37%) (p=0.0001). The average wait for consultation and the duration of consultation were 9.9 and 10.4 minutes for CT and 1.2 and 7.1 minutes for ultrasound.

CONCLUSION

Patients prefer hearing examination results from both their ordering provider and the interpreting radiologist. Most patients find radiologist consultation beneficial. Patients are comfortable hearing results from the radiologist, with most displaying decreased anxiety after consultation.

Association of communication between hospital-based physicians and primary care providers with patient outcomes

BACKGROUND

Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.

METHODS

We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome.

RESULTS

A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59).

CONCLUSION

Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.

Web-based results distribution: new channels of communication from radiologists to patients

Radiologists face substantial challenges in the timely and appropriate communication of diagnostic test results. As with other systems in health care delivery, the radiology reporting system is not designed to be optimally safe, timely, and patient centered. To improve the quality of care, there must be a new commitment to organizing services around patients' needs, including the reporting of diagnostic test results directly from radiologists to patients. The rationale for this change is that if both referring physicians and patients are given imaging examination results from radiologists immediately after their interpretation, it would be less likely that important diagnostic information would be lost or overlooked. The results would be provided to all stakeholders in a more timely fashion, the potential for important information to "fall through the cracks" would be diminished, and safety would be improved. Providing these results to patients directly online would also allow radiologists to facilitate increased patient satisfaction and patient-centered care by treating patients as "co-customers" and equal partners with referring physicians with regard to access to information and shared decision making.

Follow-up of abnormal or inadequate cervical smears using two guidance systems: RCT on effectiveness

BACKGROUND

To improve follow-up compliance after an initial inadequate or abnormal cervical smear, two follow-up guidance systems were tested for effectiveness. A comprehensive system (cytopathology laboratory monitored the follow-up of all abnormal and inadequate smears) was compared to a selective system (monitoring was left to the smear taker; laboratory acted as a safety net).

METHODS

In an RCT on all family practices (N = 171) in the catchment areas of two cytopathology laboratories (Nijmegen region, The Netherlands, 1998-2000), practices were allocated at random to one of the follow-up guidance systems. All women included were registered at the practices, invited to the national screening program and had abnormal or inadequate smears. Measurements comprised of (1) follow-up compliance at baseline and 1 year after the initial smear and (2) diagnostic outcome of the follow-up smear.

RESULTS

During the study period, 132 practices sent their cervical smears to the laboratories. The comprehensive system covered 1226 women, the selective 1034. In the comprehensive system, the increase in follow-up compliance for initial inadequate and slightly abnormal smears was significantly higher (8.9%) than in the selective one, which implied an extra detection of eleven, more serious, abnormalities per 1000 women.

CONCLUSION

The comprehensive system was more effective than the selective and is suitable for use on a larger scale.

What Factors Are Associated with Diagnostic Follow-Up after Abnormal Mammograms? Findings from a U.S. National Survey

The purpose of this study was to identify factors associated with diagnostic follow-up after an abnormal mammogram in a national sample of women in the U.S. The sample was selected from the year 2000 National Health Interview Survey and included 1901 women aged 30 and above who reported ever having an abnormal mammogram. The outcome measure was receipt of at least some diagnostic follow-up after an abnormal mammogram. Bivariate and multivariate logistic regression analyses were used to explore the associations between sociodemographic characteristics, general health and health behaviors, cancer risk and risk perceptions, and health care utilization characteristics and follow-up. Approximately 9% of women who reported ever having abnormal mammograms reported not completing any additional diagnostic follow-up. Controlling for all other factors, women with less than a high school education were less likely to report follow-up after an abnormal mammogram than were women who had at least completed college (odds ratio = 0.56; 95% confidence interval: 0.32, 0.98). Younger women and women in poorer health were also less likely to report follow-up. Women who perceived a high versus low level of cancer in their family were more likely to report follow-up (odds ratio = 1.65; 95% confidence interval: 1.04, 2.62), controlling for all other factors. In a national sample of women with abnormal mammograms, a substantial number did not complete any diagnostic follow-up, potentially reducing the effectiveness of mammography screening programs in the U.S. Additional research on subsequent screening behaviors for women with incomplete follow-up and in-depth exploration of the roles of patient-provider interactions and health care system factors related to the index abnormal mammogram is warranted.

Is the promise of cancer-screening programs being compromised? Quality of follow-up care after abnormal screening results

Cancer screening has increased dramatically in the United States, yet in some populations, particularly racial minorities or the poor, advanced disease at diagnosis remains high. One potential explanation is that follow-up of abnormal tests is suboptimal, and the benefits of screening are not being realized. The authors used a conceptual model of access to care and integrated constructs from models of provider and patient health behaviors to review published literature on follow-up care. Most studies reported that fewer than 75 percent of patients received some follow-up care, indicating that the promise of screening may be compromised. They identified pervasive barriers to follow-up at the provider, patient, and health care system levels. Interventions that address these barriers appear to be effective. Improvement of data infrastructure and reporting will be important objectives for policy makers, and further use of conceptual models by researchers may improve intervention development and, ultimately, cancer control.

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

BACKGROUND

Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics.

METHODS

We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding.

RESULTS

Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92).

CONCLUSIONS

Interventions that address a woman's prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.

Effect of discharge summary availability during post-discharge visits on hospital readmission

OBJECTIVE

To determine if the delivery of hospital discharge summaries to follow-up physicians decreases the risk of hospital readmission.

SUBJECTS

Eight hundred eighty-eight patients discharged from a single hospital following treatment for an acute medical illness.

SETTING

Teaching hospital in a universal health-care system.

DESIGN

We determined the date that each patient's discharge summary was printed and the physicians to whom it was sent. Summary receipt was confirmed by survey and phoning each physician's office. Each patient's hospital chart was reviewed to determine their acute and chronic medical conditions as well as their course in hospital. Using population-based administrative databases, all post-hospitalization visits were identified. For each of these visits, we determined whether the summary was available.

MAIN OUTCOME MEASURES

Time to nonelective hospital readmission during 3 months following discharge.

RESULTS

The discharge summary was available for only 568 of 4,639 outpatient visits (12.2%). Overall, 240 (27.0%) of patients were urgently readmitted to hospital. After adjusting for significant patient and hospitalization factors, we found a trend toward a decreased risk of readmission for patients who were seen in follow-up by a physician who had received a summary (relative risk 0.74, 95% confidence interval 0.50 to 1.11).

CONCLUSIONS

The risk of rehospitalization may decrease when patients are assessed following discharge by physicians who have received the discharge summary. Further research is required to determine if better continuity of patient information improves patient outcomes.

Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening

OBJECTIVE

The purpose of this study was to determine the effectiveness of interventions designed to improve follow-up after an abnormal Pap smear.

METHODS

We performed a qualitative meta-analysis of interventions designed to improve follow-up after an abnormal Pap smear and included studies that met the following criteria: randomized or concurrently controlled study design, defined outcomes, and data available for abstraction. Interventions were classified as behavioral, cognitive, sociologic, or combined strategies (e.g., behavioral and cognitive). Abnormal Pap smears were defined as any test result requiring additional follow-up. Effectiveness was measured by the rate of compliance with recommended follow-up.

RESULTS

Twenty-two interventions in 10 studies met the inclusion criteria. Cognitive interventions utilizing interactive telephone counseling were the most effective, improving compliance by 24 to 31%. Behavioral interventions, such as patient reminders, were also effective, increasing follow-up by up to 18%. Not all of these results achieved statistical significance. The single sociologic intervention we identified used video-taped peer discussions to provide a message about abnormal Pap smears and appropriate follow-up. This intervention was not associated with increased follow-up after an abnormal test. The effectiveness of interventions using multiple types of strategies to improve follow-up was inconsistent.

CONCLUSIONS

Cognitive strategies led to the greatest improvement in compliance with follow-up of abnormal Pap smear screening tests. Extension of similar interventions to follow-up of abnormal breast and colon cancer screening, development of physician- and system-targeted interventions, and evaluation of the cost-effectiveness of these strategies are important priorities for future research.

Informing patients of diagnostic mammography results: mammographer's opinions

PURPOSE

The authors' purpose was to determine mammographers' practices and attitudes regarding disclosing results of diagnostic mammograms to patients.

MATERIALS AND METHODS

In 1995, the authors mailed a questionnaire to 500 members of the Society of Breast Imaging; 399 (80%) responded to the survey.

RESULTS

Three-quarters of respondents stated that mammographers should disclose results to their patients, and approximately half were already doing so (52% for normal results, 51% for abnormal results). A sizable minority (25%) said that not telling patients was the best practice and identified several barriers to direct disclosure, including lack of time. Although bivariate analysis showed direct disclosure to be more common among female mammographers, the sex difference did not persist in multivariate analysis. In both bivariate and multivariate analyses, reading more than 100 mammograms per week and having a radiology practice in a university or academic setting were each strongly associated with direct disclosure.

CONCLUSION

Implementation of the Mammography Quality Standards Reauthorization Act of 1998 may not require a major change in mammographers' current practice. It remains critical to establish systems that help radiologists disclose results and communicate with referring physicians efficiently and effectively.

Consultations for 'maladaptive denial of illness' in patients with cancer: psychiatric disorders that result in noncompliance

Patients who present with late stages of cancer often have complicated medical and psychiatric problems which are labeled as 'maladaptive delay or denial.' In some of these patients, psychiatric problems have either contributed to the delay in medical presentation for care or have interfered with treatment of the late stage cancer. The authors review some of the factors that contributed to delay and noncompliance in a series of patients with cancer who were evaluated by the psychiatric consultation service of a university hospital. Specifically, psychoses and cognitive impairment played a major role in delay and noncompliance. The authors discuss recommendations for management of such patients, and suggest that clinicians often benefit from the assistance of the psychiatric consultant as part of the treatment team. Multiple resources and multiple types of intervention are needed in order to help such patients negotiate the clinical environment.

Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem

OBJECTIVE

To describe factors related to compliance diagnostic follow-up among minority women of low socioeconomic status with abnormal screening mammograms.

METHODS

A retrospective cross-sectional survey using a structured telephone interview. Three cancer screening clinics at an urban inner-city public hospital. All women with abnormal screening mammograms between September 1990 and January 1992 were eligible; women were interviewed in August 1992. Abnormal mammograms were those requiring specific, non-routine clinical follow-up; non-compliance was defined as delayed follow-up (four to six months after the date of the mammogram), or no follow-up at the time of interview (more than 6 months after abnormal).

RESULTS

Sixty-two of 442 screened women had abnormal results; the overall rate of non-compliance with follow-up was 50%. Among the 42 (68%) women who agreed to be interviewed, non-compliers were less likely to state that they had been told to receive follow-up than compliers (65% versus 100%; p = 0.008). Non-compliant women were less likely to have suspicious mammography interpretations (p = 0.05), and more likely to report barriers to follow-up, such as cost of lost wages and medical care, system barriers, or fears, than compliant women (61.9% versus 9%, p = 0.01). There were no differences between the two groups for age, education, insurance, source of care, family history, knowledge or attitudes.

CONCLUSIONS

These preliminary results suggest that follow-up of low income, minority women with abnormal screening mammograms could be enhanced by improved communication of results. Future studies should extend these findings with larger samples and in other settings and populations.

Evaluation of factors potentially associated with inadequate follow-up of mammographic abnormalities

BACKGROUND

To increase the proportion of women who receive the recommended follow-up for mammographic abnormalities, factors which inhibit follow-up must be identified. Patient and health care delivery related factors were evaluated, stratified by type of follow-up recommendation, to determine reasons for inadequate follow-up.

METHODS

All Caucasian and African American women at the Henry Ford Medical Group, in southeastern Michigan, with an abnormal screening mammogram result between January 1, 1992 and July 31, 1992 were identified. All women with inadequate follow-up, and a random sample of women with adequate follow-up, were invited to participate in a telephone interview that assessed three major dimensions of the Health Belief Model (susceptibility, benefits, and barriers), general health and health behaviors, and related characteristics. The relationship between these factors and inadequate follow-up was evaluated separately for women with immediate and 6-month follow-up recommendations, using univariate and multivariate analyses.

RESULTS

A total of 555 women were invited to participate in the study (219 with inadequate follow-up and 336 with adequate follow-up). Interviews were completed for 418 women (75.3%). Women who were not notified of their mammographic abnormality were excluded from this study, leaving 399 women available for analysis. Among the women who had the recommended immediate follow-up, those who reported difficulty in obtaining medical appointments were 4 times more likely to have inadequate follow-up (95% confidence interval [CI] 1.5, 11.3), after adjusting for other variables. Among the women with six-month follow-up recommended, those who received fewer mammograms in the past 5 years were more likely to have inadequate follow-up (odds ratio [OR] = 4.0; 95% CI 1.6, 10.4). In this group, sociodemographic characteristics were not associated with inadequate follow-up, although women with transportation problems were at a higher risk (crude OR = 5.2; 95% CI 1.6, 16.7; adjusted OR = 3. 1; 95% CI 0.5, 18.3). Among women with 6-month follow-up recommended, those who perceived their health as poor or fair (crude OR = 2.4; 95% CI 1.2, 5.1; adjusted OR = 2.3; 95% CI 0.8, 6.8) and those who did not examine their own breasts frequently (crude OR = 2.3; 95% CI 1.0, 5.4; adjusted OR = 2.7; 95% CI 0.5, 18.3) were also more likely to have inadequate follow-up.

CONCLUSIONS

Results from this study demonstrate that the relative importance of factors associated with inadequate follow-up of abnormal mammograms differs according to the type of follow-up recommended. For both types of recommendations, the factors identified are noteworthy because they are amenable to intervention. Efforts should be made to facilitate appointment scheduling for follow-up of abnormal mammograms, and information about previous mammography screening should be obtained to identify women who are at a high risk for inadequate follow-up.

Patient compliance in mobile screening mammography

RATIONALE AND OBJECTIVES

We assessed the follow-up behavior of women who had abnormal results of screening mammograms taken on a mobile van.

METHODS

A retrospective cohort study was conducted between 1988 and 1991 of all women served by a mobile mammography van in rural North Carolina. Compliance with radiologist recommendations for follow-up was assessed through review of patient records and mail surveys of patients with incomplete records.

RESULTS

Compliance was 44% for negative or benign mammograms, 57% for indeterminate mammograms, and 62% for probably malignant or malignant mammograms. Women who had a previous mammogram or had a malignant finding were more likely to comply with follow-up recommendations (p < .0001) than women with normal or benign results and no history of mammography. Compliers and noncompliers did not differ with respect to family history of breast cancer or personal history of breast discomfort.

CONCLUSION

Compliance with recommendations in this setting was lower than expected. This may be because rural women using mobile van mammography have limited access to the resources needed for appropriate follow-up. Further research is needed to examine explanations for poor compliance in this setting.

Mammography use and outcomes in a community. The Greater Lansing Area Mammography Study

BACKGROUND

Mammography is widely known to reduce morbidity and mortality from breast cancer, but a population-based assessment of mammography use and follow-up of mammography findings has not been reported previously.

METHODS

An observational, population-based, follow-up study was conducted of all women having mammograms in the Greater Lansing, Michigan, metropolitan area, between June 1987 and June 1988. A total of 17,811 Greater Lansing women participated. The adherence of women to mammography screening guidelines was estimated, and mammography's utility to detect breast cancer was assessed through follow-up review of breast biopsy results.

RESULTS

Thirty-seven percent of the expected number of women 35 years of age and older had mammograms. Adherence to screening guidelines declined with age, and less than 5% (302 of 6700) of women 55 years of age and older reporting having annual mammograms. Seventy-six percent of women reported that their physicians prompted the examination. The predictive value of a positive mammogram was 21.9% for women without symptoms and 32.4% for women with symptoms. Mammography's sensitivity and specificity for breast cancer detection were 71% and 98%, respectively.

CONCLUSIONS

The study highlights the need to target mammography to women 50 years of age and older, underscores the importance of physicians in promoting mammography, and demonstrates the analytic value and limitation of mammography in clinical decision-making.

Evolving medical-legal concepts for clinicians and imagers in evaluation of breast cancer

The past decade has seen an intense focus on the evaluation of American women for the detection and diagnosis of breast cancer. A concomitant increase in lawsuits filed for delay in diagnosis of breast cancer has occurred, creating consternation in the medical community. Efforts in responding to this public health challenge, comprised by fear of legal reprisal, may be supported by careful and deliberate planning that incorporates risk management principles and an understanding of different goals to be attained with consequent medical and legal responsibilities.