At a time when there is increased discussion about when women over 40 should receive routine mammography screenings and concern over mammography’s effectiveness, the State of Illinois is taking a major step forward to improve the quality of mammography.

At the Metropolitan Chicago Breast Cancer Task Force’s 2011 “Uniting to End Disparities” Breast Cancer Conference , Director Julie Hamos, from the Illinois Department of Healthcare and Family Services, announced that Illinois is initiating a statewide mammography quality improvement program in 2012 based on the groundbreaking work of the Metropolitan Chicago Breast Cancer Task Force’s Chicago Breast Cancer Quality Consortium project. The national office of Susan G. Komen for the Cure ? has invested $2.1 million into the Consortium Project. The Avon Foundation for Women has also invested $1.25 million toward the Task Force’s work.

Growing disparities
In 2008, after publication of disturbing data showing growing disparities in the death rate from breast cancer in Chicago, the Metropolitan Chicago Breast Cancer Task Force was established along with its healthcare provider collaborative project, the Chicago Breast Cancer Quality Consortium. The central hypothesis of the Task Force is that unequal access to the highest quality breast care contributes significantly to Chicago’s disturbingly high breast cancer death rate for women of color. The Consortium collects quality data on breast cancer screening and treatment. Komen’s managing director of community health, Mollie Williams, said that the Chicago program will help Komen find solutions nationwide for disparities in breast cancer outcomes for African American women. Nationwide, African American women are 39% more likely to die of breast cancer than white women. Here in Chicago, the gap is even higher at 62%.

On Friday, the Consortium released a report with results from its second year of data collection. This year, the Consortium received screening data from 39 hospitals, 4 public health clinics and 14 hospital affiliated mammography facilities and treatment data from 20 hospitals. This is a 23% increase in reporting entities compared to last year’s data submission. The Consortium analyzed the data and provided results to each participating hospital.

Opportunities for improvement
While the current data shows significant improvement in the quality of data collected there are many opportunities for improvement. Last year’s data was based on screening and treatment provided in 2006 whereas the new data is based on screening and treatment provided in 2009. Many facilities have updated mammography equipment since 2006 and moved to digital machines and many have instituted new electronic medical records and tracking systems for mammography, However substantial variation remains in facilities’ ability to demonstrate that they meet mammography quality benchmarks. While less variation was found in treatment, a certain number of treatment providers were unable to demonstrate they met quality standards in a wide variety of areas. It goes to the heart of the purpose of mammography program to be able to show that it finds cancer and finds it when it is small and early stage. Likewise, ensuring and being able to show that each breast cancer patient gets treatment according to national guidelines in a timely fashion is key to the survival of patients.

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Sixty percent (30 of 50) of reporting facilities were able to demonstrate that they met the quality standard for finding cancers. The Consortium’s quality standard was defined this year as finding between 3 and 10 cancers for every 1,000 mammograms. Thirty percent(15 of 50) of reporting facilities were able to demonstrate that they met the quality standard for early detection, or finding cancer when it is still small. The quality standard is defined as at least 30% of detected breast cancers should be very small or low-risk. A little over one third (18 of 50) of the reporting entities were able to demonstrate that they met the standard for ensuring patients received follow up imaging after an abnormal mammogram. The standard is defined as having had a “lost to follow-up” rate of less than or equal to 10%. Seventy five percent (15 of 20) of reporting facilities were able to demonstrate that they met the standard for timely treatment. The quality standard is defined as at least 80% of patients receiving treatment for breast cancer within 60 days of diagnosis. Seventy(14 of 20) of the reporting facilities were able to demonstrate that they met the standard for recommending radiation therapy after breast conserving surgery. The standard is defined as at least 85% of patients being recommended for radiation therapy after breast conserving surgery.

Most of the reporting facilities (19 of 20) were able to demonstrate that they met the standard for hormone receptor testing. The standard is defined as at least 90% of patients having their tumors tested for hormone receptors.
The Task Force anticipates data from more providers over the next 2 months and a final updated community report will be available in early 2012.

The Consortium also received an additional grant of $500,000 from Susan G. Komen for the Cure to do further in depth analysis of the processes of breast care across the continuum from screening through diagnosis to treatment. This comprehensive process mapping was performed at 26 facilities in Metropolitan Chicago and found significant variation in services available, timeliness of services and patient centered care. Facilitators and barriers to best quality care were identified.

Barriers to a patient getting the best care possible:
– Burden is usually on Primary Care providers to coordinate breast care for patients in lower resourced areas;
– Patient access to breast cancer specialists in radiology, surgery, medical oncology and radiation oncology is typically related to where a person initially went for care rather than medical need;
– Lack of prior film (comparison film) availability for mammography can result in unnecessary repeat imaging, difficulty in seeing breast changes over time, delays in reading mammograms and other problems;
– Follow-up on abnormal results is inconsistent across sites, and relies on inadequate manpower;
– Many breast cancer patients do not have an individual supporting/tracking across their course of care ensuring that they get all the care they need;
– Rembursement practices by payers often slow down breast care, specifically timeliness of diagnostic mammograms and of breast biopsies;
– Breast cancer survivorship care is inconsistent and often not actively managed and this has the potential to affect survival if a re-occurrence happens.

Elements that can help patients get the best care possible:
-Public awareness of accessible, affordable screening resources.
Acceptance of patient self referrals for screening mammography that allows patients direct access to screening mammography;
– Timely transfer of images between care sites or the creation of a centralized mammography image center;
– Same day results to patient for diagnostics and when indicated same day biopsy.
– A centralized hub for biopsy/pathology results;
– Patient follow-up and tracking, with centralized services to support low-resource site operations;
– Breast cancer community organization awareness of the benefits of high quality referrals for diagnosis and treatment;
– Creation of a patient referral structure by geographic area based on patient needs including type of breast cancer (aggressive form versus non aggressive form, early vs. late stage), capacity and volume;
– Use of incentives and measures to encourage cooperation between hospitals and other institutions involved in breast care.

For more information on these projects, visit Chicago Breast Cancer Quality Consortium.

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