Confluence Health - AMGA · Confluence Health 2 Formed in 2013 as an affiliation between Wenatchee...

Confluence Health

Screening Mammography: Creating a Uniform Patient Message

in a Cloud of Controversy

Julie Smith, MD - Medical Director Cancer Service Line Randal Moseley, MD - Medical Director of Quality and Care Transformation

AMGA Webinar 9/16/2015

Confluence Health

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Formed in 2013 as an affiliation between Wenatchee Valley Medical Center and Central Washington Hospital Mission is to improve our patient’s health by providing safe, high-quality care in a compassionate and cost-effect manner. Clinics in 12 communities over 12,000 square mile service area in North Central Washington State 270 physicians and over 100 advanced practice clinicians About 200 inpatient beds in two hospitals in Wenatchee

Confluence Health Cancer Service Line

• Received CoC Outstanding Achievement Award for our 2014 Survey

– Dual Survey with CWH&C and WVH&C

– Plan to become Network Program

• Launched Oncology Service Line in Confluence Health

– Brings oncology services and care under same leadership moving in a common direction

– Allows the CH Cancer Program to evaluate and direct care across the continuum

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Institute for Clinical Systems Improvement

(ICSI)

American Academy of Family Physicians

Canadian Task Force on Preventive Health Care

Advisory Committee on Cancer Prevention in the EU

HEDIS

The Problem with Mammography

Cochrane

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What Our Patients See (or not)

Lay Press

Primary Care recommendations vs. Mammographer recommendations

Insurance company direct patient mailings

• Patient-centered decision aids are hard to find

• Benefits typically emphasized over harms¹

• Often no fully transparent discussion of harms:

– Frequency of false alarms²

• Over 10 years, >50% need additional images

• 20% of these undergo biopsy

– Over-diagnosis²

• Estimate 20% of CAs diagnosed by mammography

• Patient perception of benefits may be inflated

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How Do Our Patients Decide?

¹JAMA Intern Med 2013;173(13):1215-1221 ²JAMA 311(13) (2014): 1327-1335

NEJM 370;21

What Is Informed Shared Decision Making?

“The process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”

A.M. O'Connor et al, “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids” Health Affairs, 7 October, 2004

Elements of Shared Decision Making

• Invite the patient to participate

• Present the options

• Provide information on benefits and risks

• Help the patient evaluate the options based on their goals and concerns

• Facilitate deliberation and decision-making

• Assist with implementation http://www.slideshare.net/fimdm/six-steps-of-shared-decision-making

Informed Medical Decisions Foundation

CH Mammography Compliance

• What is our baseline rate of screening mammography? • Age 50-74:

– 21,709 patients with an internal PCP – 1,476 patients excluded based on “N/A” marked in

Health Maintenance. – Of the 20,233 remaining, 61% with at least one

screening mammogram within past 24 months – National rate (CDC, 2010) = 72%

• Would rates be higher if our patients received a unified message?

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Workgroup Team Members

• Quality department

• Internal Medicine & Family Medicine MDs

• OB/GYN MD

• PCPs representing outlying clinics

• Community Health Clinic partner MD

• Oncology MD

• Women’s Imaging Radiology MDs

• Marketing

• CMIO

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Challenges within the group

• Strong conflicting opinions aligned with individual specialty society recommendations

• Professional autonomy

• Perceptions of malpractice risk

• Conflicting views of literature; benefit vs. harm

• Differing risk models of uncertain validity

• Breast density impact

• Developing shared decision making tools

• Near absence of readily available patient-centered tools

• Keeping the focus: Patient needs vs. our opinions of screening mammography best practice

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3 Main Questions for Patients

• Age 40-49

– Should I have screening mammography?

• Age 50-74

– How often should I have a mammogram?

• Age 75+

– Should I continue screening mammography?

Ages 40-49 Should I have screening mammography?

• Confluence Health recommends women in this age group discuss with the PCP whether to have screening mammograms, with the key being that a woman in this age group understand her personal risk of breast cancer

• Recommended risk assessment:

– Baseline mammography at age 40 to determine breast density

– Use breast cancer risk calculation tool: www.cancer.gov/bcrisktool

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9/17/2015

Ages 50-74 How often should I have a mammogram?

• Confluence Health recommends all women in this age group have a screening mammogram at least once every 2 years

• The question is whether to get a mammogram every two years or yearly

• The key is to understand that choice, and know personal risk

• Use breast cancer risk tool: www.cancer.gov/bcrisktool

• Discuss this decision with Primary Care Provider

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Ages75+ Should I continue screening mammography?

• Confluence Health recommends women in this age group discuss with their PCP whether to continue screening mammograms

• The key is to understand that the value of continuing mammography depends upon age and overall health

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Age 40-49

Baseline mammogram & risk assessment, shared decision making for mammography choices: Yes or No

Annual mammogram Until age 50

Age 50-74

No mammography

Risk assessment, shared decision making for mammography choices: Annual vs. Biannual

Biannual mammogram until age 50

Yes mammography

Annual mammogram Until age 74

Biannual mammogram until age 74

Age 75

Shared decision making for mammography choices: Continue or discontinue

CH Screening Mammography Algorithm

9/17/2015

9/17/2015

Patient surveys of materials

• Likert scale used to answer 3 questions:

– Easy to understand?

– Fair and balanced?

– Provides help with provider discussions?

• Comments: Any information that was confusing and should be clarified?

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Age 40-49 survey results

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Age 50-74 survey results

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Age 75+ survey results

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Patient Comments

• The information would have been helpful in making my first mammography decision

• Nothing was confusing, I was pleased with the information about the possibility of over-diagnosis

• Do women dying from breast cancer die from the treatment or the cancer itself?

• I’ll go with whatever my primary care doctor says!

• Bigger print needed for the elderly

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Roll Out - Patients

• Patient educational materials: MyChart, print

• New verbiage of standard mammography patient result letter

• Internet website for Confluence Health

• Community newsletter mailing to 120K homes

• Cancer Committee Annual Report

• Community outreach

• Website video vignette with a PCP:

– https://www.youtube.com/watch?v=jAAxGARE_ec

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Roll Out - Providers

• Confluence Health Board and WVMG Board

• BPA/HMA in Epic individualized by age group

• New verbiage of standard mammography report

• “Physician Toolbox” materials

• Cancer Committee Annual Report

• Meeting with every affected provider group

• Presentation to SCCA Network Summit June 2015 meeting for regional feedback

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9/17/2015

9/17/2015

9/17/2015

Lessons Learned & Next Steps

• Right people at the table

• Don’t always expect objectivity

• This will take longer than you think

• Don’t declare victory too soon

• Metrics:

– SDM discussions

– mammography rates

• Ongoing education, refinement, updating

Questions???

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randal.moseley@confluencehealth.org

julie.smith@confluencehealth.org