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Breast and Cervical Cancer Screening: Clinicians' Views on Health Plan Guidelines and Implementation Efforts
Affiliations of authors: University of Massachusetts Medical School, Worcester, MA (JGZ); University of Massachusetts School of Public Health–Amherst, Amherst, MA (EP); Group Health Cooperative, Seattle, WA (ST); HealthPartners Research Foundation, Minneapolis, MN (LIS); Kaiser Permanente Colorado, Denver, CO (JM); Kaiser Permanente Northern California, Oakland, CA (CS); Kaiser Permanente Southern California, Pasadena, CA (AMG); Henry Ford Health System, Detroit, MI (MUY)
Correspondence to: Jane G. Zapka, ScD, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655 (e-mail: Jane.Zapka{at}umassmed.edu).
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ABSTRACT |
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Background: Optimizing breast and cervical cancer screening rates within health plans requires clinician support for screening guidelines, an awareness of whether there are tools available and functioning to aid screening implementation, and a perception of collegial and leadership support for quality screening services. This study investigated clinicians' perceptions of guidelines, reminders for screening, and plan and practice commitment in order to assess where opportunities exist to improve the screening process. Methods: A stratified sample of 761 primary care clinicians from three comprehensive health plans were surveyed to assess awareness of and agreement with guideline elements, perception of guidelines' usefulness, awareness of plan strategies to promote guideline adherence, perception of support for high-quality screening services, and ratings of plan efforts to maximize members' access. Results: Clinician awareness of and agreement with guideline elements was high (98% breast, 94% cervical). Across guideline elements, agreement was lower for mammography than cervical screening, notably for upper age limit recommendations (58% breast, 79% cervical). Knowledge of systems that cue patients and clinicians that screening is due varied by cancer test, and clinician report and plan report data about the existence of systems were, at times, not congruent. Views about consistent operation of systems differed by test (mammograms, 74%–92%; Pap, 66%–84%). Clinicians rated local colleagues and local and plan medical leadership as very committed to high-quality screening, albeit with somewhat lower ratings for cervical testing. Although the majority rated overall plan efforts to maximize screening as very good or excellent, perceived consistency of systems to cue a woman that she is due for testing and perception of collegial support were independently and significantly related to ratings of plan efforts. Conclusions: Improvements in knowledge of systems that support guideline implementation varied, and action to ensure accurate perception of reminders, as well as consistent implementation of systems, may be important for improving screening rates and outcomes. Plan efforts and clinician efforts at the practice level are closely linked and need to be aligned to maximize screening rates. This requires plan and practice–level analyses of structures and processes that could be improved.
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INTRODUCTION |
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The effectiveness of screening for breast and cervical cancer is both widely accepted and supported by a substantial evidence base, despite recent controversy about the validity of some mammography studies (1–4). As a result of this belief in the benefit of screening, and the promotion of these tests, national rates for mammography and Pap screening are relatively high, especially in managed care plans (5). However, there is still room for improvement in some populations, and there may be a core of women at high risk because they have never been screened (5–7). For example, nationally, some 82% of women have had a Pap within 3 years, 72% have had a mammographic examination within 2 years, and the Health Plan Employer Data and Information Set (HEDIS) (8) suggests that average rates were at 78.1% and 74.5% for Pap and mammogram, respectively, in 2000 (5). Thus, 18%–28% of women nationally are not receiving these important tests at a minimum frequency, and avoidable invasive cervical and late-stage breast cancers still occur (7–9). Within integrated health care plans, as many as 18% of diagnosed cancers may be late stage, and the majority of invasive cervical and late-stage breast cancers that occur are due to an absence of screening (7,10). Although reducing mortality is the ultimate goal of screening, avoiding late-stage breast and invasive cervical cancer are important intermediate end points (11).
Further improvements in Pap smear and mammography screening rates need to consider the context within which screening occurs and to maximize systems to support the implementation of screening. As conceptualized in the continuum of cancer care, identifying potential failure points in the processes of care that may lead to the occurrence of late-stage breast and invasive cervical cancer might be important for quality improvement efforts (12). These include failures in detection, communication, and follow-up of recommendations (13). Individual patients and clinicians, environmental factors, and organizational strategies affect these processes of care (14,15). Because promulgation of guidelines alone has only limited effect and is insufficient to maintain needed clinician behaviors (16–19), multilevel organizational strategies are critical to continued improvement of screening rates. Key organizational strategies include well-designed delivery systems, clinical decision support, clinical information systems, and patient self-management support (20–22).
Although it is assumed that clinician awareness of and support for guidelines are necessary to success, this association has not been evaluated. In addition, organizational theory would suggest that perception of leadership and organizational commitment to an activity are critical to its success. The notion of "professional norms" has been emphasized in previous work about the importance of the practice environment (23). Rolnick and O'Connor (24) have observed that key lessons learned in assessing the effect of clinical guidelines include both the importance of champions within the clinical environment and the need for tools and systems. Therefore, we assessed the performance of these organizational strategies, as well as the factors affecting their implementation, in a survey of primary care clinicians in three health plans. We had previously collected information about the policies and practices these health plans reported having in place to facilitate Pap and mammography screening (13). We expected that primary care clinicians in these plans were in an excellent position to report on the clinical effect of several organizational factors on screening, provide their perceptions of leadership in the process, and rate their plan's overall efforts to maximize screening.
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METHODS |
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Setting
Three integrated health care delivery systems—Group Health Cooperative, Kaiser Permanente Colorado, and Kaiser Permanente Northern California—participated in this study. These plans each had above-average HEDIS rates for screening mammography and Pap smears. In 1999, the plans' commercial HEDIS rates for Pap tests ranged from 77% to 84% (national average was 72%). Their mammography rates that year were 76%–82% (national average of 73%). These plan types are a small segment of the managed care market, but they provide care for millions of Americans and serve as benchmarks and models for other types of care systems. The plans were members of the Cancer Research Network, a consortium of research organizations affiliated with nonprofit integrated health care delivery systems and the National Cancer Institute. The Cancer Research Network (CRN) consists of the research programs, enrollee populations, and databases of 11 integrated healthcare organizations that are members of the HMO Research Network. The health care delivery systems participating in the CRN are Group Health Cooperative, Harvard Pilgrim Health Care, Henry Ford Health System/Health Alliance Plan, HealthPartners Research Foundation, the Meyers Primary Care Institute of the Fallon Healthcare System/University of Massachusetts, and Kaiser Permanente in six regions: Colorado, Georgia, Hawaii, Northwest (Oregon and Washington), Northern California, and Southern California. The 11 health plans have nearly 10 million enrollees. The CRN conducts collaborative research on variations in cancer prevention and treatment policies and practices. The overall goal of the CRN is to increase the effectiveness of preventive, curative, and supportive interventions for major cancers through a program of collaborative research. These three plans participated in a larger study, Toward Reducing Cervical and Late Stage Breast Cancer (DETECT) (12), in which it was demonstrated that 53% of late-stage breast and 56% of invasive cervical cancer had not been screened within recommended intervals, while 8% and 12% had positive screening tests, but follow-up took more than a year before diagnosis (7,10). One of the specific aims of DETECT was to explore reasons for success or failure in the processes of delivering these screening services.
The three plans are staff/group models: plan A has 480 000 members receiving care at 28 primary care sites, plan B serves 3.1 million members at 37 sites, and plan C serves 340 000 members at 15 sites. At plan A, mammography is available at six sites and the program is coordinated by one radiology group, at plan B there are 33 mammography sites managed by 18 different radiology groups, and at plan C one group coordinates seven mammography sites. In each plan, Pap smears are available at all primary care sites and are read by one pathology group. The plans, however, have different approaches to primary care clinician staffing, both by discipline and specialty (see Table 1).
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All three plans have practice guidelines for both cervical and breast cancer screening that include key elements of risk definition, periodicity, and lower and upper age limits. For example, the mammography recommendation for women over age 75 years is stated as an informed "clinician/patient decision" in one plan, is not commented on in the second, and is explicitly recommended as a time for discontinuation in the third. Clinician information systems strategies to facilitate guideline implementation also vary by screening type. For example, all plans have clinical information systems that cue a woman when she is due for mammography, but each differs in approach. In one plan a tailored reminder is mailed to all members, in the second a standard generic notification is mailed to all members, and in the third plan all women receive notification when they make visits to the health plan (printed on the visit registration slips), and some sites conduct additional mailed outreach.
The study was reviewed and approved by the research committees and institutional review boards responsible for each organization.
Clinician Sample
Clinicians eligible for this study were physicians, physician assistants, and nurse practitioners in obstetrics/gynecology, family medicine, or internal medicine. Inclusion criteria included plan employment for at least 1 year and at least half-time ambulatory adult practice. Clinicians who were hospitalists or on leave were excluded. A sample of clinicians, stratified by specialty, was obtained from each plan. An initial sample of 761 clinicians was identified: 244 (plan A), 249 (plan B), and 268 (plan C). This sample size was based on an estimated overall return rate of 60% and a desired analyzable final sample of at least 160 surveys per plan. Initial sample pulls ranged from 28% to 95% of the eligible clinicians because of differences in plan size. Of these, 11% (81) did not meet the inclusion criteria, leaving 680 eligible respondents.
Measures
The following measures were included in the survey.
Clinicians' reported awareness of plan guidelines. We first asked whether a guideline existed in their health plan. We also elicited clinicians' agreement with four guideline elements: description of risk categories, lower age to begin screening, upper age to limit screening, and interval between screens. Response choices were "yes," "no," "don't know," and "plan has no guideline."
Clinicians rated the usefulness of each guideline in their clinical practice. A 4-point rating scale ranged from "not at all" to "very useful."
Four items assessed awareness of systems strategies in place to promote guideline adherence: systems that cue/prompt a woman she is due for screening, cue/prompt the clinician that a particular woman is due for screening, ensure that a woman is notified of an abnormal test, and identify women who fail to appear for follow-up of an abnormal test. On the basis of the previously collected organizational assessment data about these systems (13), respondent answers were coded as agreement or nonagreement with plan report. For each strategy, respondents were asked to rate the implementation of the system, and specifically how consistently the system worked (seldom, sometimes, routinely).
A clinician's perception of support from colleagues and plan administration was assessed by items asking how committed (word and deed) to high-quality screening services were primary care colleagues at their care delivery site, clinical leaders at their care delivery site, medical group leadership, and plan leadership. The 4-point rating scale ranged from "not at all" to "very," with "don't know" as an option.
Two items asked clinicians to rate their plan's efforts to maximize members' access/use of screening. A 5-point scale ranged from "excellent" to "poor," with "don't know" also an option. This was dichotomized for analysis as "excellent/very good" vs. "good/fair/poor."
Several provider characteristics were examined: gender, birth year, number of years with the plan, discipline, and specialty.
An extensive pretest of the survey, including cognitive interviews (25), was undertaken with clinicians from each site who were not part of the sample. The final instrument was an optically scanned three-page questionnaire. All questions were asked separately for breast and cervical cancer screening.
Data Collection
Data collection (September–December 2000) involved a four-phase strategy (26). In phase I, participants received the survey in a first-class mailing, along with a cover letter (signed by a health plan or medical leader, as well as by the director of the National Cancer Institute), a prepaid return envelope, a complimentary coffee coupon, and a stamped return postcard that identified them as returning the survey. Instructions were to return the postcard at the same time that they returned the survey, but separately. In this manner, survey responses were anonymous while providing a mechanism for nonresponder follow-up. Phase 2 was a remailing to all study clinicians who had not returned their initial postcard. In phase 3, a physician leader or designate from each site directly contacted nonrespondents, reminding them to complete the survey and sending new materials if requested. Persistent nonrespondents were called by a telephone survey research group in phase 4.
Analyses
The study employed a two-stage cluster design. The primary sampling unit was the plan (n = 3), the secondary sampling unit was specialty (n = 2, collapsing family medicine and internal medicine as a result of small sample size within one plan), and the unit of observation was the individual clinician. Sampling weights were calculated based on plan and specialty population counts. Unweighted descriptive statistics are reported for respondent demographics. Further analyses take into account the cluster design and are weighted accordingly. Bivariate chi-square statistics and odds ratios with 95% confidence intervals assessed the association of each independent variable with ratings of the dependent measure, the rating of efforts to maximize screening. Proportional odds polytomous logistic regression was initially used to model the association between each of the dependent variables and independent variables with statistically significant bivariate associations. Insignificant differences between levels of the dependent variable led the authors to collapse the four categories into two categories: excellent and very good versus good, fair, and poor for ratings of effort. Using this dichotomous outcome, rating of plan efforts, logistic regression modeled the association with those variables for which individual associations were statistically significant at the 25% level in the bivariate analyses. Demographic characteristics were evaluated as potential confounders and were considered in the final model. Two-way interactions between independent variables were tested for effect in the final model. Significant interactions with plan were retained in the final model. All analyses were conducted using SAS Version 8, STATA Version 7 and SUDAAN Version 8.0 software. With a sample of 621, we had 80% power to detect a significant odds ratio of 1.69 in the logistic model of ratings of plan effort.
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RESULTS |
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Respondents
Of the 680 eligible clinicians, 621 (91%) returned completed surveys. Table 1 reports respondents' characteristics by plan. Plan A clinicians were significantly older, had longer affiliation with the plan, were predominantly family medicine clinicians, and had the highest proportion of physician assistants. Although the majority of respondents in all plans were physicians, plan B had more nurse practitioner respondents and the greatest proportion of internal medicine clinicians. Plan C had roughly equal proportions of family medicine and internal medicine clinicians and about 22% Ob-Gyn clinicians.
Guideline Awareness, Agreement, and Usefulness
All three plans have screening guidelines for both cancers, and the vast majority of clinicians were aware of them (99% for breast, 94% for cervical), although the difference between screens was significant (p<.001). As reported in Table 2, clinician agreement with guideline content ranged from 58% to 98% for the four guideline elements. The least agreement overall (58%) was with the mammography upper age limitation recommendation. A slight majority of clinicians rated the breast and cervical screening guidelines respectively as very useful (56%, 53%), but an additional proportion found theirs somewhat useful (33%, 28%) in clinical practice. Only 2% reported that these guidelines were not at all useful.
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Systems Implementation, Commitment, and Ratings
Table 3 reports the clinician respondents' agreement with the plan report of systems in place to promote screening. Agreement was generally lower for cervical screening than for mammography systems. For mammograms, all three plans reported having a system to cue the woman when she is due for screening, ensure the woman has been notified of an abnormal result, and identify women who have failed to appear for follow-up of an abnormal result. The percentage of clinicians who agreed that these systems were in place was 85%, 86%, and 65%, respectively. Overall, 71% of all the clinicians agreed with their plan's report about cueing the physician when a member is due for a mammographic examination (data not shown), but in the two plans without physician cueing, 39% of clinicians reported a system when the plans said that one did not exist.
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For cervical screening, one plan reported not having a system established to notify a woman who is due for a Pap test. Overall, only 41% of clinicians in that plan agreed with the plan's report (data not shown). However, 80% of the clinicians from the plan without cues reported that they indeed had them. Two plans do have a system to cue the clinician when a woman in their panel is due for a Pap test; 71% of the clinicians from all plans agreed with the plans' report (data not shown), and 21% of the clinicians from the one plan without cues reported a system. Two plans have a system to ensure that the woman has been notified of an abnormal Pap; 56% of clinicians overall in the three plans agreed with their specific plan; however, 72% of clinicians at the plan reporting no notification system reported having one. Although all plans reported a system that identifies women who have failed to appear for a Pap follow-up, 51% of clinicians reported awareness.
Table 4 lists the clinicians' ratings of how consistently the systems work. We included the ratings of all clinicians reporting a system (whether their report agreed with the plan report or not), as perceptions can determine other beliefs and actions. More clinicians reported the systems related to breast screening to routinely work than those related to cervical screening, with the highest ratings given to notification of abnormal mammograms (92%) and abnormal Pap smears (84%). The ranges demonstrate wide variability among the plans with respect to reports of routine operation.
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Table 4 also reports respondent ratings of commitment to high-quality screening. Clinicians rated plan leadership commitment significantly lower (p<.01) than primary care colleagues and medical leadership at the care site and the plan level; 22%–28% of the sample said they did not know the commitment (to either screen) of the plan leadership. Nevertheless, 54%–65% feel that commitment is very strong. Using the cluster sampling procedures, which account for site, the proportion of respondents who reported very high commitment of colleagues and leaders appears to be greater for breast than for cervical screening.
The proportions of clinicians reporting ratings of excellent for plan efforts to maximize access to breast and cervical cancer screening (bottom of Table 4) were relatively low (33% and 23%, respectively) and differed significantly for breast versus cervical screening (p
.0001), even when controlling for site. However, about one-third rated plan efforts as very good (35% and 34%, respectively).
The final multivariate model for rating of plan effort for maximizing access to and use of cancer screening is presented in Table 5. Perceiving consistent function of the cueing system for a woman who is due for testing is significantly related to excellent ratings of plan efforts for both breast and cervical screening.
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Perceived commitment at the various levels is important for both screens, although with variable patterns. As seen in Table 5, referent categories to excellent ratings differed between screens to better illustrate where the differences occurred. Perceived very high commitment of immediate clinical colleagues was related to very high effort ratings for cervical screening, whereas very high commitment of the plan medical leadership was independently and significantly related to very high ratings for mammography service efforts.
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DISCUSSION |
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This study, with a very high response rate, demonstrated a high level of awareness and support for guidelines, differences in reports by type of screen (mammography and cervical), lack of agreement with plan reports of systems in place and working routinely, variable perceived commitment among groups of colleagues, and very good to excellent overall ratings of plan efforts to maximize access to screening.
These generally high levels of awareness and support for plan guidelines and implementation efforts parallel findings of Salem-Schatz and colleagues (27), who reported that attitudes toward practice guidelines of internists and family physicians in a large, mixed-model HMO were very positive and more favorable than a nationwide survey.
Interestingly, agreement with specific guideline elements varied across the two guidelines, with more agreement with each of the cervical guideline elements. The least agreement was demonstrated for the mammography upper age recommendation. This guideline component is not as uniform across national consensus groups as other elements, and the issue of appropriateness of screening for "well old-old females" has been discussed in the scientific literature (28) and the popular press. This may partly explain lack of consensus among study participants. As plans revise guidelines, fostering greater clinician input and debate about specific elements may promote greater understanding and consensus on specific elements of the guidelines.
Previous studies have underscored the importance of organizational strategies to increase screening in women who do not get tested regularly (15,29–36). A surprising proportion of the clinicians' reports of the existence, or lack thereof, of several tracking systems did not agree with the reported for these systems by their plan administration. Part of this difference may be attributed to the existence of differing local practice systems, rather than planwide systems. It could also reflect differing use of clinical specialties within the plans (e.g., women in one plan may use a gynecologist as a specialist and be screened by them in addition to seeing another primary care physician). This may lead to variable perceptions of who is getting reminders. As noted earlier, the plans vary by clinician staffing, size, number of primary and screening sites, and specialty (radiology and pathology) structure. All of these differences could contribute to a misconception of systems and misperception of routine operation of systems. This finding may be especially important if the plan actually does not have a system but many clinicians think it does. Clinicians could assume less need to confirm that tests are up to date. Reliance on a system of cues to women that does not exist could reduce mammography screening and account for some of the lack of screening in the associated studies, but this needs further evaluation by the specific plans. The discord between clinician perceptions and plan report is also worrisome for follow-up of abnormal tests because a small but substantial proportion of women had prolonged follow-up after abnormal tests in these plans (7,37). Again, it would be useful for plans to confirm the details of follow-up system reminders to maximize screening implementation.
As important as knowing about a system is clinicians' perceptions about the consistency with which the clinical information system functions. From 8% to 34% of clinicians reported that some system did not work routinely, with such reports being more frequent for those supporting cervical screening. The generally lower reports of routine system consistency for cervical screening may reflect structural and utilization differences. For several systems, trends in the ratings of overall plan effectiveness were related to these perceptions. From a related study (13), we learned that the plans varied in their choice of implementation strategy. For example, plan A reports not having a system to remind women a Pap is due, whereas in plan B, a notation is printed on a registration slip at all centers, with some centers also notifying women by mail, and at plan C a "safety net" reminder notifies a woman by mail when she is beyond the 3-year interval. When Pap screening visits are less driven by plan reminders, clinicians may feel they need to be more attentive to the guideline and give overall plan efforts a lower rating. Other plan factors not studied in this research also may be important, including organizational culture, trust in leadership, or identification with plan philosophy.
For both screening tests, respondents from all plans reported higher commitment to quality services for local and medical leadership as compared with plan leadership. Having distinguished plan medical leadership separately, the last category of "plan leadership" could have been viewed as more administrative and less related to quality. Overall, clinicians viewed the commitment of local colleagues, local and plan clinical leadership, and plan leadership to be higher for breast than cervical screening. High perceptions of commitment ("very committed") were independently related to overall ratings of plan effort. The higher ratings of commitment to mammography screening than to cervical screening may reflect more clinical and public attention, promotion of HEDIS measures, and more standardized follow-up procedures. Characteristics of the organization, both structural and sociological, are again probably associated with plan ratings. It may be that leadership support and implementation of systems explain some of the differences between plans, but differences in delivery system design and clinician make-up may also be important. For example, staffing and service arrangements differ for breast and cervical cancer screening, and within screens, they differ across plans. For example, at plan A, 70% of the mammograms are ordered through a special screening program, so primary care clinicians are not directly involved. In contrast, Ob-Gyn physicians do 92% of the Pap smears at plan B, 66% at plan C, and only 18% at plan A. So although all plans have above average HEDIS measures, they are achieved via variable service arrangements.
Landon and colleagues (23) emphasize that the diverse types of managed health care organizations, (e.g., staff/group model organizations, IPAs, PHOs) affect the quality of medical care. They further assert that plans influence physician behavior through financial incentives, management strategies, structural characteristics and information, and normative influence. Numerous complex interacting factors seem to affect clinicians' perceptions and satisfaction (38). This study confirms that even in plans of similar basic organization (staff/group model HMOs) there is still a variable constellation of these domains that affect clinician perceptions across different services, and various combinations of structural and process factors contribute to high-quality screening services. Future research should specifically identify the implementation strategy (e.g., outreach vs. in-reach for cueing) and contextual factors present in addition to the generic type system.
The generalizability of these findings has limitations because the study focused on high-performing, nonprofit, staff-model plans. The application of our findings to beyond the managed care setting may be limited, but some consideration may be appropriate. Although these plans had high HEDIS rates, the overall level of screening is comparable to the U.S. population, and poor outcomes still occur. Although the types of plans represented in this sample account for a small segment of the managed care market, they provide care for millions of Americans and serve as benchmarks for other types of care systems. It is possible that significant relationships were not detected because of the lack of statistical power to test other effects of additional cluster analyses (such as practice). An additional limitation is the inability to validate that the plan's report of a system is the gold standard. Clinician reports may reflect knowledge of practice-generated systems that are not planwide, or they may suggest erratically or incompletely implemented systems that the plan assumes are functioning.
Even with these limitations, this survey illuminates factors related to perceived usefulness of guidelines, as well as clinicians' assessment of their plan's efforts to improve screening services. Borowsky et al. (39) have demonstrated the value of surveying private practice physicians about the extent to which they perceive that the competing health plans with which they contract have policies that promote or impede delivery of high-quality care. This study provides another example of the value of obtaining clinician reports on the congruence and perceived effectiveness of medical group or health plan policies and implementation efforts. Along with patient reports about their perceptions of the care, clinicians can help us to learn more about what works and what does not in a health care world that still needs improvement.
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NOTES |
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The project described was supported by Grant Number NIH 5 U19 CA79689 from the National Institutes for Health (Edward Wagner, MD, MPH, Principal Investigator) and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute.
The Cancer Research Network (CRN) organizations participating in this study consist of the following organizations and principal staff: Group Health Cooperative, Stephen Taplin, MD, MPH (Principal Investigator), Robin Altaras, BS, Deb Casso, MPH; Kaiser Permanente Northern California, Lisa Herrinton, PhD (Principal Investigator), Michelle Manos, PhD, Carol Somkin PhD; Kaiser Permanente Colorado, Judy Mouchawar, MD, MSPH (Principal Investigator), Kim Bischoff, MHA, Eric France, M.D., MPH, Ned Calonge, MD, MPH; Meyers Primary Care/Fallon, Terry Field, ScD (Principal Investigator), Jane Zapka, ScD, Elaine Puleo, PhD, Mary Jo White, MSPH, and Karin Valentine Goins, MPH. We acknowledge the invaluable assistance of Christine Foley in manuscript production.
Preliminary reports from the clinician's survey were presented in April 2001 at the HMO Research Network, Seattle, WA and in 2002 at the 26th Annual meeting of The American Society for Preventive Oncology, Bethesda, MD.
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