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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).
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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