Person:

Haas, Jennifer

Breast cancer screening holds a prominent place in public health, health care delivery, policy, and women's health care decisions. Several factors are driving shifts in how population-based breast cancer screening is approached, including advanced imaging technologies, health system performance measures, health care reform, concern for "overdiagnosis," and improved understanding of risk. Maximizing benefits while minimizing the harms of screening requires moving from a "1-size-fits-all" guideline paradigm to more personalized strategies. A refined conceptual model for breast cancer screening is needed to align women's risks and preferences with screening regimens. A conceptual model of personalized breast cancer screening is presented herein that emphasizes key domains and transitions throughout the screening process, as well as multilevel perspectives. The key domains of screening awareness, detection, diagnosis, and treatment and survivorship are conceptualized to function at the level of the patient, provider, facility, health care system, and population/policy arena. Personalized breast cancer screening can be assessed across these domains with both process and outcome measures. Identifying, evaluating, and monitoring process measures in screening is a focus of a National Cancer Institute initiative entitled PROSPR (Population-based Research Optimizing Screening through Personalized Regimens), which will provide generalizable evidence for a risk-based model of breast cancer screening, The model presented builds on prior breast cancer screening models and may serve to identify new measures to optimize benefits-to-harms tradeoffs in population-based screening, which is a timely goal in the era of health care reform.

The breast imaging modalities of mammography, ultrasound, and MRI are widely used for screening, diagnosis, treatment, and surveillance of breast cancer. Geographic access to breast imaging services in various modalities is not known at a national level overall or for population subgroups. METHODS: A retrospective study of 2004-2008 Medicare claims data was conducted to identify ZIP codes in which breast imaging occurred, and data were mapped. Estimated travel times were made for each modality for 215,798 census block groups in the contiguous United States. Using Census 2010 data, travel times were characterized by sociodemographic factors for 92,788,909 women aged ≥30 years, overall, and by subgroups of age, race/ethnicity, rurality, education, and median income. RESULTS: Overall, 85% of women had travel times of ≤20 minutes to nearest mammography or ultrasound services, and 70% had travel times of ≤20 minutes for MRI with little variation by age. Native American women had median travel times 2-3 times longer for all 3 modalities, compared to women of other racial/ethnic groups. For rural women, median travel times to breast imaging services were 4-8-fold longer than they were for urban women. Black and Asian women had the shortest median travel times to services for all 3 modalities. CONCLUSIONS: Travel times to mammography and ultrasound breast imaging facilities are short for most women, but for breast MRI, travel times are notably longer. Native American and rural women are disadvantaged in geographic access based on travel times to breast imaging services. This work informs potential interventions to reduce inequities in access and utilization.

Abstract Digital breast tomosynthesis (DBT) has shown potential to improve breast cancer screening and diagnosis compared to digital mammography (DM). The FDA approved DBT use in conjunction with conventional DM in 2011, but coverage was approved by CMS recently in 2015. Given changes in coverage policies, it is important to monitor diffusion of DBT by insurance type. This study examined DBT trends and estimated associations with insurance type. From June 2011 to September 2014, DBT use in 22 primary care centers in the Dartmouth ‐Brigham and Women's Hospital Population‐based Research Optimizing Screening through Personalized Regimens research center (PROSPR) was examined among women aged 40–89. A longitudinal repeated measures analysis estimated the proportion of DBT performed for screening or diagnostic indications over time and by insurance type. During the study period, 93,182 mammograms were performed on 48,234 women. Of these exams, 16,506 DBT tests were performed for screening (18.1%) and 2537 were performed for diagnosis (15.7%). Between 2011 and 2014, DBT utilization increased in all insurance groups. However, by the latest observed period, screening DBT was used more frequently under private insurance (43.4%) than Medicaid (36.2%), Medicare (37.8%), other (38.6%), or no insurance (32.9%; P < 0.0001). No sustained differences in use of DBT for diagnostic testing were seen by insurance type. DBT is increasingly used for breast cancer screening and diagnosis. Use of screening DBT may be associated with insurance type. Surveillance is required to ensure that disparities in breast cancer screening are minimized as DBT becomes more widely available.

Current shifts toward patient-centered healthcare and accountable payment options point to the more personalized production of better health, not just healthcare, as a next organizational paradigm. Transformation to a system geared toward promoting health requires us to think broadly about what it means to engage patients meaningfully, to give them a voice in their health and care, and to capture more of their varied experience and attitudes beyond the provider visit. The collection and use of patient-reported outcome data into electronic health records represents an important step forward for the transition to a more patient-centered health system. We set out an agenda for better understanding how and when patient-reported outcomes may improve patient health and care experience.

Background: Clinician surveys provide critical information about many facets of health care, but are often challenging to implement. Our objective was to assess use by participants and non-participants of a prepaid gift card incentive that could be later reclaimed by the researchers if unused. Methods: Clinicians were recruited to participate in a mailed or online survey as part of a study to characterize women’s primary health care provider attitudes towards breast and cervical cancer screening guidelines and practices (n = 177). An up-front incentive of a $50 gift card to a popular online retailer was included with the study invitation. Clinicians were informed that the gift card would expire if it went unused after 4 months. Outcome measures included use of gift cards by participants and non-participants and comparison of hypothetical costs of different incentive strategies. Results: 63.5 % of clinicians who responded to the survey used the gift card, and only one provider who didn’t participate used the gift card (1.6 %). Many of those who participated did not redeem their gift cards (36.5 % of respondents). The price of the incentives actually claimed totaled $3700, which was less than half of the initial outlay. Since some of the respondents did not redeem their gift cards, the cost of incentives was less than it might have been if we had provided a conditional incentive of $50 to responders after they had completed the survey. Conclusions: Redeemable online gift card codes may provide an effective way to motivate clinicians to participate in surveys.