We implemented a tracking and feedback registry to increase the likelihood that breast cancer surgery patients would connect with an oncologist as a way to ameliorate systemic problems that caused underuse of adjuvant treatment. After the initiation of the patient tracking system in 2004, the number of completed oncology consultations increased, the frequency of adjuvant underuse decreased, and the racial disparity in adjuvant underuse was eliminated. Before intervention, there was no racial difference in rates of completed oncology consultation. However, system failures, cases in which physicians recommend therapy and patients do not refuse care but care still does not ensue, did occur more commonly among black and Hispanic women particularly those treated at municipal hospitals, settings that tend to have less than optimal communication between surgeons and oncologists (7
). The tracking and feedback registry, designed to target the system failure cause of underuse, was most effective at municipal hospitals that had greater frequencies of underuse due to system failure. Especially in such settings, this simple intervention appeared to eliminate previously detected racial disparities in adjuvant treatment underuse. The registry, however, did not reduce adjuvant underuse in whites and Asian women, groups whose underuse was more often related to older age and comorbidities.
Interventions to reduce disparities in health care should raise the overall quality of care by addressing causes that occur more commonly among disparate populations and sites of care (22
). The tracking and feedback registry had important components of a quality intervention. It targeted a cause of treatment underuse that was more common among minority women. Implementation was systems based, was applied to all women with a new primary breast cancer, and included both people and technology, key components of socio-technical systems needed to change clinical practice (25
). All surgeons performing breast cancer surgery in addition to the surgery, oncology, and pathology leadership needed to be engaged to make the project work. We obtained a 97% rate of participation by voluntary consent among surgeons and believe that this high rate was due to two key elements: first, the surgeons’ desire to ensure that their patients would get the best care; second, previous discussions with each surgeon about his or her patients who had underused adjuvant treatment (7
), which raised awareness of potential system failures within each practice. Practices were “activated” in that each surgeon was asked to designate a contact person in his or her office who was responsible to relate to the surgeon tracking information that we provided concerning follow-through with oncology referrals. Frequency of contact depended on the surgeon's volume of breast cancer cases; for high-volume practices, it was weekly, for low-volume practices, we called when prompted by the tracking software. Contact times were fit to accommodate each practice's preference.
An important challenge to improving cancer treatment lies in the dispersed locations of its multidisciplinary providers. Breast cancer adjuvant care is often delivered in ambulatory settings and is often provided by multiple providers (26
) in unaffiliated institutions and physicians' offices. The challenges created by fragmentation, although important, were not the most important pitfalls faced by our cohort of patients at greatest risk of underuse due to system failure, namely black and Hispanic women. Most of these patients sought care at hospitals with higher underuse rates and when referred, usually to oncologists within the same institution, failed to see the oncologist and to receive adjuvant treatment. It is these women who appeared to benefit the most from the tracking and feedback intervention. This finding suggests that the intervention would be most successful in a closed delivery system or single hospital where gaps in follow-up occur.
Our findings suggest a number of simple ways in which patient follow-through and receipt of adjuvant treatments can be improved. First, we recommend an expanded role for tumor registrars, particularly those in municipal hospitals or at sites that serve predominantly minority patients (29
). The tracking and feedback registry can enable tumor registrars to actively improve the quality of cancer care in real time by tracking oncology connections and giving feedback to surgeons, rather than merely retrospectively tracking treatment data for quality assurance. Hospitals administrators should consider underwriting tumor registry positions to take this more active role in improving cancer care. Second, health insurers should consider requiring a medical oncology consultation for patients diagnosed with invasive breast cancer because women seeing an oncologist are more likely to get treated.
Were there other changes at the hospitals during this time period that might account for the marked improvement in care? Five of the six hospitals now have electronic medical records systems, two of which were implemented after the year 2000, but in one of these two hospitals the adjuvant therapy underuse rate rose. The hospital with the greatest improvement in adjuvant treatment rates had an electronic medical records system before the initial preintervention period, so decreased underuse could not be associated with the new records system. Although electronic medical records systems provide critical clinical information, their effect on clinical care is mixed (30
). Clinical prompts appear to improve practice (30
). None of the hospitals in our study had electronic medical records systems with clinical prompts to provide adjuvant treatment. Four of the six hospitals had a patient navigator program that helps women navigate through the complex care setting to schedule and get to needed appointments. But in these four hospitals, navigation was in place both before and during the tracking and feedback intervention.
Our study has important limitations. First, ideally, to assess the efficacy of an intervention, a randomized trial should be performed. However, because surgeons' practices are limited in number, there were too few to randomize by surgical practice. It was impractical to randomly assign patients within a practice due to the threat of contamination, that is, the possibility of changing practice for some patients but not for others. For these reasons, we employed a pre–post test design that, due to the absence of a concurrent control group, encompasses inherent challenges to discern whether effects are due to changes over time, the intervention, or other confounding factors. To minimize the effects of hospital and surgeon practice, we conducted analyses that controlled for clustering within these groupings. To provide a national concurrent control group, we compared underuse rates with SEER data. This comparison with national data suggests that the reduction in underuse found with the tracking and feedback intervention is real. Our tracking registry was designed to increase patient follow-through with referrals and not to address other causes of underuse, such as lack of physician recommendation among older and sicker women, or patient refusal due to fear or other beliefs. Without qualitative postintervention interviews, we are unable to assess which element of the tracking and feedback intervention was the most potent. Finally, all participating physicians practiced at New York City teaching hospitals and thus may not represent the practices of community-based physicians and may not be able to be generalized to other locales.
To summarize, a tracking and feedback registry may be a simple and efficient mechanism to substantially improve treatment outcomes among women with new, primary, early-stage breast cancers. We found that the implementation of such an intervention was associated with an increase in patients’ follow-through with referrals to an oncologist and with reduced underuse of adjuvant treatments. Because, in the absence of such an intervention, minority women were more likely than white and Asian women to experience a failure to see an oncologist and to go untreated, implementation of the registry eliminated racial disparities in adjuvant treatment underuse.