We conducted a cluster-randomized clinical trial to test the impact of a novel population-based informatics intervention to increase mammography rates in a primary care network. We demonstrated significantly higher mammography rates in intervention practices for women who were overdue for screening compared to control practices. The easy-to-use Web-based electronic system was accessed by over 90% of intervention providers, and intervention mammography rates were higher in all examined patient demographic sub-groups.
Our results extend prior studies demonstrating the benefit of reminder systems for improving preventive cancer screening rates in general and for mammography in particular.7–10,12–14,17,24–27
To date, most computerized systems have focused on reminders during office visits,9,14,28,29
although some have used population-based reminder systems targeted to all eligible women.7,13,26
While traditional point-of-care reminder systems involve physicians directly in clinical decision making, we are not aware of population-based electronic systems with the screening intervention controlled by a clinician. Chaudhry et al. studied a Web-based population-based system used by secretaries in a single practice.7
Our study extends this work by focusing on patients who have not had breast cancer screening for at least 2 years, efficiently involving clinicians, and performing the study in a large, heterogeneous primary care network. To address limitations of existing approaches, we developed a conceptual model of primary care preventive services that relies on an inclusive, system-wide population perspective to connect patients with their specific physician or the practice where they received the most care. Because taking a position of inclusive population management requires moving beyond the confines of an outpatient visit, we implemented a visit-independent clinical information system to collect, organize, and present clinical data, and support and enhance provider workflow.19
This population-based perspective required training practice personnel in patient outreach efforts. This approach parallels the vision of the “medical home” where care is not episodic and office-based, but instead is continuous and location independent.30
Our study provides rigorous evidence that a non-visit-based population surveillance approach represents a feasible and effective approach to deliver preventive care.
Prior research has shown that systematic screening initiatives are more successful when they take advantage of established patient-provider relationships.31,32
We hypothesized that correctly categorizing patients based on their connection to a specific physician would let physicians use their unique knowledge to better allocate resources and interventions to improve care.20
Higher rates of appropriate deferrals by physicians support the role of such personal knowledge. Our approach of efficiently including physicians in the decision-making process for patients closely linked to them while using a practice population manager to screen patients without a close physician connection represents a novel model of care that seeks to maximize the benefit of non-visit-based care without diminishing the role of the traditional patient-provider relationship.20
Removing routine but time-consuming tasks that could be amenable to non-visit-based care plans may have the additional benefit of allowing more time during the office visit to address other important topics.33,34
In this way, our care model is designed to augment the face-to-face contact that both fosters patient-physician connectedness and provides the physician with the unique knowledge needed to use such systems.
For overdue patients not connected to a specific physician, we used practice population managers to help ensure screening for these patients. Most of these population managers were already performing similar activities to meet pay-for-performance contract activities for our managed care population. Efforts to increase the use of office personnel for such non-visit-based care will require new payment mechanisms.35
Our study is one of the largest controlled trials of an informatics-based primary care intervention. The major study limitation is generalizing results beyond a single primary care network with a well-developed information technology infrastructure. However, our results may be viewed as a goal for integrated care, such as proposed in the medical home model.30
Because of the nature of our intervention, we could not randomize at the patient level, but rather performed a practice level, cluster-randomized trial. The heterogeneous nature of our practices also support the generalizability of our findings, but led to small differences in patient and practice characteristics between intervention and control groups. We adjusted results to control for these differences, and our subgroup analyses show similar benefit for the intervention across each of these characteristics.
The 8% absolute increase in screening between intervention and control groups is relatively modest, but we believe is clinically relevant. Given the high baseline rate of screening in our network (79.4%), networks with lower baseline screening rates may expect to see larger increases in screening if they instituted such a program. Our reported mammography rates also likely underestimate the true number of individuals who had a mammogram performed during the study period because we only had access to reports within our health care system. The slightly higher baseline rate of outside mammograms in the intervention group found during a random chart review suggests our results likely underestimate the system’s true benefit since fewer patients in the intervention group were truly overdue for screening. This is also supported by higher rates of outside mammograms among women in the intervention who did not have a mammogram completed within our health care system during the follow-up period.
Health information technology is often cited as a key to overcoming deficiencies in the quality and safety of care that continue to exist.36
However, the hope that information technology will usher in a transformational change in health care remains largely unfulfilled.16,37,38
We developed and tested a novel informatics tool for population-based breast cancer screening in a primary care network that was designed to redefine rather than simply support traditional models of care delivery. Our trial demonstrated a high level of provider participation and a significant increase in mammography rates. These results support the integral role of information technology to help transform the delivery of health care from visit-based to visit-independent primary care management.