Ever since I began consulting to breast centers, my particular emphasis has been that a necessary element of every successful breast center is sustainability. The great contradiction of patient care is that, while the memorable events in a patient's experience are almost invariably the human interactions for which there is no reimbursement, we are paid only for the clinical care that is delivered. In other words, we need to provide excellent clinical care in an economically effective manner, in order to support the aspects of care that our patients identify with excellence. Or is it the other way around ? ? ?
Successfully combining clinical excellence, efficiency and service excellence has given rise to the mantra "doing well by doing good", and has been made possible by the fact that clinical excellence has generally been consistent with service excellence. We have understood that providing a special, satisfying experience for the women we serve is critical to attracting the women we need to meet our financial targets, but beyond the ubiquitous patient satisfaction surveys that have proliferated, actual measurement of service excellence has proven to be an illusive target.
I mention this challenge because service excellence is made up of several factors, each of which has a cost. In a rapidly changing healthcare environment in which the only inevitability is cost reduction, you must know which elements of service excellence are important to your patients in order to protect them from cost control pressure. The time to do this is not after you have been told to cut people or things that are or may be important. The time is now.
We recommend using a tool like Survey Monkey to regularly assess how you are doing and what is important with your patients. Survey Monkey is a cloud based product that has a HIPPA compliant version that is available for less than $1,000 per year and allows unlimited usage. We especially like the unlimited usage feature, as it allows broad based surveying that can be done on a regular basis to ensure that your findings are validated across both population and time.
Is it the granite counter tops, the nurse navigator, the warm and fuzzy robes, the ease of parking, friendly receptionist, reminder letters, the coffee in the waiting area, the rose you give to each patient as she leaves, the ability to schedule an appointment on-line, ability to access the report via secure internet, magazine selection, neat appearance of the staff, availability of Saturday appointments, ability to receive all diagnostic testing, including biopsy, in a single visit, friendliness of the staff, early morning appointments, or the cookies on Friday? Only the Survey Monkey knows!! Seriously, though, all of these have been identified as being very important in one center or another. As we fine tune our breast centers to be more responsive to our patients, we need a clearer understanding of what our patients are thinking.
Those who caution against the use of adjuvant screening for breast cancer often assert, “mammography is the only screening modality that has been shown to decrease mortality”. This statement is deceptive at best. In the landmark Swedish Two County Trial[i] women were randomized to groups that were either invited or not invited to be screened with mammography, and the results were reported based upon that status. In other words, the decrease in mortality was correlated to whether a woman was invited or not, rather than whether she was actually screened. The distinction is important, because one of the more important findings of the study was to find a direct correlation between tumor size and mortality over 20-years — without regard to how the cancer was found.[ii]
To reach this finding the investigators combined all cancers detected in both arms of the trial, and studied mortality from all causes for 20-years following enrollment. The results make it clear that it is finding a cancer when it is small that is important, not how the cancer was found. In fact, a few salient points from Duffy, et al., will illustrate the importance of early detection:
• 20-year survival rate for women with tumors less than 1cm — 88%
• 20-year survival rate for women with tumors 1-1.4cm — 84%
• 20-year survival rate for women with tumors 1.5-1.9cm — 72%
• 20-year survival rate for women with tumors 2.0-2.9cm — 55%
• 20-year survival rate for women with tumors 3.0-4.9cm — 40%
• 20-year survival rate for women with tumors 5.0cm and over— 15%
It should also be noted that morbidity increases with tumor size, as the National Cancer Institute guidelines for treatment include chemotherapy for all cancers with tumors 2cm and larger.[iii] In addition to its impact on morbidity, chemotherapy is extremely expensive, increasing the cost of treating a breast cancer tenfold.
We have known for many years that the sensitivity of mammography decreases with increasing radiographic density,[iv] and that there are other technologies, e.g., ultrasound[v] and MRI, that can be utilized with mammography to screen both women with dense tissue and, in the case of MRI, women who are at high risk of developing breast cancer. The questions arise, “who should receive ultrasound or MRI in addition to their screening mammogram, and how can practices that now screen for breast cancer solely with mammography?
The first of these questions can be answered by reference to various studies that have found that women with high breast density can benefit from screening ultrasound,5 and the recommendations of the American Cancer Society that all women identified at high risk (20-25%) receive MRI as well as screening mammography.[vi] The second is more difficult, as it requires that we reengineer how we deliver screening; expanding the concept to include adjuvant imaging for those who require more than just a mammogram, but doing so in a convenient manner that respects the time demands on patients.
The Breast Group is dedicated to developing solutions that facilitate the early detection of breast cancer, and we will devote many blogs and much of this website to delivering tips and suggestions that facilitate great care in a difficult economic environment. We urge you to look beyond individual screening modalities to the overarching goal of early detection, but don’t just look at the situation. Commit to implement the necessary changes to assure that the devastation of breast cancer is at least minimized.
[Note that we would be happy to provide a more complete list of references upon request, as well as supplemental materials on topics described above.]
[i] Tabar et al., J of Epidemiol and Community Health, 1989, 43:107-14.
[ii] Duffy et al., Breast J, 2006;12 Suppl 1:S91-5.
[iii] National Cancer Institute
[iv] Pisano, et al., NEJM, 2008; 246(2):376-83.
[v] Berg, et al., JAMA, 2008; 299(18):2151-63.
[vi] Saslow, et al., CA Cancer J Clin, 2007; 67:75-89.
I just returned from the 24th annual meeting of the National Consortium of Breast Centers in Las Vegas, where I delivered five talks, participated on one panel and presented a poster in the poster session. Yes, it was a lot of work, but I thoroughly enjoyed the opportunity to speak to and interact with the hundreds of physicians, administrators, technologists and nurses who attended the meeting. The meeting was my 17th and it was particularly gratifying to welcome new members to the NCoBC. If you are involved in any way with breast care, I encourage you not only to join the NCoBC, but to participate in its many quality initiatives.
Every year there is one talk that just seems to reach out and create a new level of awareness about something you may not have considered. For me this was the talk given by Harold P. Freeman, MD. Dr. Freeman, whose list of accomplishments is truly astounding, has dedicated his career to serving underserved populations. He discussed the disparities in healthcare in the US, pointing out that although most minority women and women in poverty had access to mammography through Medicaid and other programs designed to enhance access to preventative care, there is a large gulf in access to therapy between the "haves" and the "have nots" in our society
Dr. Freeman, a 25-year advocate of patient navigation challenged us to confront the relationship between race, poverty and cancer, citing the problems of the poor, many of whom are not English speakers, in accessing multi-specialty care in systems where the care may involve tens of visits to four or more locations in the course of therapy. Cancer is daunting at best, but faced from the perspective of poverty many simply give up, and many more receive their care only in part, late, or both.
The solution, asserted Dr. Freeman, is to formally include patient navigation in the care of all cancer patients, providing reimbursement through insurance, and including specifically through Medicaid. Navigation has become one of the hallmarks of excellence in breast programs across the US, and we agree entirely with Dr. Freeman in his advocacy. Rep. Steve Israel (D-NY) introduced a bill in the last session of congress that would have provided funds for patient navigation, but it failed. This is NOT an issue that should be political or politicized. Please contact your representative and indicate your support for funding for patient navigators. It truly is a life or death issue.