The length of time between a positive screening mammogram and follow-up care in the US can average 26 days, and up to 43 days for women of color.[i],[ii] These delays can be due to scheduling issues, healthcare access, lack of coordinated services, health inequities, or physician referrals, to name a few examples, but the longer the delay, the more advanced breast cancer can become. Delayed follow-up care after a positive screening mammogram has been associated with larger tumor size at diagnosis[iii]. For Gary Dee, MD, FACR President of Midstate Radiology Associates, LLC (Midstate Radiology), and Chair of the Hartford HealthCare Radiology Council and the team of care providers and staff at Hartford HealthCare’s two comprehensive breast centers in the Central Region, it was simply unacceptable.
The leadership team for the comprehensive breast centers in the Central Region of Hartford HealthCare refocused their efforts to design two rapid breast cancer comprehensive diagnosis centers to reduce barriers to care, allowing patients to get diagnosed sooner. In less than two years, they actively focused on decreasing the time from screening to biopsy resulting in a decrease, on average, from 12 days to 2.5 days to provide a more rapid diagnosis. This vision required a patient-centered team effort leveraging best-in-class imaging technology and unparalleled access to the very best coordinated follow-up care by ultra-committed staff.
“We feel an obligation to our patients – this is why we do what we do – anything less is unacceptable,” explained Tom Cappas MBA, MS RT (R)(MR), Director of Radiology, Hartford HealthCare Central Region and Director of Operations for Midstate Radiology. “It’s in our culture; it’s who we are and we see no other way to provide care. We see the frequency of cancer going up; especially in populations of color and we are obsessed with removing barriers, not being the barrier. Our patients deserve this new approach.”
Lowering patient anxiety and getting faster diagnoses with a dedicated team approach
Coordination of care is really the linchpin of Hartford HealthCare’s rapid diagnosis model and one of the key factors behind its success. For the majority of patients, according to Cappas, the screening mammogram is the only element of their annual visit, but there are other women who will have indeterminate mammogram findings and may need follow up imaging, or a biopsy. Once identified, these patients are connected with Kim Kerr, RN, the program’s Women’s Health Coordinator. In her role, she provides counsel to the patients as they begin their journey to a diagnosis, and quickly communicates with the team to get the patient to follow-up imaging or for a surgical consultation.
“For many of the patients who need follow up imaging, those tests will be negative, but their anxiety is real and can be avoided. Patients have said that the time spent not knowing is sometimes worse than having a diagnosis,” added Cappas.
Coordinating care to get patients the information they need is logistically carried out through the design of a space where some members of the team are literally across the hall from one another and able to coordinate care based on results from multiple physicians. The program’s multi-disciplinary team comprises radiology, oncology, breast surgeons, pathology, physician liaisons and the Women’s Health Coordinator.
“We really have a dedicated team,” said Natalie Pelletier MBA, RT (R)(M), Mammography Manager at Midstate Radiology. “Our technologists play such a critical role, and our radiologists are always willing to review and talk with the patients at the time of the initial screening appointment. If an area is seen on the screening study, that’s when Kim takes over. She talks with the patients, gets their referring physician involved, and even our consulting breast surgeons and oncologists, who are such an integral part of the care team. It’s not just a tagline; the patients really do come first, and our team approach allows us the flexibility to move patients through quickly to get to their diagnosis.”
Same-day follow-up care to minimize outward migration and create an unmatched patient experience
The role of the Women’s Health Coordinator is pivotal to a positive patient experience. The coordinator guides the patient and works with them to coordinate follow-up exams or consultations and to answer any questions after their initial screening and all the way through surgical care.
“My role has really helped because I am able to meet with patients in real-time. Once they speak with the radiologist, I come to them. I talk with them. I go through the procedures with them and I answer any questions they may have. I think we’re extremely fortunate that Hartford HealthCare has invested in the physical infrastructure to enable us to work in such a coordinated fashion. There is just a hallway that separates us from where the radiologists and our breast surgeons are.”
Patients are able to get same-day appointments with the surgeons and same-day appointments for biopsies. Kerr believes this very personalized coordination of care and minimizing delay for follow-up is responsible for the decrease in Hartford HealthCare’s outward migration rates from 73 percent prior to the start of this program to approximately three percent, not to mention routinely positioned in the top 5 percent in the U.S., and many months actually achieving a top 1 percent distinction from Press Ganey for patient experience, according to Cappas.
Even throughout the COVID-19 pandemic, in which an estimated 285,000 American women missed their annual screening mammograms[iv], the Central Region’s comprehensive rapid breast cancer diagnosis centers continued to offer patient screenings once the American College of Radiology removed restrictions on preventative studies, with renewed safety protocols and even more innovation. And now that they are running at full capacity, their dedicated staff has extended hours and increased accessibility so that they can accommodate patients who may have missed their exams, as well as patients who are currently due for screenings. They actually performed several thousand more screening mammograms in their fiscal year 2020 compared to the prior fiscal year which is remarkable because ten weeks in 2020 were restricted due to the first wave of the COVID pandemic. Cappas confidently states, “The success is due to the formula. We need not be the barrier; we need to remove barriers to access and care. He feels others were challenged to remove those barriers, allowing the Central Region’s breast centers to see so many new patients in this trying year.”
Driving outcomes through partnership: leveraging advanced technology and intelligent efficiencies
In 2017, Hartford HealthCare announced a seven-year partnership with GE Healthcare to leverage GE Healthcare’s advanced analytics and innovative technologies to build a world-class health system for the patients of Hartford HealthCare. The two teams had begun working together when the vision for the rapid diagnosis center was initially conceived. Together they determined the best strategies for improving access to care including capacity and workflow redesign, leveraging advanced imaging technologies such as 3D Tomosynthesis for screening mammography, seamlessly coordinating care, and developing appropriate resourcing strategies to utilize the best system in each location for each patient’s condition.
“I came into this role,” Cappas explained, “right around the time that Hartford HealthCare had joined forces in a partnership with GE Healthcare. Together we took a deep dive into our productivity and analyzed any barriers to patient care, no shows, and all aspects of our imaging operations and daily workflows. We noticed opportunities. Patients were getting their initial imaging, and then a large majority were leaving our system for follow-up care. Those who remained were not getting their care in an acceptable timeframe for the team.”
The new program design begins with a seamless scheduling and registration process, including imaging authorization. Hartford HealthCare leveraged their partnership with GE Healthcare to upgrade screening mammography from 2D to 3D tomosynthesis in the Central Region. Screening mammograms are performed using GE Healthcare’s Senographe Pristina™ Mammography System. 3D Tomosynthesis not only accelerates screening times, but also provides superior image quality and diagnostic accuracy at the same low dose as 2D systems and is optimized for increased patient throughput and getting a more rapid diagnosis[v],[vi]. According to Cappas, using 3D mammography helped Hartford HealthCare find more breast cancers and reduce the need for callbacks. Because of the potential for earlier diagnosis enabled by 3D tomosynthesis, Dr. Dee and the radiologists at Midstate Radiology supported the efforts to make 3D tomosynthesis standard of care for breast cancer screening and played a significant role in paving the way for legislation that would mandate national coverage.
The Central Region’s rapid diagnostic comprehensive centers will also soon begin offering SenoBright™ HD Contrast Enhanced Spectral Mammography (CESM) for patients’ follow-up imaging exams. CESM uses iodinated contrast to reveal areas of increased blood supply within the breast which can help identify breast lesions. CESM provides a cost-effective, and less-invasive alternative to MRI[vii] for those patients whose initial screening mammogram findings were indeterminate.
“Using technology to innovate and find other ways to compliment the large array of cutting-edge services that we have is paramount,” said Cappas. “Our vision of being the most trusted for personalized, coordinated care is extremely powerful and is our guiding light to the work we do. Because of this we constantly seek out cutting-edge techniques and technology. If the technology is there, and we believe it is with CESM, we will take the necessary steps to help with legislation for coverage just like we did for 3D mammography. We’re willing to take that journey because, to our core beliefs, it’s the right thing to do for our patients.”
Applying coordinated care and the rapid diagnosis model to other clinical areas
With the success that Hartford HealthCare has experienced in its rapid diagnosis model for women’s health, Cappas and the care team are looking into the possibilities of expanding their approach into other clinical areas, such as pulmonology.
“Imaging plays such an integral role as the front door to achieve our mission, so we will coordinate more areas of care like we’re doing in women’s health. Working in silos in healthcare just does not work. Our President and CEO Jeff Flaks consistently challenges us to be better than normal and applying this rapid diagnosis model to other clinical areas is one way we can do that. Globally, we see similar barriers to lung cancer just like we see with breast cancer. There are gaps of care in the coordination of diagnosis to treatment there as well and we will show others the way based on our model of care and formula to remove barriers,” Cappas added.
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[i] Kovar A, Bronsert M, Jaiswal K, et al. The Waiting Game: How Long Are Breast Cancer Patients Waiting for Definitive Diagnosis? Ann Surg Oncol. 2020 Oct;27(10):3641-3649
[ii] Selove R, Kilbourne B, Fadden MK, et al. Time from Screening Mammography to Biopsy and from Biopsy to Breast Cancer Treatment among Black and White, Women Medicare Beneficiaries Not Participating in a Health Maintenance Organization. Womens Health Issues. 2016 Nov-Dec;26(6):642-647
[iii] Durham DD, Robinson WR, Lee SS, et al. Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography. Cancer Epidemiol Biomarkers Prev. 2016;25(11):1474-1482. doi:10.1158/1055-9965.EPI-16-0148 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5115635/)
[iv] Mast C, Munoz del Rio A. Delayed Cancer Screenings—A Second Look. Epic Health Research Network. July 17, 2020. https://ehrn.org/articles/delayed-cancer-screenings-a-second-look
[v] Superior diagnostic accuracy demonstrated in a reader study comparing the ROC AUC of GE screening protocol (V-Preview + 3D CC/MLO with 3D in STD mode) to that of 2D FFDM alone. V-Preview is the 2D synthesized image generated by GE Seno Iris mammography software from GE DBT images. FDA PMA P130020 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P130020.
[vi] Comparison of patient dose delivered by FDA approved DBT devices as of February 2018 for a breast of average density, based on data presented in [1-2] and data on file. Device comparison includes GE SenoClaire, GE Senographe Pristina 3D in STD mode, Hologic Selenia Dimensions, Siemens Mammomat Inspiration, Fuji Aspire Cristalle [1. Bouwman, R. W. and al., et. 2015, Physics in Medicine & Biology, pp. 7893-7907; 2. NHSBSP Equipment Reports 1306, 1404, 1307, and on Fujifilm AMULET Innovality.]