Conference Presentation

The following is a text version of the presentation given at the Conference on Timely Access To Health Care, held February 8-9, 2007 in Toronto, Ontario.

Program Strategies to Tame Wait Times While Improving Outcomes: The Nova Scotia Breast Screening Program

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Presentation Outline

• Objectives
• NS BSP Fixed and Mobile Sites
• Strategy - Elements
• Clinical Protocol for Diagnostic Work-upFollowing an Abnormal Screen
• Nova Scotia Breast Screening Program - I
• Nova Scotia Breast Screening Program - II
• NSBSP Strategic Initiatives
• Needle Core Biopsy - I
• Needle Core Biopsy - II
• Needle Core III -Time trends in the rates of open surgery
• Needle Core IV -Malignant:Benign Ratio on Surgery
• Needle Core Biopsy V -Indicator Targets and Performance (50-69 yrs)
• Patient Navigation - I
• Patient Navigation - II
• Patient Navigation - III
• Navigation IV - Purpose & Methods
• Navigation V - Results
• Database Development - I
• Database Development - II Central Mammography Booking
• Database Development III Provincial Diagnostic Wait Times - Time Trend
• Database Development IV - Biennial Participation Rate Time Trend (50-69 yrs)
• Database Development V -Growth of Screening Volume (1991-2005)
• Geographic Information Systems (GIS) I
• GIS II - Population Size & Location/Duration of Mobile Unit Visits
• GIS III- Screening Participation Rates
• Scenario 1: Distance Traveled to Fixed Sites = 30 km
• Distance Traveled = 50 km and Mobile Stops
• Distance = 50 km, Mobile Stops, Population
• Challenges and Opportunities
• Next Steps

Objectives

• To demonstrate our process and progress in addressing wait times for mammography in Nova Scotia
• To outline the key elements in the strategy
• To highlight our successes, challenges, and opportunities

NS BSP Fixed and Mobile Sites

Strategy - Elements

• Collaboration
• Leadership
• Quality driven
• Continuum of care focus
• Provincial in scope
• Patient/Client focused
• Capacity building

Clinical Protocol for Diagnostic Work-upFollowing an Abnormal Screen

Nova Scotia Breast Screening Program - I

• NSBSP has been a dynamic provider of breastservices to the women of Nova Scotia since 1991
• Fixed sites - growth over time
• Mobiles - responds to changing needs

Nova Scotia Breast Screening Program - II

• The NSBSP has used its database since 1991 as a "real time tool" to provide the "best outcomes" possible with available resources
• How?
  • Implementing new strategies
  • Responding as needed
  • Outcome evaluation
• Response levels:
  • Woman
  • Site
  • Medical team
  • Program

NSBSP Strategic Initiatives

Top of Page

1. INeedle core biopsy program
2. Patient navigation
   • supports clinical pathway
   • dissemination of CPG
3. Program database (screening & diagnosis)
   • link diagnostic reporting database
   • central mammography booking
4. Geographic Information Systems Mapping

Needle Core Biopsy - I

• NS is only provincial screening program to institute this procedure as part of standardized protocol for clinical work-up following abnormal mammography (1991)
• Establish national standards
• Advantages:
  • reduces wait times
  • decreases benign breast surgery

Needle Core Biopsy - II

• SNCB is as accurate as surgery, cheaper and less morbidity for women
• SNCB audits Radiologists, Surgeons, Pathologists
• NCB volume: 36 (1991) →794 (2005)
• Screen vol. 1896( 1991)---50,895 (2005)

References:
1. NSBSP Experience: use of needle core biopsy in the diagnosis of screening-detected abnormalities. Caines J Chantziantoniou K, Wright BA, et al. Radiology 1996;198:125-30.
2. Stereotaxic needle core biopsy of breast lesions using a regular mammographictable with an adaptable stereotaxic device. Caines JS, McPhee MD, Konok GP, Wright BA.AJR 1994;163:317-21.
3. Ten years of breast screening in NSBSP: 1991-2001. Caines J et al. CARJ 2005;56:82-93.

Needle Core III -Time trends in the rates of open surgery

Needle Core IV -Malignant:Benign Ratio on Surgery

Needle Core Biopsy V -Indicator Targets and Performance (50-69 yrs)

Patient Navigation - I

Top of Page

introduction: 1991 (limited fashion)

• physician assistance with abnormal screen referrals
• physician/patient contacted by local NSBSP team leader and informed of appointment details at diagnostic centre
• improved wait times to first diagnostic work-up
• acceptance by medical community
• to date 375,642 screens -21,284 women navigated

Reference:
Patient navigation: improving timeliness in the diagnosis of breast abnormalities.
Psooy B, Scheuer D, Borgaonkar J, Caines J. CARJ 2004;55:145-50.
Influence of direct referrals on time to diagnosis after an abnormal breast screening result Kathleen M. Decker MHSA et al: Cancer Detection and Prevention 28 (2004) 361-367

Patient Navigation - II

Two parallel systems

1. NSBSP - asymptomatic women requires accreditation, volume, data collection
   Navigation
2. Diagnostic system - symptomatic and screens ??? accreditation, volume, no data collection
   No Navigation

Inconsistency, confusion, increased wait times, duplication
"Women slip through the cracks"

Patient Navigation - III

• expansion 2000
  • requests received from medical community to extend the service to also navigate women with abnormal diagnostic reports through the diagnostic process
  • full time navigator position was established in central region due to large the diagnostic component
• results
  • reduced diagnostic interval
  • increased patient and physician satisfaction
  • promotes clinical pathway

Reference:
Waiting for a Diagnosis after an Abnormal Breast Screen in Canada, published 2000.

Navigation IV - Purpose & Methods

To determine the impact of Patient Navigation on timeliness in the diagnosis of breast abnormalities

Group\Year	1999	2000
NSBSP	Navigation	Navigation
Diagnostic (Referrals)	No Navigation	Navigation

Step 1: Was timeliness different between the groups ?

Step 2: Was navigation responsible for the differences ?

CARJ 2004:55(3):145-50.Top of Page

Navigation V - Results

Database Development - I

• NSBSP Diagnostic Mammography Database
  • improved diagnostic database designed to integrate the NSBSP screening database with a diagnostic database
  • provide one provincially standardized diagnostic mammography reporting module with upgraded services
• more comprehensive and accurate data capture
  • better quality indicator measurement (ptrate 46% to 53%)
  • better understanding of resource use
  • capacity to evaluate interventions in 'real time'

Database Development - II Central Mammography Booking

• central booking of all provincial screening and diagnostic examinations
• implemented in 2000 in the Central Region
• phase-in process to be completed in 2006
• improved Diagnostic Interval
  • partly due to channelling the flow of asymptomatic women to the screening facilities and freeing up diagnostic capacity

Database Development III Provincial Diagnostic Wait Times - Time Trend

Database Development IV - Biennial Participation Rate Time Trend (50-69 yrs)

Database Development V -Growth of Screening Volume (1991-2005)

Geographic Information Systems (GIS) I

Top of Page

• Is a computer technology that uses a geographic information system as a framework for understanding a problem
• Links information to location, then layers different types of information to understand how they may work together
• Has been applied to analyze variations in health services utilization
• First time used to evaluate a provincial screening program

GIS II - Population Size & Location/Duration of Mobile Unit Visits

GIS III- Screening Participation Rates

Scenario 1: Distance Traveled to Fixed Sites = 30 km

Distance Traveled = 50 km and Mobile Stops

Distance = 50 km, Mobile Stops, Population

Challenges and Opportunities

Top of Page

• dynamic provision of breast screening services:
  • last 2 fixed sites joining program in 2006
    • NSBSP: complete mammography capture in NSi.e., participation = screening
• increasing service capacity:
  • what are current inequalities in participation/retention?
  • what are current inequalities in wait times for both screening and diagnostic work-up?
  • how to allocate capacity to address inequalities
    • region-specific interventions?
  • how to schedule mobile units to continually complement fixed sites?
• priorities: participation vsretention vswait times

Next Steps

• use GIS in on-going surveillance of need for/use of screening
  • help target under-serviced populations
  • evaluate impact of 2 new sites & FFDM
    * participation vs retention vs wait times
• goal: use road-mapping approach to develop various scenarios for scheduling of mobile units
• Canadian Breast Cancer Foundation Atlantic Chaptergrant obtained in Jan 2007 for full-scale project
  * Stephanie Lea, Master's studentApplied Health Services Research, Dalhousie U
  * Dr. Jennifer Payne, PhD, Epidemiology
• introduction of full-field digital mammography in 2006