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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- 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
- 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
- Implementing new strategies
- Responding as needed
- Outcome evaluation
- Response levels:
- Medical team
NSBSP Strategic Initiatives
- INeedle core biopsy program
- Patient navigation
- supports clinical pathway
- dissemination of CPG
- Program database (screening & diagnosis)
- link diagnostic reporting database
- central mammography booking
- 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
- 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)
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
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
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
- NSBSP - asymptomatic women requires accreditation, volume, data collection
- Diagnostic system - symptomatic and screens ??? accreditation, volume, no data collection
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
- reduced diagnostic interval
- increased patient and physician satisfaction
- promotes clinical pathway
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
Step 1: Was timeliness different between the groups ?
Step 2: Was navigation responsible for the differences ?
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
- 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
- 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
- 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