The Effect of Automated Mammogram Orders Paired With Electronic Invitations to Self-schedule on Mammogram Scheduling Outcomes: Observational Cohort Comparison

Background Screening mammography is recommended for the early detection of breast cancer. The processes for ordering screening mammography often rely on a health care provider order and a scheduler to arrange the time and location of breast imaging. Self-scheduling after automated ordering of screening mammograms may offer a more efficient and convenient way to schedule screening mammograms. Objective The aim of this study was to determine the use, outcomes, and efficiency of an automated mammogram ordering and invitation process paired with self-scheduling. Methods We examined appointment data from 12 months of scheduled mammogram appointments, starting in September 2019 when a web and mobile app self-scheduling process for screening mammograms was made available for the Mayo Clinic primary care practice. Patients registered to the Mayo Clinic Patient Online Services could view the schedules and book their mammogram appointment via the web or a mobile app. Self-scheduling required no telephone calls or staff appointment schedulers. We examined uptake (count and percentage of patients utilizing self-scheduling), number of appointment actions taken by self-schedulers and by those using staff schedulers, no-show outcomes, scheduling efficiency, and weekend and after-hours use of self-scheduling. Results For patients who were registered to patient online services and had screening mammogram appointment activity, 15.3% (14,387/93,901) used the web or mobile app to do either some mammogram self-scheduling or self-cancelling appointment actions. Approximately 24.4% (3285/13,454) of self-scheduling occurred after normal business hours/on weekends. Approximately 9.3% (8736/93,901) of the patients used self-scheduling/cancelling exclusively. For self-scheduled mammograms, there were 5.7% (536/9433) no-shows compared to 4.6% (3590/77,531) no-shows in staff-scheduled mammograms (unadjusted odds ratio 1.24, 95% CI 1.13-1.36; P<.001). The odds ratio of no-shows for self-scheduled mammograms to staff-scheduled mammograms decreased to 1.12 (95% CI 1.02-1.23; P=.02) when adjusted for age, race, and ethnicity. On average, since there were only 0.197 staff-scheduler actions for each finalized self-scheduled appointment, staff schedulers were rarely used to redo or “clean up” self-scheduled appointments. Exclusively self-scheduled appointments were significantly more efficient than staff-scheduled appointments. Self-schedulers experienced a single appointment step process (one and done) for 93.5% (7553/8079) of their finalized appointments; only 74.5% (52,804/70,839) of staff-scheduled finalized appointments had a similar one-step appointment process (P<.001). For staff-scheduled appointments, 25.5% (18,035/70,839) of the finalized appointments took multiple appointment steps. For finalized appointments that were exclusively self-scheduled, only 6.5% (526/8079) took multiple appointment steps. The staff-scheduled to self-scheduled odds ratio of taking multiple steps for a finalized screening mammogram appointment was 4.9 (95% CI 4.48-5.37; P<.001). Conclusions Screening mammograms can be efficiently self-scheduled but may be associated with a slight increase in no-shows. Self-scheduling can decrease staff scheduler work and can be convenient for patients who want to manage their appointment scheduling activity after business hours or on weekends.

Recovery of Screening Mammogram Cancellations During COVID-19

Background In response to the COVID-19 pandemic, the American Society of Breast Surgeons and American College of Radiology released a joint statement recommending that all breast screening studies be postponed effective March 26, 2020. Study Design A retrospective review of all canceled mammograms at a single tertiary care institution from January 1-August 31, 2020 was performed to evaluate the effect of this recommendation by quantifying both the number and reason for mammogram cancellations before and after March 26, 2020. Utilization of the electronic patient portal for appointment cancellation as a surrogate for telehealth uptake was noted. Results During the study period, 5340 mammogram appointments were kept and 2784 mammogram appointments were canceled. From a baseline of 30 (10.8%) canceled mammograms in January, cancellations peaked in March (576, 20.6%) and gradually decreased to a low in August (197, 7%). Reasons for cancellations varied significantly by month ( P < .0001) and included COVID-19 related (236, 8.5%), unspecified patient reasons (1,210, 43.5%), administrative issues (147, 5.3%), provider requests (46, 1.7%), sooner appointments available (31, 1.1%), and reasons not given (486, 17.5%). In addition, compared to a baseline in January (51, 16.5%), electronic patient portal access peaked in August (67, 34.0%). Conclusion Screening mammogram cancellations have gradually recovered after early COVID-19 restrictions were lifted and increasing use of electronic patient access appears to be sustained. Consequences for future staging at the time of diagnosis remain unknown. Understanding to what extent the pandemic affected screening may help surgeons plan for post-pandemic breast cancer care.

Adherence to screening mammogram guidelines in the transgender/non-binary population.

120 Background: Data is limited regarding rates of breast cancer and mammography screening within the transgender/non-binary (TGNB) population. Screening recommendations vary and there is no global consensus. TGNB patients face unique challenges that may preclude screening and risk assessment, such as barriers to accessing healthcare, lack of provider education, and limited data regarding hormonal impacts on risk. This study aims to address adherence to current screening mammogram recommendations within the TGNB population at a single hospital system. Methods: A retrospective chart review was performed using ICD codes, sexual orientation and gender identity data, and key words to identify TGNB patients that had contact with the Northwestern Hospital system between March 2019 and February 2021. Patients designated female at birth (DFAB) and age ≥ 40 with breasts at time of screening eligibility were included as well as patients designated male at birth (DMAB) and age ≥ 50 with ≥ 5 years of hormone therapy (HT). Rates of screening mammogram were evaluated along with analysis of demographic factors that may predict for or against adherence to recommendations. ASBrS and USPSTF guidelines, screening mammograms starting at age 40 and 50, respectively, were applied to patients DFAB. UCSF Center for Transgender Health and Fenway Health guidelines (screening mammogram at age 50 and ≥ 5 years of HT) were applied to patients DMAB. Results: The table illustrates screening adherence rates according to guidelines with two definitions of adherence. We evaluated patients who had screening mammogram “on-time” which was defined at age 40 or 50 with a two year grace period. We also defined adherence as having had a screening mammogram within the two year study period regardless of age. Univariate analysis and multivariate analysis evaluating for insurance status, employment status, level of education, and hormone use did not identify any factors associated with likelihood of adhering to screening guidelines in either the DFAB or DMAB population. Conclusions: Adherence to screening mammogram recommendations among the TGNB population at Northwestern Hospital system is low across all sub-groups. In contrast, the ACO rate of adherence to screening mammogram (within the last two years) at our institution for all-comers (age ≥ 50-74) in 2019 was 77.33%. Demographic data failed to elucidate any association with likeliness to undergo appropriate breast cancer screening. This disparity demands the development of initiatives aimed at increasing breast cancer screening rates for the Northwestern TGNB population.[Table: see text]

How to Minimize Patient Anxiety From Screening Mammography

Anxiety has been portrayed by the media and some organizations and societies as one of the harms of mammography. However, one experiences anxiety in multiple different medical tests that are undertaken, including screening examinations; it is not unique to mammography. Some may argue that because this anxiety is transient, the so-called harm is potentially overstated, but for some women the anxiety is significant. Anxiety can increase or decrease the likelihood of obtaining a screening mammogram. There are multiple ways that anxiety associated with screening mammography can be diminished, including before, during, and after the examination. These include simple measures such as patient education, improved communication, being aware of the patient’s potential discomfort and addressing it, validating the patient’s anxiety as well as providing the patient with positive factual data that can easily be implemented in every breast center. More complex interventions include altering the breast center environment with multisensory stimulation, reorganization of patient flow to minimize wait times, and relaxation techniques including complementary and alternative medicine. In this article we will review the literature on measures that can be taken to minimize anxiety that would maximize the likelihood of a woman obtaining an annual screening mammogram.

Association of Breast Cancer Screening Behaviors With Stage at Breast Cancer Diagnosis and Potential for Additive Multi-Cancer Detection via Liquid Biopsy Screening: A Claims-Based Study

PurposeTo evaluate mammography uptake and subsequent breast cancer diagnoses, as well as the prospect of additive cancer detection via a liquid biopsy multi-cancer early detection (MCED) screening test during a routine preventive care exam (PCE).MethodsPatients with incident breast cancer were identified from five years of longitudinal Blue Health Intelligence® (BHI®) claims data (2014-19) and their screening mammogram and PCE utilization were characterized. Ordinal logistic regression analyses were performed to identify the association of a biennial screening mammogram with stage at diagnosis. Additional screening opportunities for breast cancer during a PCE within two years before diagnosis were identified, and the method extrapolated to all cancers, including those without recommended screening modalities.ResultsClaims for biennial screening mammograms and the time from screening to diagnosis were found to be predictors of breast cancer stage at diagnosis. When compared to women who received a screening mammogram proximal to their breast cancer diagnosis (0-4 months), women who were adherent to guidelines but had a longer time window from their screening mammogram to diagnosis (4-24 months) had a 87% increased odds of a later-stage (stages III or IV) breast cancer diagnosis (p-value &lt;0.001), while women with no biennial screening mammogram had a 155% increased odds of a later-stage breast cancer diagnosis (p-value &lt;0.001). This highlights the importance of screening in the earlier detection of breast cancer. Of incident breast cancer cases, 23% had no evidence of a screening mammogram in the two years before diagnosis. However, 49% of these women had a PCE within that time. Thus, an additional 11% of breast cancer cases could have been screened if a MCED test had been available during a PCE. Additionally, MCED tests have the potential to target up to 58% of the top 5 cancers that are the leading causes of cancer death currently without a USPSTF recommended screening modality (prostate, pancreatic, liver, lymphoma, and ovarian cancer).ConclusionThe study used claims data to demonstrate the association of cancer screening with cancer stage at diagnosis and demonstrates the unmet potential for a MCED screening test which could be ordered during a PCE.