Targeted Inpatient Screening Mammogram Program to Reduce Disparities in Breast Cancer Screening Rates

THE INNOVATION

Significant disparity exists in breast cancer screening rates between commercially insured patients and low-income patients who are insured by Medicaid or are dually eligible (insured by both Medicare and Medicaid).^1-3 We examined the feasibility of performing targeted screening mammograms during hospitalizations to help remove barriers that low-income patients face in the outpatient setting, such as challenges in scheduling and keeping appointments, lack of transportation, and difficulty taking time off from work.^4,5

WHO & WHERE

Targeted screening mammograms were performed among Medicaid and dually eligible patients admitted to the General Medicine service at a large, urban, academic medical center between March 2019 and March 2020.

HOW

A daily report was generated using the electronic medical record system to identify potential intervention candidates who were admitted to the General Medicine service and met all of the following criteria: (1) had a primary care physician who is affiliated with the academic medical center, (2) was overdue for breast cancer screening, (3) did not have an outpatient mammogram already scheduled, and (4) was insured by Medicaid or both Medicare and Medicaid. A chart review was performed to exclude patients who met any of the following criteria: (1) inability to complete mammogram due to physical disability (eg, paraplegia), critical illness, or altered mental status, (2) admitted involuntarily under Section 12 for psychiatric emergency, or (3) limited life expectancy. Up to 3 e-mails were sent to each eligible patient’s inpatient clinicians, asking them to consider completing a mammogram before hospital discharge. A Breast Imaging staff member contacted the inpatient nurse to coordinate screening mammograms for appropriate candidates during weekdays.

Of 48 clinicians, 39 (81%) responded to the e-mails asking them to consider obtaining a screening mammogram before discharge. Twenty-one patients were deemed appropriate candidates; 13 patients were deemed inappropriate (inability to stand independently for 5-10 minutes or being medically unstable); 5 patients refused. Of the 21 appropriate candidates, 17 patients successfully completed inpatient mammograms. A remaining 4 patients were discharged before inpatient mammogram could be coordinated. There was no difference in average hospital length of stay between those who completed the screening mammogram and those who did not. All screening mammogram results were negative (BI-RADS Category 1 or 2) except for 1 (BI-RADS 0).

LEARNING

This program demonstrates the feasibility of performing targeted inpatient screening mammograms to improve breast cancer screening rates among Medicaid and dually eligible patients. Medicaid patients appear to be more suitable candidates than dually eligible patients who tend to have significant competing medical comorbidities or physical disabilities that preclude them from undergoing screening mammogram during their hospitalization (Supplemental Appendix). Most patients identified in this pilot would have faced significant psychosocial barriers to completing the mammogram as an outpatient as evident from the fact that 35% never had a screening mammogram previously and patients were, on average, 4 years overdue for their breast cancer screening. Improving population health outcomes among underserved patient populations will increasingly become important as the health care system transitions from fee-for-service to value-based payment models. Therefore, implementation of an inpatient screening mammogram program can be a valuable tool for improving breast cancer screening rates among patients who are difficult to engage in the outpatient setting.