An Update

Breast Cancer Awareness
Roundtable Discussion and Workshop

On October 31st, 2006, the Institute on Social Exclusion (ISE) hosted a roundtable discussion on access to breast cancer care for low income women in metropolitan Chicago. Impetus for the Roundtable was the alarming backlog of women who were waiting for diagnostic mammograms at Stroger Hospital.  The Roundtable was organized to heighten public awareness of this problem and to facilitate development of an action plan to address it.  It was attended by more than 50 individuals representing virtually all major stakeholder groups in the fight against breast cancer, including state and local government officials, direct service providers, advocacy organizations, breast cancer survivors, universities and drug companies.

In October 2006, roughly 11,000 referrals for mammograms were waiting to be appointed (i.e., given appointments) at Stroger Hospital. Some women had been waiting since March 2005. Of the 11,000, about 5,300 referrals were for diagnostic mammograms. These were referrals for women whose screening mammograms had revealed some sort of abnormality and/or for women who had a breast problem such as a lump, discharge, or pain. The 5,700 balance were women waiting for standard screening mammograms.

According to attendees Mary Driscoll, Director of Patient Care Services/Chief Nursing Officer Ambulatory and Community Health Network of the Cook County Bureau of Health Services, and Pamela Ganschow, Director, Breast and Cervical Cancer Screening Program at Stroger Hospital, the roundtable served as a catalyst in the mobilization of resources that, to date, has resulted in a significant reduction of the backlog. By summer 2007, the diagnostic backlog was down to about 1,000 women – an 82 percent reduction. The 5,700 women waiting for screening mammograms were being diverted to other areas hospitals.

The process that led to these service improvements involved two months of planning how best to meet the needs of the women waiting for diagnostic and screening mammograms. During the planning period, partnerships were developed with the State Illinois Breast and Cervical Cancer Program (IBCCP) and with local breast care programs, such as those at Mercy Hospital, to assist Stroger Hospital in handling current and backlogged mammography requests. Additionally, at Stroger, a detailed assessment of diagnostic mammography capacity was made; existing mammography appointment slots were reorganized to meet current demand in a timely fashion and prevent the creation of additional diagnostic mammography backlog; and an additional 100-150 mammogram appointment slots per week dedicated to the diagnostic mammogram backlog were mobilized.

Beginning in March 2007, backlogged referrals for diagnostic mammograms were triaged, and the most serious cases – those with the most suspicious abnormalities—were appointed by June. By mid-summer, all of the most urgent needs were addressed, and plans were in placed to service the mammographic needs of the remaining 1000 women, including those who with low suspicion breast abnormalities required a 6-12 month follow-up.  Going forward, in addition to addressing the backlog, the main priority at Stroger Hospital will be to service women with requests for diagnostic mammograms within four weeks of their order and to, thereby, avoid the development of another backlog.

One of the outcomes of the Adler Roundtable was a Ten-Point Action Plan which was, at the time, the best estimation of what would have to be done to eliminate the backlog at Stroger. Some action items have been implemented; others were implemented in ways not considered at the roundtable; and others were not implemented at all. Below, we summarize progress on each Action Plan item.

1. Develop a strategy for needed policy changes. No formal strategy was developed for needed policy changes. There was, however, an important change in organizational practice: the outsourcing of the new screenings of women with low to average risk for breast cancer from Stroger Hospital to other area providers whose services were funded through the Illinois Breast and Cervical Cancer Program (IBCCP). Through the use of an improved electronic referral system for specialty health care – Internet Referral Information System (IRIS) – women who would have otherwise been screened at Stroger were diverted to other healthcare sites for screening. The effects of this procedural change were to (i) provide women with low or no cost, timely screening mammograms and additional diagnostic care/treatment, if needed; (ii) avoid the accumulation of additional screening (backlog) mammograms at Stroger; and (iii) help minimize the accumulation of additional diagnostic mammograms at Stroger, which would result from onsite screening mammograms.
2. Divert referrals for screening mammograms from Stroger Hospital to Illinois Breast and Cervical Cancer Program sites. As noted above, all new screening mammograms have been diverted from Stroger to other sites (e.g., Mercy Hospital) through the Illinois Breast and Cervical Cancer Program.  The only exception is that Stroger continues to provide screening mammograms for women with a history of breast cancer or who are at a very high risk for developing breast cancer (e.g., those with a BRCA1 [breast cancer type 1 early onset] or BRCA2 [breast cancer type 2 susceptibility protein] mutation).
3. Assess backlog to determine demographics, time and other background information needed to develop a Backlog Reduction Plan (BRP). Of the women in the backlog, 60% were African American, 30% were Latina, 10% were other, largely Eastern European. Seventy-four percent live in the city of Chicago, 8% lived in the west suburbs, 4% lived in the south suburbs, and 4% lived in counties other than Cook. The most current addresses and phone numbers were retrieved from our hospital information system and used when contacting the women by phone and mail, to notify them of their appointment.
4. Identify a cadre of nurses at Stroger Hospital who can systematize the backlog and notify patients on plans for follow-up. Hospital staff sent out a series of notifications to women in the diagnostic backlog: live phone calls, follow-up letters, follow-up phone calls, and appointment reminders.
5. Write white paper on the mammography needs at Stroger Hospital mammography and submit to President of the Cook County Commission Board. No white paper was written.
6. Develop a marketing plan for the providers and patients of the Illinois Breast and Cervical Cancer Screening Program. No formal marketing plan was developed, but marketing activities, such as provider education – is taking place through IRIS. When providers go onto IRIS to make referrals, they have the opportunity to learn about the IBCCP and the range of services it provides. Additionally, increased numbers of flyers advertising the IBCCP and other services have been posted in many area clinics.
7. Establish a process for voluntary assistance and resource sharing to support indigent care by other hospitals. Refine the concept of "charity care" to include outpatient services.  Although Rush University Medical Center is assisting Stroger with the backlog of some medical procedures (e.g., colonoscopies), there has been greater hesitation to push for voluntary assistance and resource sharing as regards mammographies. The reluctance stems from a concern that assistance may mean an associated shift in resources away from Stroger, complicating an already challenging problem.  In any case, the IBCCP has, to a great degree, mitigated the need for voluntary assistance and resource sharing.
8. Establish the American Cancer Society's Navigator System at Stroger Hospital with adequate funding and staffing.  In May of 2007, the American Cancer Society hosted the opening of its new Patient Navigator System Office at Stroger Hospital.
9. Identify funding sources and write grant proposals to underwrite Backlog Reduction Plan. Stroger has not received grant funding to address the backlog problem. Mercy Hospital has received an award from the Avon Foundation to assist Stroger Hospital with the screening mammography backlog.
10. Identify technology needs required to address mammography backlog. Funds have been made available to replace old computer equipment that is expected to increase efficiency and service capacity. The main need at Stroger to increase capacity and begin offering screening mammography again is to hire additional mammographers. The combination of the nationwide shortage of mammographers and the fact that Stroger does not offer a competitive salary makes the hiring of additional mammographers almost impossible.

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