Cutting Down on Missed Opportunities

Skipped appointments tell us more about our patients' access to care than you might think.missed opportunities

As a professional organization, the ACR has been a tremendous advocate for women's access to screening mammography annually starting at age 40, which gives the maximum life-saving benefit.

Through countless hours of meetings, deliberations, and planning, the Commission on Breast Imaging, led by Debra L. Monticciolo, MD, FACR, has worked tirelessly on behalf of the women who benefit from these efforts. As potential detractors to these services arise, we must remain vigilant in preserving access to this life-saving technology. However, the full impact of screening mammography specifically — and medical imaging in general — lies in our ability to extend the benefits of our services to the populations at large.

Well-documented health disparities exist among individuals who differ by race, ethnicity, and economic status. Individuals with financial challenges, those whose primary language is not English, and people with lower education levels are less likely to have strong engagement in the health care delivery system. For women's health care in particular, breast cancer mortality is highest among African-American women, and cervical cancer mortality in African-American women is double that of Caucasian women.

At Massachusetts General Hospital, Efren J. Flores, MD, found these factors held true in the hospital's patient population. Flores' research demonstrated that patients who miss appointments are more likely to reside in low-income neighborhoods, regions with high unemployment, and locations with high proportions of African-American and Hispanic patients. In patients for whom English is not the primary language, Flores observed that the lack of reminder messages in the appropriate language is a common source for missed appointments. These patients often prefer text message reminders over verbal messages, as it is easier to translate a text message than an audio one.

Historically, medical specialists have viewed patient engagement as the concern of the primary care provider. The new health care paradigm shifts the focus to a shared responsibility between medical specialists, primary care physicians, and patients. Even measures as simple as changing the language we use about these patients can reflect this evolution in accountability. By switching labels from "no show" or "noncompliant" to "missed care opportunity," we demonstrate our investment in the health of our patients.

Patient navigators may also help reduce missed care opportunities by providing additional support to patients for whom medical instructions are poorly understood, either based on education level or language barriers. Patient navigators are an important element for population health management in primary care practices. Engaging these individuals with information specific to imaging examinations, including screening mammography, can help navigators direct patients to the appropriate preventative, diagnostic, and therapeutic care. In the future, predictive algorithms may help identify patients at risk for low patient engagement and potential missed care opportunities. Individuals at high risk for missed care opportunities may be targeted for specific interventions, such as transportation assistance and personal support, to ensure compliance with care plans.

We can no longer be satisfied with relatively low compliance rates for screening mammography, as is the case in many disadvantaged communities. Our patients' access to care is everyone's business. The potential impact on lives saved across the population of eligible women in the United States is enormous. As radiologists, we must help our primary care colleagues increase patient access to screening and diagnostic mammography services. These may include the following:

• Adding text-based reminder messages, allowing easy translation to the patient's primary language

• Partnering with care coordinators to ensure patients are up-to-date with screening recommendations
• Increasing educational efforts about the benefits of screening mammography in disadvantaged communities

The ACR has been and will continue to be an important champion for annual screening mammography starting at age 40. Imaging 3.0™ empowers radiologists to assume a greater role in the care delivery engine. A key part of this evolution is recognizing the social determinants of health care in radiology and helping to reduce socioeconomic barriers that limit patients from receiving the benefits of our services. A little effort in this domain can pay dividends with both patients and their doctors. In this case, an ounce of prevention is truly worth a pound of cure.

BrinkBy James A. Brink, MD, FACR, Chair



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