June 10, 2022 — Targeted text reminders and other interventions erased disparity in the rate of breast cancer screening between economically advantaged and disadvantaged patients, according to an OSF HealthCare study published in Population Health Management.
While screening has been shown to reduce breast cancer deaths, women who are economically disadvantaged are less likely to have breast cancer screening and more likely to die of the disease, often because the breast cancer isn’t detected until it reaches a more advanced stage. Mammography screening rates plummeted during the COVID-19 pandemic, which only increased the disparity between economically advantaged and disadvantaged patients.
OSF HealthCare researchers analyzed the effectiveness of interventions created and supported by the OSF OnCall digital health team to reduce that disparity, with: text messages that included a link to schedule a mammogram and information about the importance of breast cancer screening; calls from a digitally-enabled community health worker (CHW) to help schedule mammograms and solve challenges such as transportation; and an invitation to a health fair offering on-site mammograms. Breast cancer screening rates more than doubled among Medicaid patients who received interventions.
The National Comprehensive Cancer Network (NCCN) guidelines recommend annual mammography for most women beginning at 40 and earlier for women at higher risk for breast cancer.
“Previous studies have found that similar interventions help increase the rate of breast cancer screening, but not whether they would reduce disparities among different populations,” said Jonathan A. Handler, MD, FACEP, FAMIA, senior author of the study and senior fellow, OSF Innovation at OSF HealthCare.
The study included more than 4,000 women in two groups: an economically disadvantaged group (those with Medicaid coverage), and an economically advantaged group (those with private commercial insurance). All were 41 or older, were aligned with an OSF primary care physician and appeared to be overdue for their mammogram – typically by two years or more. All with Medicaid were randomly assigned to one of three intervention arms and compared with a subset of commercially insured women randomized to receive no intervention
All in the Medicaid group received the first intervention (at least one text message reminder). The moderate intervention arm also received additional educational content, a reminder text after a mammogram was scheduled, and phone outreach by a CHW to answer questions, assist with scheduling a mammogram, and address other issues related to the screening. The third arm had all of those interventions, and also received an invitation to a health fair where attendees could participate in interactive educational activities, schedule a mammogram or receive a same-day mammogram at the health center after attending the event.
In the Medicaid group, the rate of mammogram screening more than doubled following the interventions, from 5.4% to 11% of eligible patients. Interventions targeted only to the Medicaid group reversed the disparity in screening rates. Before interventions, the Medicaid group had 2.6% lower breast cancer screening rate than those with private insurance. After the interventions, the Medicaid group’s screening rate was 3.7% higher than those with commercial insurance who had been randomly assigned to receive no intervention.
Medicaid covers mammograms
Researchers determined Medicaid participants who had moderate to maximum intervention had a significant improvement in screening rates. Many in this group were reluctant to get a mammogram because of the expense until learning from a CHW that appropriate screening is covered by Medicaid.
Screening rates also increased after intervention among privately-insured women who were assigned to intervention arms. Therefore, researchers said economically disadvantaged women might require more intense intervention than their economically advantaged counterparts, with private insurance, to close the disparity gap moving forward.
“The goal is equity in health outcomes, not always standardization of an intervention or what we think of as equality. So it’s vital to strategically implement interventions among patients who would most benefit,” said Sarah Stewart de Ramirez, MD, MPH, principal investigator of the study, medical director for Population Health Services at OSF HealthCare, and associate dean for Population Health Equity Innovation at the University of Illinois College of Medicine Peoria. “For example, we found that simply providing interventions such as a text message equally to the entire patient population might actually widen that disparity, because economically advantaged patients have fewer hurdles to access care and therefore are more likely to be able to act on those reminders.”
Dr. de Ramirez added, “Ultimately, we hope to find an engagement approach that achieves equity while also improving screening rates for all women. It’s imperative that we continue to study new population based interventions so we can apply them with the same science as clinical interventions, and ensure our patient populations receive the highest level of care, wherever they are.”
The study was funded by the American Hospital Association’s Institute for Diversity and Health Equity and Blue Cross Blue Shield of Illinois.
For more information: osfhealthcare/innovation