Breast cancer is the second leading cause of cancer death among American women. Early detection, especially through mammography, has been shown to be effective in reducing mortality from the disease, but screening mammography rates in the general population fall well below recommended levels. Our proposal tests strategies which can be tailored to reach the large proportion of women in the United States who have some form of third party health care coverage. The principal aim of our research is to determine whether physician and patient adherence to current mammographic screening guidelines in community-based primary care practice settings can be enhanced through the implementation of """"""""systems-driven"""""""" strategies which do not rely on the active involvement of the physician or patient for their initiation. This proposal combines several strategies in a factorial design. The setting in which the strategies will be tested is the Tufts Associated Health Plan (TAHP), a 110,000 member Independent Practice Association in the metropolitan Boston area. Thus, they can be replicated in any third party payment system in which the performance of a mammographic examination results in a bill for the specific service being submitted to the payor. The strategies to be implemented are 1) general education of patients and physicians, 2) automated """"""""physician-surrogate"""""""" patient reminders, and 3) regular performance feedback to physicians of the proportion of their eligible patients who have had mammograms. These strategies will be implemented using the existing, centralized billing facilities of TAHP. They do not rely on the individual physician or his/her office staff for their proper functioning. Outcome variables will include 1) age-specific screening mammography rates, 2) individual physician performance scores, 3) system costs, and 4) patient and physician satisfaction. This proposal is designed as a three-year study, with a 21 month intervention trial.
