A study measures compliance rates of patients with state and federal safety-net funding
BY MELISSA CARANDANG, MD; WESLEY BABARAN, MD; LAWRENCE WAGMAN, MD; LIANNE
NACPIL, MPH, CTR; TIMOTEA LARA, RN, MSN, NP-C; NORMA CASTRO; AND SHANNIN GREENE
The multidisciplinary breast cancer clinic at St. Joseph Hospital, Center
for Cancer Prevention and Treatment (CCPT), Orange, Calif., was designed
with a specific infrastructure to serve women with state and federal safety
net funding. In 2011 CCPT initiated a study to measure patient compliance
with post-therapy surveillance in this population, conducting a descriptive
retrospective chart review on previously diagnosed breast cancer patients
seen at the multidisciplinary breast cancer clinic during the two years
from 2011 to 2013. Post-therapy surveillance compliance was assessed in
three categories: clinic appointments (n=82), annual mammography for patients
with one or both breasts intact (n=75), and yearly evaluation for those
prescribed anti-hormone therapy (n=61). CCPT compared compliance rates
based on patient characteristics: age, stage, distance from the clinic,
insurance carrier, race, and ethnicity. Study results found the average
per patient combined compliance for all post-therapy surveillance to be
92.5 percent at 12 months, 54.4 percent at 18 months, and 82.4 percent
at 60 months. When comparing characteristic groups by test categories,
CCPT found no clinically significant patterns or trends; however, overall
annual mammogram compliance was consistently higher than both clinic appointment
and anti-hormone therapy compliance.
The St. Joseph Hospital, Center for Cancer Prevention and Treatment established
its multidisciplinary breast cancer clinic in 2008 as a component of the
National Cancer Institute Community Cancer Centers Program (NCCCP) grant.
The goal: to serve women with a confirmed breast cancer diagnosis and
“safety net” financial status—the patient population
for the study discussed in this article.
Clinic components include scheduling, nursing, culturally geared navigation,
operating services, breast imaging, electronic health records, translation
services, and research (Table 1, page 37). As the breast cancer clinic
is staffed by both hospital-employed and private practice multispecialty
oncologic physicians, CCPT has developed guidelines for physician participation
in the cancer program. Some physicians treat patients in the hospital’s
outpatient department and bill under 1206(d) in the Outpatient Prospective
Payment System (OPPS), while others see patients in their private physician
practice offices and bill for services under the Physician Fee Schedule (PFS).
The CCPT multidisciplinary breast cancer clinic follows National Comprehensive
Cancer Network (NCCN) guidelines for breast cancer post-therapy surveillance,
including clinic appointments, mammograms, and confirmation of anti-hormone
therapy use. During this study period, the standard practice was to advise
patients in accordance with NCCN post-therapy surveillance. Note: this
analysis precedes the multidisciplinary breast cancer clinic’s consistent
distribution of a formal breast-cancer- specific treatment summary survivorship
plan, which is currently required by the Commission on Cancer (CoC).
In 2014 CCPT conducted a retrospective, descriptive chart review on 82
previously diagnosed breast cancer patients seen at the multidisciplinary
breast cancer clinic between 2011 and 2013. Post therapy surveillance
- Clinic appointments every 4 to 6 months for the first 5 years after treatment.
- Annual mammograms for the first 5 years after treatment.
- Annual compliance with recommended anti-hormone therapy use for the first
5 years after treatment.
As is expected in the breast cancer patient population, CCPT believed that
primary care providers, in a variety of settings, would potentially assume
patients’ long-term cancer surveillance.
Individual patient and test results were tallied and analyzed for compliance.
All 82 patients were evaluable for clinic appointment compliance. For
annual mammograms, the patients who were included in the study had one
or both breasts intact (n=75), while patients with a history of bilateral
total mastectomies were excluded. CCPT also assessed the compliance of
all patients who had been prescribed anti-hormone therapy (e.g., aromatase
inhibitors or tamoxifen); data was collected to document evidence of assessment
and adherence at the follow-up appointments (n=61). Patients who were
not prescribed anti-hormone therapy were excluded.
CCPT then compared compliance for the three main parameters based on subject
- Stage at diagnosis
- Distance from home to clinic
- Type of insurance
Table 2, page 38, shows the subject characteristics of the study.
Overall, during the 5-year study period, the compliance rate for attending
scheduled clinic appointments for all 82 patients ranged from 54.3 percent
to 96.3 percent. Patient compliance with
mammograms completed for 75 patients ranged from 78.6 percent to 97.3
percent. Finally, compliance with reported anti-hormone therapy use for
61 patients ranged from 62.5 percent to 93.3 percent. CCPT saw a large
dropoff in the average per patient combined compliance for the three parameters
18 months post-treatment, but compliance increased and remained consistently
higher after 2-years post-treatment (see Figure 1, page 40).
During analysis of the compliance with clinic appointments based on patient
age, the average was approximately 70 percent throughout the groups. The
average compliance of reported anti-hormone therapy use based on age groups
was slightly higher at 81 percent, while mammogram compliance was the
highest overall, with averages ranging from about 80 percent to 90 percent.
All patients in the study were newly diagnosed and staged at their initial
multidisciplinary breast cancer clinic evaluation. When measuring the
compliance with clinic appointment based on stage at diagnosis, the range
was large—59.3 percent at Stage 0 to 80.6 percent at Stage III.
The compliance with reported anti-hormone use based on stage at diagnosis
was slightly higher with a range of 75.1 percent (Stage 0) to 87.5 percent
(Stage IV). Mammograms completed showed the highest compliance, ranging
from 85.1 percent (Stage II) to 91.7 percent (Stage IV).
As the distance from the clinic increased, the average compliance of all
three post-therapy surveillance measurements did show a slight downward
trend. For clinic appointments, the compliance was highest for patients
who traveled 0.0 to 9.9 miles for treatment (76.6 percent), whereas the
patients who traveled more than 20 miles had a slightly lower average
(67.6 percent). The compliance with reported anti-hormone therapy use
was around 77 percent. Again, mammograms completed were the highest all
around, ranging from 81 percent (patients traveling 10 to 19.9 miles)
to 93.5 percent (patients traveling 0 to 9.9 miles).