Improving Female Preventive Health Care Delivery Through Practice Change: An Every Woman Matters Study

Elisabeth L. Backer, MD; Jenenne A. Geske, PhD; Helen E. McIlvain, PhD; Diane M. Dodendorf, PhD; and William C. Minier, MD


J Am Board Fam Med. 2005;18(5):401-408. 

In This Article

Abstract and Introduction

Background: The levels of breast and cervical cancer screening in Nebraska primary care remain suboptimal despite awareness of their importance, and despite implementation of the Every Woman Matters program to assist low-income women. The GAPS model was used to develop a practice-based intervention to identify and reduce barriers to delivery of breast and cervical cancer screening services.
Methods: Seven primary care practices actively participated in this multimethod case study. A research nurse collected data and facilitated the intervention process at each site. Qualitative data from field notes, patient encounters, and in-depth interviews of physicians and key informants were collected to describe the process of Papanicolaou and mammogram service delivery, and to identify barriers/facilitators to screening, and potential change areas. Chart reviews provided information regarding the preintervention and postintervention identification/execution of Papanicolaou smears and mammograms. Qualitative and quantitative analyses led to individual practice case studies. Cross case comparisons identified common themes.
Results: The individual practice plans for change had many commonalities, ie, developing screening databases and reminder systems. The biggest differences involved practice contexts. Despite use of the GAPS model and a financial incentive to obtain "buy in" from providers and staff, change was difficult for all but 2 of the practices.
Conclusion: The complexity of practice context and its effect on change cannot be underestimated. Individual practice providers and staff are often unaware of the potential challenges, and unable/unwilling to overcome them.

The practice of screening for disease has been shown to save lives, reduce health care costs, and reduce suffering. Periodic screening for breast and cervical cancer has been particularly effective in reducing the burden of disease in women.[1,2,3,4,5,6] Even so, screening rates in many practices fall short of recommended levels, leaving patients at unnecessary risk.[7,8] Barriers to screening exist at manylevels including the patient, physician, and practice systems.[9,10,11,12]

Every Woman Matters (EWM), a state-run federally funded program, is designed to remove barriers to preventive breast and cervical cancer screening by raising public awareness of the risk and making screening more financially accessible to low-income women. Eligible women receive a clinical breast examination, mammography, and Papanicolaou smear test at reduced or no cost. The EWM program provides services to practices to aid in implementation of the program. However, even with this program, the level of breast and cervical cancer screening falls short of the ideal.

Numerous decades of trying to improve preventive service delivery have shown that there are no magic bullets[13,14]; most interventions to alter physician and practice behavior have shown only modest success.[15] Systematic reviews of change strategies recognize practices as complex systems and call for more effective and complex strategies that assist practices in initiating and sustaining change.[16] Changing practice behavior entails teamwork among clinicians and staff, requires flexibility and willingness to change, and should be based on individualized interventions based on each system's unique and dynamic pattern.[15,17] The GAPS model is based on these concepts. Using the GAPS model to enhance preventive care and modify office operations, we involved office staff at each step: goal-setting, assessing existing routines, planning the modification of routines, and providing support for these improvements.[17]

Our practice-based intervention study was designed in collaboration with the Nebraska Health and Human Services EWM Program to help individual practices identify barriers to their delivery of breast and cervical cancer screening services, develop plans for reducing barriers, and encourage provision of the EWM program to low income patients. We hypothesized that individualized, facilitated interventions could significantly increase the rates of up-to-date mammogram and Papanicolaou test screening in these practices.


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