Implementing an Individualized Breast Cancer Risk Assessment at the Coalville Health Center

Breast cancer ranks as the second most common cancer among women, with incidence rates on the rise. Early detection through personalized risk assessment and adherence to screening guidelines improves the chances of detecting cancer in its early stages. Performing individualized breast cancer risk assessments can help patients understand when they should start annual screenings based on shared decision-making with their primary care provider. Local Problem: Women in rural communities often face disparities in accessing quality and regular screening. This rural clinic is in Northern Utah, an area with the second-highest incidence rate of breast cancer in the state. This clinic previously had no formal method for breast cancer screening. Methods: This quality improvement (QI) project first involved a retrospective chart review to establish a baseline for current breast cancer screening methods prior to the implementation of the evidence-based risk assessment. The evidence-based individualized risk assessment was adapted from the National Comprehensive Cancer Network guidelines and presented to the providers at the clinic during a process-based presentation. Pre-and post-presentation surveys were distributed to gauge provider knowledge and comfort regarding breast cancer screening and risk factors. Data were collected over six weeks to track the number of risk assessments conducted and missed opportunities. Eligibility criteria for the chart review and data collection included a female over the age of 18 that presented for an annual physical, annual wellness visit, or pap smear. Interventions: A baseline for the number of risk assessments performed was established during the retrospective chart review. The breast cancer risk assessment was implemented in the clinic following a workflow and educational presentation. Pre-and post-surveys were administered to the providers before and after the presentation. The findings of the project were discussed during a post-implementation provider discussion after the six weeks of data collection. Results: The pre-implementation baseline assessment found that of the 87 encounters that met the eligibility criteria, 26 (30%) should have received an individualized breast cancer risk assessment. However, as there was no documentation of this occurring in the EHR or elsewhere, all (100%) were classified as a missed opportunity. In comparison, data associated with the post- implementation found that of the 42 encounters during the implementation period that met the eligibility criteria, five (12%) were classified as missed opportunities. This represents an 88% reduction in missed opportunities. Post-intervention, all providers (n=3) reported increased confidence and competence in discussing breast cancer risk factors. Conclusions: The use of an individualized breast cancer risk assessment is a valuable tool for enhancing provider comfort and competence in identifying high-risk women and its usage reduces the proportion of missed opportunities and increases the proportion of completed cancer risk assessments.

1 Implementing an Individualized Breast Cancer Risk Assessment at a Rural Clinic in Northern Utah Jennifer L Falkner, Rosemary Conder, Jeanette Vernon, Larry Garrett College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III 31 March 2024 2 Abstract Background: Breast cancer ranks as the second most common cancer among women, with incidence rates on the rise. Early detection through personalized risk assessment and adherence to screening guidelines improves the chances of detecting cancer in its early stages. Performing individualized breast cancer risk assessments can help patients understand when they should start annual screenings based on shared decision-making with their primary care provider. Local Problem: Women in rural communities often face disparities in accessing quality and regular screening. This rural clinic is in Northern Utah, an area with the second-highest incidence rate of breast cancer in the state. This clinic previously had no formal method for breast cancer screening. Methods: This quality improvement (QI) project first involved a retrospective chart review to establish a baseline for current breast cancer screening methods prior to the implementation of the evidence-based risk assessment. The evidence-based individualized risk assessment was adapted from the National Comprehensive Cancer Network guidelines and presented to the providers at the clinic during a process-based presentation. Pre- and post-presentation surveys were distributed to gauge provider knowledge and comfort regarding breast cancer screening and risk factors. Data were collected over six weeks to track the number of risk assessments conducted and missed opportunities. Eligibility criteria for the chart review and data collection included a female over the age of 18 that presented for an annual physical, annual wellness visit, or pap smear. Interventions: A baseline for the number of risk assessments performed was established during the retrospective chart review. The breast cancer risk assessment was implemented in the clinic following a workflow and educational presentation. Pre- and post-surveys were administered to 3 the providers before and after the presentation. The findings of the project were discussed during a post-implementation provider discussion after the six weeks of data collection. Results: The pre-implementation baseline assessment found that of the 87 encounters that met the eligibility criteria, 26 (30%) should have received an individualized breast cancer risk assessment. However, as there was no documentation of this occurring in the EHR or elsewhere, all (100%) were classified as a missed opportunity. In comparison, data associated with the postimplementation found that of the 42 encounters during the implementation period that met the eligibility criteria, five (12%) were classified as missed opportunities. This represents an 88% reduction in missed opportunities. Post-intervention, all providers (n=3) reported increased confidence and competence in discussing breast cancer risk factors. Conclusions: The use of an individualized breast cancer risk assessment is a valuable tool for enhancing provider comfort and competence in identifying high-risk women and its usage reduces the proportion of missed opportunities and increases the proportion of completed cancer risk assessments. Key words: breast cancer risk assessment, missed opportunities, shared decision-making, improved provider comfort 4 Implementing an Individualized Breast Cancer Risk Assessment at a Rural Clinic in Northern Utah Problem Description Women in rural communities suffer from increased healthcare disparities when compared to women in urban settings. Among these is a lack of quality and routine breast cancer screening due to limitations in access and long travel distances (Tsapatsaris et., 2021), and inaccessibility to providers and specialty care (Atere-Roberts et al., 2020). Breast cancer screening is important in reducing mortality from this disease through early intervention. Lack of quality and routine screenings can lead to late-stage diagnosis and an increase in disease burden. In the United States, breast cancer is the second leading cause of cancer deaths in women, with a 2.6% mortality rate (American Cancer Society, 2023). Data from the American Cancer Society shows that Utah’s mammography rate is 60%, which is considerably lower than the national average of 67% (American Cancer Society Cancer Facts & Statistics, 2023). Where this rural clinic is located has the second highest incidence rate of breast cancer diagnoses in Utah (Utah Department of Health and Human Services, 2023). Available Knowledge Breast cancer is the second most common cancer in women in the United States, following skin cancer. The risk of a woman developing breast cancer in her lifetime is approximately 13%. The incidence of breast cancer has increased by 0.5% per year in recent years (American Cancer Society, 2023). However, death rates due to cancer have been declining since the 1980s due to increased screening, breast cancer awareness, and more effective treatment (American Cancer Society, 2023). 5 Mammograms are the most used procedure for breast cancer screening. Although mammograms are the most effective method currently used for detection, they have limitations, such as false-negatives, false-positives, and risks associated with radiation exposure (American Cancer Society, 2023). According to the National Comprehensive Cancer Network (NCCN) (2023), clinical breast exams (CBE), or breast exams performed by clinicians, are indicated in a variety of settings. There has been debate in recent years regarding breast self-examinations (BSE) and whether women should be performing them on a routine basis. The patient performs this type of breast exam at home to check for new abnormalities. Self-examinations have not shown a reduction in breast cancer mortality (National Comprehensive Cancer Network, 2023). Many providers in primary care refer to the standard screening guidelines to begin breast cancer screening for women. Although this is the standard of care, new evidence suggests that women should have an individualized risk assessment performed by their primary care provider (PCP) (Beidler et al., 2023; National Comprehensive Cancer Network, 2023; Shrager & Burnside, 2019). Patients can make an informed decision based on shared decision-making with the provider after reviewing for significant risk factors and their personal risk assessment (Beidler et al., 2023; National Comprehensive Cancer Network, 2023; Shrager & Burnside, 2019). NCCN guidelines recommend that all women undergo a risk assessment before age 25. Individualized risk assessments include a detailed family history of female cancers; a pedigree suggestive of known genetic predispositions (including BRCA 1 and 2 mutations); a history of lobular carcinoma in situ (LCIS); and a history of radiation therapy to the thoracic region. Once the risk assessment is performed, providers and patients can decide together when screening should begin. It is important for patients to understand the benefits of screening, including the early detection and treatment of malignancy, and risks regarding radiation exposure 6 with mammography. The limitations of mammography screening (e.g., false-negatives and falsepositives) are also an important conversation so patients can understand that the screening is only the first step if the mammogram comes back abnormal. There are diagnostic mammograms, ultrasounds, and magnetic resonance imaging (MRI) that are also useful in identifying breast cancer. Individualized risk assessments are even more useful in regions where mammograms are not as accessible, like rural communities (National Comprehensive Cancer Network, 2023). Women in rural communities have an increased risk for healthcare disparities compared to women in urban areas. These disparities can directly impact quality of life and late disease detection. Women living in rural settings are less likely to be screened for breast cancer when compared to women living in urban settings (Theodoropoulos et al., 2019), making individualized risk assessments performed by PCPs particularly valuable and impactful. Rationale The framework chosen for this project is the Improvement Model from the Institute of Healthcare Improvement (IHI), which is used to guide improvement within healthcare systems (IHI, 2023). This model is a simple yet effective tool for quality improvement. It is not meant to replace current models already in use; rather it accelerates improvement and builds upon what is currently being used. The Plan-Do-Study-Act (PDSA) cycle is an integral part of the IHI model because the cycle provides an opportunity to test changes on a small scale to assess whether a project or intervention has the potential to succeed. The IHI model keeps the big picture at the forefront of any improvement project by asking three simple questions; what are we trying to accomplish, how will we know that a change is an improvement, and what change can we make that will result in an improvement (IHI, 2023). 7 Specific Aims This Doctor of Nursing quality improvement project aims to adapt an individualized evidence-based breast cancer screening guideline and implement the screening process in a rural Utah clinic. Methods Context This project occurred at a privately owned family practice clinic located in northern Utah. It provides care to patients of all ages and currently staffs two physicians, two physician assistants, six medical assistants, and one nurse. This is a rural family medicine clinic and access to specialty care typically involves commuting to the Salt Lake Valley, over 40 miles away. The project began with assessing the number of women who came in for an annual wellness visit, physical exam, or pap smear over a three-month period via a retrospective chart review, as they were the targeted population for this project. The chart review revealed that before this project, there were no formal screening process in place for breast cancer aside from reviewing family history. A mammogram referral before age 40 relied solely on the experience and assessment of the individual provider. Intervention(s) The first phase of this project involved a retrospective chart review to establish a baseline for breast cancer screening methods. The chart review encompassed a 90-day period from July 1, 2023, through September 30, 2023. Inclusion criteria included women who presented to the clinic for an annual visit, physical exam, or pap smear. Data collected included the number of women referred for imaging, the number flagged with an overdue mammogram in the Electronic Health Record (EHR), and the number of women with an up-to-date mammogram. Missed 8 opportunities were also identified. A missed opportunity was defined as no documentation of a risk assessment conducted on an eligible patient. The second phase of this QI project involved a two-hour session with the providers to discuss knowledge and abilities utilizing the breast cancer screening recommendations and guidelines and deliver a process-based presentation developed by the project lead. The presentation included a risk assessment workflow and education about breast cancer rates, risk factors, and various resources available for breast cancer. The risk assessment tool was adopted from the NCCN guidelines. A pre-survey (Appendix A) was administered to the clinic’s two physicians and two physician assistants. The pre-survey assessed provider demographics, breast cancer screening knowledge, and important risk factors for breast cancer development. It was administered via Redcap directly before the presentation occurred. The presentation (Appendix B) was delivered to providers, and it contained information on breast cancer statistics at a national and state level, various screening recommendations based on risk, risk factors for breast cancer, and the results of the retrospective chart review. It also provided information on the use of an evidence-based individualized risk assessment as well as instructions on how to perform the risk assessment, patient eligibility criteria, recommendations based on results, and the International Classification of Diseases (ICD) -10 code (Z15.01) for documentation that the risk assessment was performed. A post-survey (Appendix C) was administered directly after the presentation to evaluate the understanding of presented material. Time was also allotted to allow providers to ask questions, identify barriers, and make recommendations about the project prior to implementation. During this session, front desk staff were instructed to provide eligible women with a female-specific review of systems form (Appendix D). The female-specific forms were adapted 9 from the clinic’s review of systems forms already in use. These forms specifically assessed a patient’s personal and family history of cancer and the date of the last mammogram. They were intended to remind the provider to perform the individualized risk assessment. An additional reminder to the providers to perform these assessments utilized flyers being placed on the clinic’s bulletin boards at the reception desk for the front office staff (Appendix E), as well as in the patient exam rooms (Appendix F). Additionally, a flyer was placed in each of the provider’s offices as a resource for the breast cancer risk assessment criteria, risk factors for breast cancer, the ICD code provided by the clinic’s billing department, and contact information for any questions or concerns (Appendix G). The third phase of the project involved weekly data collection utilizing a chart review process over six weeks from November 6, 2023, to December 16, 2023, evaluating the number of women seen in clinic for an annual wellness visit, physical exam, or pap smear. An essential part of this phase involved provider check-ins to ensure the risk assessment and charting were being performed accurately. The check-ins were performed every two weeks during implementation. Providers were encouraged to contact the project lead if they experienced any problems between check-ins. The collection of weekly data also supported the PDSA methodology of rapid change as problems could be identified early and modification to the project could be implemented as necessary. The final phase of the intervention was a post-implementation analysis. This included a discussion with the providers regarding the usability, feasibility, and satisfaction of the evidencebased screening recommendations and individualized risk assessment. The providers opted for an in-person discussion, led by the project lead, rather than a survey to express their thoughts about 10 the intervention. Providers were given data on the current number of risk assessments performed and missed opportunities. Study of the Intervention(s) Descriptive statistics were used to compare the number of pre-intervention and postintervention screenings to assess the impact of this QI project. The number of completed assessments, as well as missed opportunities, was calculated. The pre-intervention data was obtained utilizing chart reviews. In contrast, post-intervention data were obtained by querying the EHR utilizing the ICD code for breast screening, which was introduced to the clinic as part of the intervention. An assessment of the pre-and post-presentation data was also completed and used to evaluate the providers’ perceived barriers, knowledge, and comfort level in performing the individualized risk assessments. Measures The retrospective chart review analyzed data from a three-month period. Patients met the criteria for a chart review if they are female, had an encounter for an annual physical exam, pap smear, or annual wellness visit. Specific data included the number of women referred to imaging, the number of missed opportunities for an individualized breast cancer risk assessment, the number of women that had a flag for an overdue mammogram in the EHR, and the number of women with an up-to-date mammogram. These data were analyzed, compiled, and presented to the clinic’s providers during the provider presentation. The pre-presentation survey collected basic provider demographics (three questions), high-risk breast cancer risk factors (two questions), imaging referral (two questions), risk assessment (one question), and guidelines (one question). The questions utilized a variety of 11 formats, including a five-point Likert scale, true/false, multiple-choice, and select-all-that-apply questions. The post-presentation survey consisted of seven questions, with four mirroring the prepresentation survey questions related to providers’ knowledge and comfort levels. The three new questions included a multiple-choice question about the correct ICD code for the breast cancer risk assessment, a “yes” or “no” question to gauge providers’ willingness to perform risk assessments on eligible patients following the session, and an open-ended question to gather insights to perceived barriers to performing the individualized risk assessment. The knowledge-based questions in both surveys were collected to determine if the presentation effectively conveyed information on current breast cancer screening recommendations, high-risk breast cancer criteria, and use of the specific ICD code. Likert scales were used to evaluate changes in provider comfort levels changed after the presentation. Assessing perceived barriers was crucial for implementation and success of this project, particularly in the context of a small rural clinic where providers have an intimate understanding of their patient population and often maintain personal relationships with them. Similar data from the retrospective chart review was collected during the implementation portion of this project, including number of women referred to imaging, the number of missed opportunities for an individualized breast cancer risk assessment, the number of women that had a flag for an overdue mammogram in the EHR, and the number of women with an up-to-date mammogram. Additional data collected included the use of the ICD-10 code for a breast cancer risk assessment documentation and into the EHR. The follow-up provider meeting occurred after the six-week intervention period. The aim was to assess the intervention’s usability and feasibility for sustained implementation at the 12 clinic, and the providers’ and staff members’ overall satisfaction with the intervention. The discussion was recorded with participant consent, which allowed for a review of the meeting without having to keep notes during the meeting. Data associated with the project, including the quantitative data, ICD code use, individualized risk assessment documentation, referral rates, and the presence of overdue screening flags in patient charts, were discussed with the providers at the clinic. Analysis This project involved the collection of both qualitative and quantitative data. Descriptive statistics were used to analyze the study sample age, the number of ICD codes utilized, risk assessments performed, and missed opportunities for eligible encounters. Knowledge questions from the pre- and post-presentation were categorized as either correct or incorrect and reported in percentage terms. Provider demographics were expressed as percentages. The comfort levels of providers, assessed with the Likert scales, were compared before and after the presentation and reported in terms of frequencies. The open-ended questions in the post-survey were thoroughly reviewed, categorized, organized, and summarized based on their similarities. Notes were taken from the follow-up discussion and a content analysis was conducted by analyzing the conversation recording to develop common categories and sub-categories. These categories were organized and summarized, and themes were developed. Ethical Considerations This project was a quality improvement project in nature and was not subject to the oversight of the University of Utah Institutional Review Board. There were no conflicts of interest concerning this study. 13 Results The pre-implementation baseline assessment found that of the 87 encounters that met the eligibility criteria, 26 (30%) should have received an individualized breast cancer risk assessment. However, as there was no documentation of this occurring in the EHR or elsewhere, all (100%) were classified as a missed opportunity. In comparison, data associated with the postimplementation found that of the 42 encounters during the implementation period that met the eligibility criteria, five (12%) were classified as missed opportunities. This represents an 88% reduction in missed opportunities. The proportion in the age ranges of those eligible for the individualized breast cancer risk assessment differed pre- and post-implementation, yet a disproportionate number of eligible patients in the 65+ age range (63%, n=25) was consistent between pre- and post-implementation (Table 3). Provider demographics, including sex, years of practice, and tenure at the clinic are summarized in Table 2. A summary of provider comfort and knowledge regarding breast cancer risk factors, identifying patients at high risk for breast cancer development, and comfort regarding breast cancer screening is in Table 4. Overall, there was an improvement in provider knowledge. Providers identified potential barriers to project implementation in a free-text survey (Table 5) with the most common response being “remembering the correct ICD code” (n=3) followed by “remembering to perform the risk assessment” and “utilizing different guidelines”. Table 6 outlines the usability, feasibility, and satisfaction of the breast cancer risk assessment. Regarding satisfaction with the risk assessment, all providers reported an increase in their confidence in discussing breast cancer risk factors and personalized breast cancer risk postassessment. In evaluating the feasibility of the risk assessment, most (66%) of the providers 14 recommended integrating the risk assessment into the women’s physical exam template in the EHR. All the providers reported sufficient time for the risk assessment. One of the providers never had the opportunity to utilize the risk assessment based upon their patient population; thus, he was not included in the post-discussion evaluating the usability, feasibility, and satisfaction of the individualized breast cancer risk assessment. Table 7 summarizes additional data that was collected but determined to be unnecessary to assess the usability of the individualized breast cancer risk assessment but was beneficial for the providers during the post-implementation discussions. Discussion Summary Upon completion of this project there was an 88% decrease in the rate of missed opportunities for an individualized breast cancer screening for a qualifying encounter to occur. Along with the decrease in missed opportunities, there was an increase in provider comfort and knowledge in performing an individualized breast cancer risk assessment. Providers already had baseline knowledge regarding breast cancer risk factors and screening, but overall, there was an improvement in comfort in identifying women at a high risk of breast cancer. A strength of this project included the minimal time burden it took to perform the individualized risk assessment and the ease of adding the risk assessment into the daily provider flow of a visit. All the providers that utilized the risk assessment recommended adding it to the EHR as part of a women’s health template. Interpretation Overall, this project was well received by the providers at the clinic and resulted in a substantial reduction in missed screening opportunities. The response from providers aligned 15 with other research on the importance of a personalized risk assessment to promote patientprovider shared decision-making and help patients better understand their risk for breast cancer development (Beidler et al., 2023; National Comprehensive Cancer Network, 2023; Shrager & Burnside, 2019). In the post-implementation discussion, providers mentioned that patients were satisfied with the risk assessment, however, the patients themselves were not interviewed on the effectiveness, as this was not one of the project's goals. This project targeted an underserved rural population, which has lower breast cancer screening rates than urban populations (Theodoropoulos et al., 2019). Performing an individualized breast cancer risk assessment helps to inform patients if they are at a higher risk for breast cancer development and encourages appropriate screening recommendations based on risk. Encouraging active participation in healthcare decision-making with providers supports patient autonomy and healthcare knowledge, especially in areas with limited access to specialty care and screening. The usability, feasibility, and satisfaction showed positive results, with all the providers recommending that this individualized risk assessment be included in the EHR. The risk assessment was reported to be quick and easy to perform when actively performing a breast exam and discussing breast health. One of the barriers identified prior to implementation was a difference in guidelines in cancer care vs. primary care. One of the providers at the clinic felt that it is a primary care provider’s duty not to overtreat or put patients through unnecessary testing. This provider felt it was beneficial to access more aggressive guidelines for a higher risk of breast cancer and then adjust their care accordingly. 16 Limitations A clear limitation to this quality improvement project was the patient age demographic and the likelihood of already having some form of breast imaging before this project. Most patients being age 65 or older limited the number of women needing education on screening recommendations. Another limitation was relying on providers to remember to perform the risk assessment. Busy clinic schedules and acute concerns can impede a provider from performing the risk assessment accurately and routinely. Another area of limitation was only collecting data on patients who presented with a chief complaint of an annual wellness visit, physical exam, or a pap smear. A breast cancer risk assessment could be performed during any visit, but those charts were not reviewed or categorized as eligible patients for the individualized breast cancer risk assessment. Conclusions Patients in rural communities are less likely to have quality and routine cancer screenings. Discussing personal risk for cancer and performing an individualized breast cancer risk assessment can help patients understand the importance of routine screening and encourage consistency. This project was successful at implementing an individualized breast cancer risk assessment and promoting positive change for the providers at this clinic. This project could be expanded to the Kamas Health Center, where some of the providers involved in this project also see patients. Adding the breast cancer risk assessment to the EHR, specifically the women’s health exam template, would support the sustainability and usability of the project. Utilizing an individualized breast cancer risk assessment increased provider knowledge and comfort when discussing breast cancer development and encouraged patients to understand their personal risk and make informed decisions about their health. 17 18 Acknowledgments I would like to thank Larry Garrett, PhD, MPH, RN for being an integral part of this project as my project chair. In loving memory of my content expert, Rosemary Conder, NP, thank you for all the support you gave me throughout this project and my career. I would also like to thank Jeanette Vernon PA-C, RN, my wonderful project sponsor, Dina Drits, the editor of this manuscript, and lastly, Eli Iacob, PhD who assisted in my data analysis as a statistician. 19 References American Cancer Society. (2023). Key Statistics for Breast Cancer. https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breastcancer.html American Cancer Society. (2023). American Cancer Society Recommendations for the Early Detection of Breast Cancer. https://www.cancer.org/cancer/types/breastcancer/screening-tests-and-early-detection/american-cancer-society-recommendationsfor-the-early-detection-of-breast-cancer.html American Cancer Society: Cancer Facts & Statistics. American Cancer Society Cancer Facts & Statistics. (n.d.). https://cancerstatisticscenter.cancer.org/#!/state/Utah Atere-Roberts, J., Smith, J. L., & Hall, I. J. (2020). Interventions to increase breast and cervical cancer screening uptake among rural women: a scoping review. Cancer Causes Control, 31(11), 965-977. https://doi.org/10.1007/s10552-020-01340-x Beidler, L. B., Kressin, N. R., Wormwood, J. B., Battaglia, T. A., Slanetz, P. J., & Gunn, C. M. (2023). Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening. JAMA Netw Open, 6(1), e2252209. https://doi.org/10.1001/jamanetworkopen.2022.52209 DuBenske, L., Ovsepyan, V., Little, T., Schrager, S., & Burnside, E. (2021). Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter. J Patient Exp, 8, 23743735211034039. https://doi.org/10.1177/23743735211034039 French, D. P., McWilliams, L., Howell, A., & Evans, D. G. (2022). Does receiving high or low 20 breast cancer risk estimates produce a reduction in subsequent breast cancer screening attendance? Cohort study. Breast, 64, 47-49. https://doi.org/10.1016/j.breast.2022.05.001 How to Improve: IHI. Institute for Healthcare Improvement. (n.d.). https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Jones, S. M. W., Schuler, T. A., Padamsee, T. J., & Andersen, M. R. (2021). Financial Anxiety is Associated With Cancer Screening Adherence in Women at High Risk of Breast Cancer. Ann Behav Med, 55(12), 1241-1245. https://doi.org/10.1093/abm/kaab010 Lee, J. M., Lowry, K. P., Cott Chubiz, J. E., Swan, J. S., Motazedi, T., Halpern, E. F., Tosteson, A. N. A., Gazelle, G. S., & Donelan, K. (2020). Breast cancer risk, worry, and anxiety: Effect on patient perceptions of false-positive screening results. Breast, 50, 104112.https://doi.org/10.1016/j.breast.2020.02.004 National Comprehensive Cancer Network. (2023, June 19). NCCN clinical practice guidelines in Oncology. https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf Theodoropoulos, N., Xie, H., Wang, Q., Wen, C., & Li, Y. (2022). Rural-urban differences in breast and colorectal cancer screening among US women, 2014-2019. Rural Remote Health, 22(3), 7339. https://doi.org/10.22605/RRH7339 Tsapatsaris A, Babagbemi K, Reichman MB. (2022). Barriers to breast cancer screening are worsened amidst COVID-19 pandemic: A review. Clin Imaging (82)224-227. https://www.clinicalimaging.org/article/S0899-7071(21)00456-3/fulltext Utah Department of Health and Human Services. (2023). Indicator-Based Information System for Public Health: Breast Cancer Diagnosis. https://ibis.health.utah.gov/ibisphview/indicator/view/BreCADth.LHD.html 21 Tables and Figures Table 1 Comparison of Missed Opportunities for Breast Cancer Risk Assessment and Risk Assessments Performed Pre- and Post-implementation 22 Table 2 Demographics for Providers at the Clinic 23 Table 3 Age of Eligible Females 24 Table 4 Likert and Total Knowledge Test Scores *only correct answers were included in knowledge questions 25 Table 5 Barriers to Implementation 26 Table 6 Usability, Feasibility, and Satisfaction of the Individualized Breast Cancer Risk Assessment 27 Table 7 Referrals and Flags 28 Appendix A 29 Appendix B Process Based Presentation 30 31 Speaker Notes: Slide 1: Hello, thank you so much for your time today, My name is Jennifer I am a DNP student at the University of Utah. I was lucky enough to have Jeanette as my preceptor last spring and I wanted another opportunity to work with her and this clinic again so I thought it would be a good idea to do my scholarly project here. Slide 2: As I’m sure you both know, breast cancer is the most common cancer in women in the United States besides skin cancer and the incidence rate is continuing to increase each year. 1 in every 8 women in the U.S will develop breast cancer at some point in their lifetime. So not only is breast cancer common, it is also on the rise. Slide 3: As mentioned in the prior slide, the breast cancer incidence rate is increasing and Summit County actually has the second highest incidence rate of breast cancer diagnoses in the state. The state of Utah is only 113.5 per 100,000 females. While working with Jeanette, I recognized that a lot of patients seen at this clinic live and work in rural areas. Living in a rural area directly correlates to a decrease in routine screening for women which can lead to a late-stage diagnosis and disease burden. As we know as healthcare providers, screening is a major factor in preventing deaths from breast cancer because we are able to catch and treat it earlier. 32 Slide 4: This slide provides an overview of the objectives, methods, and outcomes for the DNP scholarly project. You have already completed the assess objective with the pre-survey, thank you again for filling that out. I won’t go into all of the details of this project but the overall objective of this project is to implement an evidence based breast cancer screening guideline and risk assessment at the clinic Slide 5: The last two steps of this project will be implementing the screening and risk assessment and tracking the data via the EHR for 6 weeks. After that is complete, I will come back and host a follow-up discussion and present my results. The main objective of the discussion is to evaluate the usability, feasibility, and satisfaction of the evidence-based screening and risk assessment. Slide 6: In order to compare data pre and post intervention, I performed a retrospective chart review over three months, July to September 2023. In total the clinic saw 936 females over the 12 weeks, the clinic saw 87 women that had a chief complaint of an AWV, physical exam, or pap smear. Since women are not screened for breast cancer every time they come to the clinic, I focused on the women seen for an AWV, physical exam, or pap smear for my data. This chart reviewed showed that a majority of women patients seen at this clinic are older than 65+, which is not ideal for this project since most women of this age typically have had a mammogram at some point in their lives before. You can see the breakdown of patient age in the pie chart. Although the patient age was not ideal, there was still room for this project to make a difference. A missed opportunity qualified as a woman between 18-70 without a breast cancer risk assessment performed. I excluded women over 70 yoa since it is patient dependent on continuing to screen for breast cancer. We will discuss this in future slides, but there is a billable ICD 10 code for performing a risk assessment, and of those 87 women, 30% of them were eligible for a risk assessment. Slide 7: I know there are several resources available for breast cancer screening guidelines, but I decided to use the National Comprehensive Cancer Network since that is what the Huntsman Cancer Hospital 33 goes by and that is an NCI certified cancer center. NCCN guidelines recommend that a risk assessment be performed on all adult women before the age of 25, that way the women that are high risk, have the option to start screening at 30 yoa. The risk assessment includes discussing family history of breast cancer (typically high risk include bilateral breast cancer, male breast cancer, and breast cancer before 50 yoa), discussing any genetic mutations like BRCA 1 or 2, a history of radiation therapy to the chest wall between age 10-30, or a personal history of lobular carcinoma in situ or a personal history of breast cancer. The ICD code listed on this slide is the billable code that you can use when you perform this risk assessment. The reimbursement rate of this ICD-10 code is Z15.01 Slide 8: I liked the way the American Cancer Society explains the high-risk classification, so I added in those details here. Women who have dense breast tissue have a higher risk of breast cancer compared to women with less dense breast tissue. There are not solid recommendations for MRI vs MMG for dense breast tissue, so having a conversation with patients about their individualized risk is helpful when deciding to start screening. The American Cancer Society recommends using a calculator to calculate risk of breast cancer although the NCCN guidelines do not require the risk assessment tool calculator so that is not a requirement for this project, but I included it here since it can be helpful in assessing risk, especially for patients with dense breast tissue when there aren’t clear recommendations. The following slides walk through the risk assessment tool calculator. Slide 9: This algorithm was created by the NCCN guidelines and is helpful in determining what to do based on symptoms, age, and risk. Slide 10: These are screening recommendations from the American cancer society that go over basic screening guidelines for women of average or high risk. 34 Slide 11: Now that my project is explained we can look forward to how it will be implemented. I would like to add on a section to the front office forms for a section with breast cancer family history for the AWV and yearly physical exams. After having this presentation, seeing the breast cancer section can remind providers to perform a risk assessment and put the ICD code in the EHR when completing patient charts. I am planning to add flyers in exam rooms and provider offices to remind about the ICD-10 code for the risk assessment. For the PAP smears, educating front of office and medical assistants to supply patients seen for a pap smear with the family history form and the same process occurs. I will be tracking all of the same data from the retrospective chart review, with an emphasis on missed opportunities and the number of risk assessments performed. I would also like to track how much you are being reimbursed for performing the risk assessment. Slide 12: I listed here the Genetic Counseling number at HCI. If you have any questions or concerns, they are available to help and are able to do virtual visits. Slide 13: Here are my references. Thank you so much for listening. I have a short post-education survey for you to fill out and help make any recommendations that I can make to this project before implementing next week. If you have any questions, please let me know. Thank you. 35 Appendix C 36 Appendix D Female Specific Review of Systems Form 37 Appendix E Front of Office Flyer 38 Appendix F Patient Exam Room Flyer 39 Appendix G Provider Office Flyer 40 Appendix H Executive Summary Introduction: Performing an individualized breast cancer risk assessments can help patients understand when they should start annual screenings based on shared decision-making with their primary care provider. Background: Breast cancer ranks as the second most common cancer among women, with incidence rates on the rise. Early detection through personalized risk assessment and adherence to screening guidelines improves the chances of detecting cancer in its early stages. Cancers diagnosed in early stages reduce disease burden and increases curative potential. However, women in rural communities often face disparities in accessing quality and regular screening. Deliverables: This quality improvement project aimed to assess the usefulness of an individualized breast cancer risk assessment, provider comfort and knowledge surrounding breast cancer risk factors and identifying high-risk patients. Results: The pre-implementation baseline assessment found that of the 87 encounters that met the eligibility criteria, 26 should have received an individualized breast cancer risk assessment. However, as there was no documentation of this occurring in the EHR or elsewhere, all were classified as a missed opportunity. In comparison, data associated with the post-implementation found that of the 42 encounters during the implementation period that met the eligibility criteria, five were classified as missed opportunities. This represents an 88% reduction in missed opportunities. Post-intervention, all providers reported increased confidence and competence in discussing breast cancer risk factors. Conclusions: The individualized breast cancer risk assessment emerges as a valuable tool for reducing breast cancer screening missed opportunities and improving provider comfort and knowledge in identifying high-risk women. It was also reported there was an increase in women’s confidence in understanding their risk of breast cancer development. Long term studies are necessary for evaluating the impact of individualized risk assessments on breast cancer stage at diagnosis.