In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card–sized Pink Cards to offer women due for screening mammography during office visits. The card includes a reminder that screening is due and can be used to obtain screening mammography on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. The Pink Card walk-in screening mammography program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.
Purpose:
The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.
Methods:
In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card–sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.
Results:
Among 3688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1968 of 2955], P < .001).
Conclusions:
The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.
Breast cancer is the most common cancer and the second leading cause of cancer mortality among women in the United States, with more than 276 000 new cases and 42 000 deaths estimated for 2020.1 Numerous national health organizations and professional societies, including the ACR, recommend routine screening mammography2- 6, which has been shown to reduce breast cancer mortality.7,8 Despite broad support throughout the United States, there are persistent disparities in screening mammography use related to factors including race/ethnicity, socioeconomic status, and geographic location.9- 12
Multiple barriers to screening mammography exist at the patient, physician, imaging facility, and health system levels.13- 16 Interventions that address access barriers are among the most effective for increasing screening mammography use.17,18 These include strategies that reduce obstacles to schedule and complete screening appointments, such as same-day appointments, scheduling assistance, extended hours at imaging centers, and transportation assistance.17,18
In November 2016, our academic breast imaging division started a walk-in screening mammography program called the Pink Card program at an affiliated community-based outpatient medical facility to increase access to breast cancer screening. The breast imaging center at this facility serves patients from two primary care and one obstetrics and gynecology (OB/GYN) practice located in the same building as well as patients referred by other providers throughout the community. The Pink Card program was made available to these three on-site practices. Through this program, physicians could offer patients they identified as due for screening during office visits the opportunity to undergo screening on the same day on a walk-in basis. The purpose of our study was to evaluate the implementation and utilization of the Pink Card program.
Study Design and Setting
This was a HIPAA-compliant, institutional review board–approved retrospective review of women who underwent screening mammography at a community-based breast imaging center between November 1, 2016, and December 31, 2018. This breast imaging center is located within a community-based suburban outpatient facility that provides primary and specialty care and is affiliated with an urban, quaternary-care academic medical center. There are two primary care and one OB/GYN practice located within the outpatient facility. The breast imaging center serves patients from these three on-site practices and from other practices in the community. The center offers screening mammography and diagnostic imaging services. It is equipped with two mammography units and staffed by three patient service coordinators at the front desk, three to four mammography technologists, one technical manager, and one operations manager.
Participants
We included women ages 40 to 74 years at time of screening mammography who underwent at least one screening mammographic examination at the breast imaging center during the study period. For women with more than one screening mammography visit at the breast imaging center during the study period, only the first visit was analyzed. We excluded women who had outside facility mammograms within our imaging database because the examination codes used for these studies in our database did not differentiate between screening and diagnostic mammography.
Walk-In Pink Card Screening Mammography Program
Women who preschedule their screening mammography appointments represent usual care at our breast imaging center. Our intervention, the Pink Card program, involves providing physicians from the on-site primary care and OB/GYN practices with business card–sized Pink Cards that can be provided to patients due for screening mammography during in-person office visits. Our electronic medical record includes a system that flags patients due for preventive services, including screening mammography, to help remind physicians and office staff members to address these needs during office visits. For screening mammography, physicians may customize the age and screening intervals they prefer to use for their own patient panels. Physicians use their own discretion in determining which patients should receive Pink Cards. The Pink Cards include location and hours of operation for the on-site breast imaging center with a reminder to patients that they are due for mammographic screening (Fig. 1). Information on how the card can be used to obtain screening mammography on a walk-in basis at our breast imaging center is also clearly communicated. The wording of the screening reminder message “Get your mammogram—it's time” was intentionally chosen to empower physicians to use their own best clinical judgement to decide on the appropriate screening interval. Orders for these examinations can be placed into the electronic medical record either directly by referring physicians or by breast imaging center staff members on behalf of these physicians when patients arrive for the walk-in examinations. Preexisting standing orders can also be used to support scheduling the examinations. At the end of every screening visit, the patient has the option to schedule her future screening examination. However, these future visits are not automatically scheduled for any patient.
Starting in November 2016, our community-based breast imaging center collaborated with the on-site primary care and OB/GYN practices located in the same outpatient medical facility to launch the Pink Card program. The program officially launched after a 1-month period of discussion and coordination among the imaging center and these three practices. Referring physicians were informed that for patients who presented for the walk-in examinations, efforts would be made to perform examinations within 30 min of arrival at the imaging center. Up to approximately four screening mammography slots were reserved per day to accommodate potential walk-in examinations. Adjustment of daily schedules to accommodate walk-in examinations was managed by the on-site managers in coordination with the mammography technologists and patient service coordinators. No additional personnel were hired, and no additional equipment was procured to support implementation of the Pink Card program.
Dependent Variable
The primary outcome measure was the proportion of women from participating practices who used the Pink Card program for their screening mammographic examinations at our breast imaging center over the study period. Among the subset of women who used the Pink Card between November 1, 2016, and November 30, 2017, we also examined whether a repeat Pink Card visit occurred within 2 years and 1 month from the index visit.
Independent Variables
Independent variables included potential predictors of use of the Pink Card program. Potential predictors included sociodemographic variables: age, race/ethnicity (White, Asian, Black, Hispanic, or other), English as primary language (yes or no), insurance status (Medicaid versus other), and marital or partnership status (partnered versus nonpartnered). Additionally, we considered being up to date for screening mammography (yes or no) as a potential predictor of Pink Card use. Being up to date for screening mammography was defined as having a previous screening mammogram documented in our electronic medical record within 2 years and 1 month from the index screening mammography visit.
Data Sources and Measurements
Women in our cohort were classified as having referring physicians from one of the three practices participating in the Pink Card program by the authorizing provider listed on their screening examination order requisition. The list of women who used the program to undergo screening mammography was determined from a database maintained by breast imaging center staff members. The number of all women eligible for screening mammography among the three practices included in this study was estimated using data from our institution's electronic data warehouse linked to the electronic medical record. This eligible population was defined as all women between 40 and 74 years of age who had at least one clinical encounter with one of the three practices during the study period. Sociodemographic variables and records of previous mammography examinations were also extracted from the electronic data warehouse. Screening examinations, diagnostic exams, and mammography examinations from outside institutions were differentiated on the basis of the examination codes used in our electronic medical record.
Statistical Analysis
Characteristics of women who presented for screening mammography were summarized using means and proportions. To contextualize these women within our community-based breast imaging center's overall screening population, we compared demographic characteristics (means and proportions) of women from the three practices that participated in the Pink Card program versus other practices that were not part of the Pink Card program. Among women from the practices that participated in the Pink Card program, multivariate logistic regression analyses were performed to evaluate independent predictors of use of the program. P < .05 were considered to indicate statistical significance. Analyses were conducted using Stata version 11 (StataCorp, College Station, Texas). Sample size was derived on the basis of convenience.
During the study period, 10 928 women underwent screening mammography at the breast imaging center. Among these, 2.5% (274 of 10 928) had prior mammograms from outside our institution and were excluded from further analysis. Of the remaining 10,654 women, 34.6% (n = 3688) had referring physicians from one of the three on-site practices that participated in the Pink Card program. The Pink Card was used by 19.9% of women (733 of 3688) presenting for screening mammography from these practices. Among the subset of 328 women whose first Pink Card visits occurred between November 1, 2016, and November 30, 2017, 28.7% (n = 94) used the Pink Card again for a subsequent screening round within 2 years and 1 month.
Among women who used the Pink Card, 48% (352 of 733) were from one primary care practice, 41.1% (301 of 733) were from the second primary care practice, and 10.9% (80 of 733) were from the OB/GYN practice. This accounted for 9.5% (352 of 3702) of the population eligible for the Pink Card program from the first primary care practice, 9.4% (301 of 3202) of the eligible population from the second primary care practice, and 2.1% (80 of 3767) of those eligible from the OB/GYN practice.
Sociodemographic characteristics of women presenting for screening mammography from the three on-site practices participating in the Pink Card program were compared with sociodemographic characteristics of women presenting for screening mammography from all other practices served by the imaging center (Table 1). Women from the participating practices were more likely to be younger (P < .001), to have Medicaid (P < .001), and to be nonwhite (P < .001) and less likely to be previously up to date for screening mammography (P < .001).
Table 1. Comparison of characteristics of women from the three practices that participated in the Pink Card program versus other practices that were not part of the Pink Card program
| Primary Care and OB/GYN Practices in the Pink Card Program | Other Practices Not Included in the Pink Card Program | |
|---|
| Characteristic | (n = 3,688) | (n = 6,966) | P |
| Age (y) | 54.2 ± 9.4 | 56.8 ± 9.3 | <.001 |
| Race/ethnicity | | | <.001 |
| Non-Hispanic white | 83.3 (3,072) | 87.5 (6,092) | |
| Asian | 8.3 (305) | 6.4 (443) | |
| Black | 2.7 (100) | 1.9 (131) | |
| Hispanic | 1.3 (48) | 1 (68) | |
| Other | 1.8 (65) | 1 (72) | |
| Unknown | 2.7 (98) | 2.3 (160) | |
| Primary language | | | .179 |
| English | 97.9 (3,610) | 98.2 (6,839) | |
| Other | 1.4 (50) | 1.1 (74) | |
| Unknown | 0.8 (28) | 0.8 (53) | |
| Insurance | | | <.001 |
| Commercial | 79.7 (2,940) | 75 (5,226) | |
| Medicare | 14.9 (549) | 20.9 (1,456) | |
| Medicaid | 3.4 (127) | 2.3 (163) | |
| Medicare-Medicaid dual eligible | 1.8 (65) | 1.4 (99) | |
| Other | 0.2 (7) | 0.3 (22) | |
| Marital status | | | .276 |
| Married or partnered | 72.7 (2,682) | 71.5 (4,979) | |
| Unpartnered | 24.9 (918) | 25.8 (1,794) | |
| Other | 1 (37) | 1 (72) | |
| Unknown | 1.4 (51) | 1.7 (121) | |
| Up to date for screening mammography | 59.7 (2,202) | 73.2 (5,100) | <.001 |
Among women from the three participating on-site practices, a smaller proportion were up to date for screening mammography among those who used the Pink Card program (31.9% [234 of 733]) compared with those who used prescheduled screening visits (66.6% [1968 of 2955]; P < .001). Multivariate logistic regression analyses showed that women who used Pink Cards were more likely to have Medicaid (P = .013) and to be Asian (P = .032) or Black (P = .002; Table 2). They were less likely to use English as their primary language (P = .003) and to be up to date for screening mammography (P < .001).
Table 2. Comparison of characteristics of women from participating practices who used Pink Card walk-in visits versus usual-care prescheduled appointments to undergo screening mammography
| Characteristic | Pink Card Walk-In Screening Visit | Usual-Care Prescheduled Visit | Odds Ratio | 95% CI | P |
|---|
| Age | 54.1 | 54.2 | 1.01 | 0.998–1.017 | .108 |
| Primary language not English | 2.8% (20/727) | 1% (30/2,933) | 2.75 | 1.425–5.327 | .003 |
| Nonwhite race/ethnicity | | | | | |
| Asian | 12.5% (89/714) | 7.5% (216/2,876) | 1.37 | 1.027–1.820 | .032 |
| Black | 4.9% (35/714) | 2.3% (65/2,876) | 2.05 | 1.301–3.242 | .002 |
| Hispanic | 1.3% (9/714) | 1.4% (39/2,876) | 1.07 | 0.490–2.337 | .867 |
| Other | 0.7% (5/714) | 2.1% (60/2,876) | 0.21 | 0.078–0.558 | .002 |
| Medicaid insurance | 5.6% (41/733) | 2.9% (86/2,955) | 1.71 | 1.118–2.609 | .013 |
| Married or partnered | 72.2% (520/720) | 75% (2,162/2,880) | 0.90 | 0.733–1.105 | .314 |
| Up to date for screening mammography | 31.9% (234/733) | 66.6% (1,968/2,955) | 0.24 | 0.199–0.285 | <.001 |
In this study we evaluated the implementation and utilization of the Pink Card program, which combines a physician-delivered reminder for screening mammography during an office visit with the opportunity to undergo screening on a walk-in basis. Over a 2-year period, this program was used by one in five women from across three practices to undergo screening at our breast imaging center. This accounted for nearly 1 in 10 of all eligible women seen by the primary care practices. Only 3 in 10 women who used Pink Cards were previously up to date for screening mammography, compared with nearly 7 in 10 women who used prescheduled screening visits. Those who used Pink Cards were more likely to be racial/ethnic minorities, to have limited English proficiency, and to have Medicaid insurance. Finally, subset analysis showed that among women who used the Pink Card once, more than one-quarter used the Pink Card again to remain up to date for biennial screening. The Pink Card program offers the potential to enhance mammography screening access and engagement, especially among vulnerable populations.
The Pink Card program may owe its ability to engage underscreened women, particularly those from vulnerable populations, to the simultaneous targeting of multiple access barriers to screening. Removing the need to preschedule appointments can reduce language and logistics barriers. By offering walk-in screening examinations that coincide with physician office visits in the same building, this program removes the need for additional dedicated screening visits. In turn, this can reduce difficulties that arise from transportation challenges, competing priorities including other personal health care needs and caregiver responsibilities, and financial burdens incurred by taking time off work, barriers commonly encountered by racial/ethnic minorities.19- 25 In its ability to address multiple access barriers to care, the Pink Card program resembles a recently described same-day breast biopsy program, which mitigated racial/ethnic disparities in time to biopsy.26 Finally, the Pink Card program is supported by a physician-delivered reminder to patients about mammographic screening, a consistent predictor of screening use in the general population and among racial/ethnic minorities.23,27,28
Our results agree with the outcomes of a single-center randomized controlled trial conducted in 1995, in which women who were overdue for screening mammography at their internal medicine clinic visits were offered the opportunity to undergo same-day screening or to schedule a screening appointment on another day.29 At 3-month follow-up, the proportion of women who completed screening mammography was higher in the same-day compared with the usual-care group (58% [144 of 249] versus 42% [120 of 284], P < .001).29 In that study, 27% of women (67 of 249) in the intervention group underwent same-day screening.29 Although differences in study design preclude direct comparison of those outcomes with ours, both studies showed that same-day screening mammography can improve screening access and engagement. The prior study demonstrated the efficacy of this intervention within the context of a single-site clinical trial. Our study analyzed its clinical implementation and use over a 2-year span, and the results support its effectiveness when integrated into routine clinical care.
Successful implementation of our program relied strongly upon a commitment by operations and technical managers, mammography technologists, and patient service coordinators at the front desk to integrate walk-in examinations into the daily scheduled workload. In particular, this program was dependent upon the ability of the breast imaging center to meet the service guarantee of performing walk-in examinations within 30 min of patient arrival. Otherwise, decreased patient and referring physician satisfaction may have outweighed potential benefits. On the basis of the volume of use across a 2-year period, we hypothesize that this program was successfully integrated into the clinical workflow of the referring practices and breast imaging center. However, we did not directly analyze patient and physician satisfaction, the frequency with which the 30-min service guarantee was met, or whether the availability of Pink Card examination slots sufficiently met demand. These will be future lines of inquiry as we continue to analyze and improve the Pink Card program. Additionally, we will further explore the factors underlying the variable rates of Pink Card usage among the three participating practices.
Among women from the on-site primary care and OB/GYN practices served by our breast imaging center, a larger proportion were racial/ethnic minorities and not up to date for screening compared with women from other practices. These results suggest that the Pink Card program was able to target physicians serving more vulnerable segments of our overall screening population. Future efforts will focus on expanding this program to other practices in our community. Although our program benefited from having the breast imaging center located in the same building as participating practices, we believe it could also be successfully implemented in other settings. For off-site imaging centers, this program could still alleviate access challenges such as language barriers to appointment scheduling, and patient engagement could still be augmented by linking access to walk-in screening with physician-delivered reminders that screening is due. Indeed, we hypothesize that our analysis underestimates the true benefits of the Pink Card program. Because these cards serve as physical reminders to screen and contain contact information, hours of operation, and location of our breast imaging center, some patients may have been prompted by these cards to schedule screening at a later date or undergo screening at a different imaging site.
Engagement with screening mammography is linked with the ability to access a regular source of health care, the lack of which is a consistent predictor of low screening mammography use.27,30 Our results suggest that even within a population of women who were able to overcome potential barriers to primary care and OB/GYN services, there were still vulnerable segments for which the Pink Card program enhanced screening access and engagement. However, in its current form, our program still reached only women with established physicians. As we move forward, our initial experiences with the Pink Card program will help us adapt it to reach even more vulnerable and underserved populations without regular sources of health care, for example by creating a workflow to offer walk-in screening mammography to women identified as due for screening during urgent care visits.
Limitations
Our analysis was limited by a lack of data on the rates at which women declined use of the Pink Card program and/or physicians declined to offer it. Furthermore, we could not differentiate between effects caused by patient selection choices on the part of physicians and effects related to patient-level factors such as attitudes toward screening or unique patient-specific barriers. For example, though our results showed that women who used Pink Card were more likely to have limited English proficiency, we could not determine if this was caused by physicians' preferentially offering Pink Cards to this subset or by a higher rate of Pink Card use among these women.
We did not account for the fraction of women who would have been up to date on the basis of diagnostic examinations or prior outside facility imaging not documented in our electronic medical record. However, this is unlikely to have significantly affected our results given the large difference in the proportion of women up to date for screening between Pink Card users and the usual-care group.
These limitations do not alter our central conclusion that the Pink Card program, which links a physician-delivered reminder to undergo screening mammography with the opportunity to be screened through a walk-in visit, can enhance screening access and engagement particularly for vulnerable populations.
The Pink Card program, an access-enhancing intervention for screening mammography that combines walk-in screening visits with physician-delivered screening reminders, can be successfully implemented in a community-based setting.
The Pink Card program can increase screening engagement among women who are not up to date for screening mammography.
Vulnerable populations such as racial/ethnic minorities and women with limited English proficiency may especially derive benefit from access-enhancing interventions such as the Pink Card program.