Insights Series Issue 5: "Reducing fear and anxiety by redesigning the patient experience"

This paper examines how Emily Sedgwick, MD, and her team at the Baylor Clinic deliver outcomes that matter to patients with a better diagnostic experience in breast care.

Siemens Healthineers Insights series Issue 5 Reducing the fear and anxiety associated with breast cancer screening A paper on ‘Deliver outcomes that matter to patients’ with Emily Sedgwick, MD SIEMENS Healthineers About Siemens Healthineers Insights series Today, every health system struggles with rising costs and varying quality. Diagnoses and treatments are designed for typical patients. Delivery of care is fragmented and focused on volume. The patient experience journey is in its infancy. And healthcare doesn’t leverage the full potential of data. How can we change that? At Siemens Healthineers, our insights make it possible to turn challenges into opportunities. Our purpose is to enable healthcare providers to increase value by expanding precision medicine, transforming care delivery, improving patient experience, and digitalizing healthcare. As your partner for better outcomes in healthcare, we strive to provide a forum for addressing these issues, and to offer insights and new approaches. By joining the conversation with industry thought leaders and change makers, we are sharing forward-thinking ideas and solutions. We are also establishing a platform for leaders in healthcare to connect and exchange with peers. The Insights series offers actionable insights on how to tackle challenges and create solutions that work. Be inspired by best practices and engage with experts at the interface of technology and care. Please visit Paper Reducing the fear and anxiety associated with breast cancer screening Executive summary Breast cancer is the leading cause of Breast cancer is impacting cancer deaths among women worldwide. 2.1 million women Methods for early detection of breast cancer have improved in recent years, each year1 as have treatment processes. But patients must take the first step, participating in necessary screening. This is particularly important for those at greater risk, for example women with a personal or family history of breast cancer. Many women, however, choose not to participate in timely screening, either through ultrasound imaging, mammography, or MRI scans. Avoiding or delaying such tests and the early detection of possible breast cancer can have serious consequences, limiting subsequent treatment options and compromising their effectiveness. This can have significant impact on patients, their families, and on the healthcare system. The reasons women choose to avoid or postpone timely screening are varied, but many have to do with the The results are clear: stress and anxiety that accompany such medical tests. • more accurate and timely diagnosis leading If the factors that contribute to this stress and anxiety to better patient outcomes can be reduced, the likelihood that more women will • a demonstrably better patient experience participate in timely screening can be increased. • increased revenue, largely as a result of higher patient numbers This is precisely what Emily Sedgwick, MD, accomplished at the Baylor Clinic in Houston, Texas, through a combi- This paper examines how Emily Sedgwick achieved nation of technological innovation, staff training, these impressive results, and offers insights on how standardization of protocols, and a series of patient- others working in comparable treatment pathways, friendly reforms. can deploy similar techniques. Siemens Healthcare GmbH, 2019 3 The challenge Before screening Breast cancer remains the world’s leading Fear of breast cancer screening discourages many women, cause of cancer deaths among women.2 even those identified as being at greater risk (e.g. those It is also one of the diseases women fear with a family history of breast cancer), from undergoing most, often creating intense fear in those timely examination. Both initial attendance as well as follow-up are negatively impacted.3 who receive a breast cancer diagnosis, as well anxiety among those who dread the thought that they might one day feel a lump in their own breast or get that call after a mammogram. Effectively managing breast cancer screening – along with its accompanying fears and complications – is a central challenge facing healthcare providers. A more efficient process can contribute to earlier detection, better treatment, and a more effective allocation of healthcare resources. In the past, the screening process was complex and time-consuming. In the U.S., the median time from the initial detection of an abnormal mammogram to biopsy was 14 days. The median time from biopsy to subsequent treatment was 23 days. MAY 15 The fear and anxiety associated with breast cancer screening has real consequences, both direct and indirect. These occur throughout the screening process, including the time before and after the actual testing. 2 pm: Screening 4 Siemens Healthcare GmbH, 2019 “A more efficient breast cancer screening process can contribute to earlier detection, better treatment, and more effective allocation of healthcare resources.” Emily Sedgwick, MD During screening After screening The screening process itself is difficult for many patients. For those women who do receive a cancer diagnosis, All medical tests, particularly those for a potentially life- this news can be particularly harmful. There is a strong threatening illness, are challenging, and the time spent association between cancer and a variety of emotional at clinics and in waiting rooms can be highly stressful. disorders including anxiety and clinical depression.9 Studies Mammography compression, with its accompanying pain suggest that more than the half of patients diagnosed with and discomfort, can be particularly unpleasant for many cancer react with moderate to high anxiety and depression. women. The period of waiting for exam results can also The risk that a woman with a breast cancer diagnosis will be a time of great stress, particularly if this period of suffer from an anxiety disorder is four to five times greater uncertainty lasts for days or even weeks. A patient’s ability than the risk among healthy women.4,5 Research also to cope with this anxiety depends on numerous factors suggests that women are more psychologically susceptible including their own vulnerability and resilience.4,5,6,7,8 It is to debilitating reactions of this type than men. never a pleasant time and any measures that can shorten this waiting period are to be welcomed. Just the thought of a positive cancer diagnosis can cause emotional distress as well as physical symptoms including restless- ness, tachycardia, shortness of breath, sweating, and muscle tension. Waiting Room RIP Siemens Healthcare GmbH, 2019 5 Delaying treatment from two weeks to more than six weeks can lower the five-year survival rate Recurring screening of breast cancer For many women, breast screening is a recurring experi- ence. Breast cancer screening guidelines in the U.S. patients by recommend that women between the ages of 25 and 40 at average breast cancer risk undergo a clinical breast as much as examination once a year.2 Women over the age of 40 should have an annual mammogram in addition to the annual breast examination. For woman with dense breast 10%10 tissue, ultrasound exams may also be recommended. For women of above-average breast cancer risk, a clinical exam every six months may be recommended. For many women, this adds up to frequent screening visits, each accompanied by fear and anxiety.11 This fear and anxiety – before, during, and after screening – can act an impediment to mammography tests for many women. A study of women identified as having particularly dense breast tissue who were invited to undergo MRI breast screening found that only 59% chose to participate. A common reason cited for non-participation was “anxiety”. Research suggests that initial attendance for screening as well as follow-up are both negatively impacted by patient fear and anxiety.12,13 Partly as a result of the harmful effects caused by this fear and anxiety, the National Health Service in the UK has amended their screening guidelines, reducing the recom- mended frequency of exams for woman of average and low risk. Clinical parameters clearly demonstrate a high correlation between early treatment breast cancer and success in combating the disease. Early and comfortable breast cancer screening is not only about having a better diagnostic experience, it also improves therapy outcomes that matter to patients. 6 Siemens Healthcare GmbH, 2019 The solution this news promptly is welcome good news. For those who do require further tests or treatment, the sooner Delivering outcomes that matter through they have this information the sooner they can proceed a better diagnostic experience. with appropriate treatment. This too reduces anxiety and increases the likelihood that treatment will be effective. The Baylor Clinic, part of the Baylor College of Medicine in Houston, Texas, is home to many of the world’s leading With these goals in mind – faster results, quicker care breast health specialists: physicians and scientists with for those who need it, and less anxiety for all patients – expertise in prevention, diagnosis, and treatment of both the team at the Baylor Clinic, led by Emily Sedgwick, MD, breast cancer as well as benign breast conditions. The set out to design an improved and more effective patient breast imaging teams working at the Baylor Clinic see experience. Their mission was to redesign their entire patients struggling with the screening process every day. diagnostic experience, to offer all patients quicker service, quicker results and, when required, quicker access to Many patients arrive at the clinic already burdened by treatment. fears and uncertainties. And once they arrive at the clinic, many patients exhibit signs of anxiety well before any A smoother and more seamless screening process would results being available to them. Once examinations have result in better, more efficient internal workflows, reducing been completed, for those women whose tests do not the burden on employees and physicians, and allowing indicate any abnormalities or signs of cancer, receiving resources to be deployed more effectively. on average 23 days on average 14 days Typical breast Screening Diagnosis Core needle Patient makes own imaging Ultrasound mammogram mammogram biopsy appointment with workflow oncologist or surgeon Sedgwick workflow Screening mammogram Diagnosis mammogram Ultrasound Patients receive Core needle support in making Referring caregiver biopsy appointments gives results and writes order for / recommends L one day the next step Siemens Healthcare GmbH, 2019 7 “My ambitious goal was to perform mammography, biopsy, and then deliver outcomes that matter to patients, all in one day.” Emily Sedgwick, MD An Improved Patient Experience through 1 Engage with patients a one-day breast biopsy program. and their families To address these issues, Emily Sedgwick, MD, and her The program developed by Sedgwick redesigned all team set out to redesign the entire patient experience workflows and care from a patient’s perspective. of women receiving breast cancer screening at the Patients and family members were asked to complete Baylor Clinic. Sedgwick’s ambitious and groundbreaking patient experience surveys to gain insights into how idea was to perform mammography, biopsy and then patients perceive the care they received, and to identify deliver outcomes that matter to patients, all in one day. areas for improvement in relations between the This package of same-day service would not only deliver patient and the care team. The goal now is to educate outcomes to patients in a more timely way, it would every patient about procedures in advance and to also make treatment available as early as the next day, build realistic expectations. if signs of cancer or abnormal results were detected. As a result of Sedgwick’s innovations, patients at the 2 Hone talent and Baylor Clinic today can have their mammograms, speak ensure staff acceptance with a radiologist, and proceed with any recommended further imaging or biopsy tests all on the same day. To expand their services, the Baylor Clinic recruited One day later, patients can get their biopsy results, usually certified mammography technologists and breast ultra- by speaking with a radiologist over the phone, saving sound technologists. In addition, one nurse position them the trouble of another visit. Another appointment dedicated to coordinating breast biopsies and arranging is then set up, if needed. breast oncology or breast surgery follow-up was created. These changes to the breast imaging team contributed To provide focus and direction to this program, Emily to the overall success of the program. The working environ- Sedgwick developed the following Five Step Process: ment was made more flexible, and staff were trained to reduce patient anxiety. Daily staff huddles were used to proactively identify problems that could cause workflow bottlenecks and to improve buy-in and support to accept additional day patients for same-day evaluations. 8 Siemens Healthcare GmbH, 2019 3 Standardize protocols and optimize image interpretation 5 Implement patient-friendly technology The Baylor Clinic changed the set-up of the radiologists In the breast imaging community, multiple methods have interpreting mammograms, implemented a range of been tested to reduce patients’ fear and anxiety when standardized processes including common imaging undergoing screening for possible breast cancer, such as scenarios and protocols as well as weekly stakeholder spa-like décor, offering patients robes, and playing music meetings with breast imaging radiologists, administrative during procedures. Technological innovations have staff and technologists. In addition, core needle biopsy also been developed to improve patient comfort including management algorithms were created for easy reference. radiolucent adhesive pads on the mammography paddles, which are curved to accommodate the lines of a woman’s body and reduced mammography com- 4 Enhance pression. One of the most effective interventions imaging referral to reduce patient fear and discomfort in the exam room is the mammography technologist. Technologists were Steps were taken to define a new breast imaging order encouraged to permit patients freedom to express process where a radiologist was permitted to perform their needs, such as feeling cold or pain, and have been diagnostic mammography, ultrasound or breast biopsy, taught to explain technology in a patient-friendly way. if needed. An electronic medical record was used to send a report to the referring physician at each step of the process, and the referring physician was called if a biopsy was recommended for a patient, with the electronic medical record notifying the physician of the biopsy result. At the same time, a breast imaging radiologist or nurse would contact the patient to discuss the biopsy result. Suggested follow ups • Health Catalyst: How care redesign and process improvement can reduce patient fear • Insights Series 3: A blueprint for setting up an impactful patient experience program • HBR Paper: A four part approach to delivering the care patients want and need • Economist paper: Improving patient experience Siemens Healthcare GmbH, 2019 9 I have been to several breast care centers in different states, Baylor stands out. Not with just the friendliness of staff and techs, but learning our results, receiving an ultrasound and biopsy if necessary on the same day ... is a blessing to women. Patient voice Conclusion Focusing on improving the patient experience and devel- oping solutions from the patient perspective can be Emily Sedgwick’s overhaul of the entire a game changer for hospitals. Others have observed the patient experience at the Baylor Clinic changes at the Baylor Clinic and have asked Emily Sedgwick produced tangible results, for patients to implement similar programs for their organizations. and for the Clinic. Measurable For example, at the Harris Health System in Texas, Emily improvements include: Sedgwick was able to successfully apply many of the innovations she had introduced at the Baylor Clinic pro- gram, with more than 35,000 patients already benefiting. Better diagnostics and outcomes Since 2010, Harris Healthcare has seen wait times from abnormal results to first day of treatment improve Cancer detection rates at the Baylor Clinic are now by almost 70%. Wait times to biopsy improved by an 6.1 cancers per 1,000 women (compared to a benchmarks even more impressive 88.9%. Wait times from abnormal of >2 per 1,000 women). The recall rate – that is, patients results to biopsy improved by 66.9%. who must return because of inaccurate or faulty tests during their first visit – has dropped to 6.2% (at the low As impressive as these results are, there is still room for end of the MQSA national benchmark of 5–12%) further progress. AI-driven decision support, for example, could support pathologists and contribute to even more substantial improvement. An improved patient experience Compared to its neighboring academic peers, the overall patient experience at the Baylor Clinic has ranked above the 96th percentile for three years within the HCAHPS/ Press Ganey scores. Increased revenue Largely as a result of the changes introduced by Emily Sedgwick, annual imaging revenue at the Baylor Clinic has increased from $500,000 in 2009 to $2,500,000 in 2018. 10 Siemens Healthcare GmbH, 2019 Literature 1 World Health Organization, Breast cancer 8 Association of Screening and Treatment With Breast Cancer Mortality by Molecular Subtype in US Women, screening/breast-cancer/en/ Last visit: 2019-06-27 2000-2012. Author Plevritis SK, Munoz D, Kurian AW, Obstetrician-gynecologists' knowledge and opinions Stout NK, Alagoz O, Near AM, Lee SJ, van den Broek JJ, 2 Huang X, Schechter CB, Sprague BL, Song J, de Koning about the United States Preventive Services Task Force (USPSTF) committee, the Women's Health Amendment, HJ, Trentham-Dietz A, van Ravesteyn NT, Gangnon R, and the Affordable Care Act: national study after the Chandler Y, Li Y, Xu C, Ergun MA, Huang H, Berry DA, release of the USPSTF 2009 Breast Cancer Screening Mandelblatt JS, JAMA. 2018;319(2):154. Recommendation Statement. Anderson BL, Urban RR, Last visit: 2019-05-08 Pearlman M, Schulkin J. pubmed/24246966 Last visit: 2019-07-04 9 The prevalence of psychological distress by cancer site. Listening to Women: Expectations and Experiences in J. Zabora, K. BrintzenhofeSzoc, B. Curbow, C. Hooker, 3 Breast Imaging. S Harvey, MD, A. M. Gallagher, M. Nolan, S. Piantadosi Last visit: 2019-05-08 C. M. Hughes Breast-Cancer Tumor Size, Overdiagnosis, and 10 Delay in Breast Cancer: Implications for Stage at 4 Mammography Screening Effectiveness. Author Welch Diagnosis and Survival, Lee Caplan, Front Public Health. HG, Prorok PC, O'Malley AJ, Kramer BS, N Engl J Med. 2014; 2: 87. Published online 2014 Jul 29. doi: 10.3389/ 2016;375(15):1438. fpubh.2014.00087 articles/PMC4114209/ Last visit: 2019-05-08 pubmed/27732805 Last visit: 2019-05-08 Effect of three decades of screening mammography 11 American Cancer Society Recommendations for the 5 on breast-cancer incidence. Author Bleyer A, Welch HG, Early Detection of Breast Cancer cancer/breast-cancer Last visit: 2019-07-04 N Engl J Med. 2012 Nov; 367(21):1998-2005. 12 Intermittent Attendance at Breast Cancer Screening, Last visit: 2019-05-08 Padraic Fleming, Sinead O’Neill, Miriam Owens, Therese Breast cancer mortality in neighbouring European Mooney, and Patricia Fitzpatrick, J Public Health Res. 6 countries with different levels of screening but similar 2013 Sep 2; 2(2): e14. Published online 2013 Sep 5. doi: access to treatment: trend analysis of WHO mortality 10.4081/jphr.2013.e14 database. Author Autier P, Boniol M, Gavin A, Vatten LJ, pmc/articles/PMC4147734/ Last Visit: 2019-05-08 BMJ. 2011; 343:d4411. Epub 2011 Jul 28. 13 Patients’ view of routine follow-up after breast cancer treatment, Vesna Bjelic-Radisic, MD, corresponding Last visit 2019-05-18 author Martha Dorfer, Karl Tamussino, and Elfriede 7 Breast cancer screening for women ages 50 to 69 years Greimel, Wien Klin Wochenschr. 2017; 129(21): 810–815. Published online 2017 Oct 17. doi: 10.1007/ a systematic review of observational evidence. Author Harris R, Yeatts J, Kinsinger L; Prev Med. 2011;53(3):108. s00508-017-1278-8; Epub 2011 Jul. 21. articles/PMC5681603/ Last Visit, 2019-05-08 pubmed/21820465 Last visit: 2019-05-08 Siemens Healthcare GmbH, 2019 11 Insights series, issue 5 About the authors Dr. Ralph Wiegner Vice President, Global Head of Improving Patient Experience and Marketing Strategy Emily Sedgwick, MD at Siemens Healthineers Emily Sedgwick is Chief Medical Officer at HCA Houston Ralph Wiegner and his team engage in thought leadership Healthcare West. She is nationally recognized for her and portfolio-related activities for improving the patient clinical expertise and innovation, having received Press experience. He is a member of both The Beryl Institute and Ganey’s prestigious Physician of the Year award in 2018 the Solutions Provider Advisory Board at The Beryl Institute. for dramatically reducing wait times for breast biopsies Prior to joining Siemens Healthineers, he spent several in Houston. Emily Sedgwick previously served as Chief years with McKinsey & Company, where he worked on Quality Officer for Baylor College of Medicine and various European and international assignments. Ralph completed her residency at Harvard Medical School’s holds a PhD in theoretical physics from the University of Brigham & Women’s Hospital. Erlangen, Germany, and completed a number of research engagements at Oklahoma State University, USA. 12 Siemens Healthcare GmbH, 2019 At Siemens Healthineers, our purpose is to enable health- care providers to increase value by empowering them on their journey toward expanding precision medicine, trans- forming care delivery, and improving patient experience, all made possible by digitalizing healthcare. An estimated 5 million patients globally benefit every day from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnos- tics, and molecular medicine, as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,000 patents globally. Through the dedication of more than 50,000 colleagues in 75 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 913184-0 Published by Siemens Healthcare GmbH · ©Siemens Healthcare GmbH, 2019

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