Prof. Berthold B. Wein
Department of Diagnostic
Screening Unit of Aachen,
Düren & Heinsberg
In June 2002, the German Bundestag decided to introduce a demographically-based national mammographic screening programme of all women between the ages of 50 and 69. This article highlights the management challenges that were experienced during the planning, implementation and evaluation of the programme.
In January 2004, the “Guidelines for the Early Detection of Cancer” (Krebsfrüherkennungs-Richtlinie) and the “Contract Between Physicians and Health Insurance Companies” (Bundesmantelvertrag für Ärzte und Kranken- bzw. Ersatzkassen) defined a new programme that planned to reduce mortality from breast cancer by up to 30% via early stage detection, similar to established programmes in the Netherlands, the United Kingdom, Sweden, Denmark and Norway. Its success is dependent on its ability to achieve a high quality of imaging, reporting and administration as well as a high participation rate, i.e. more than 65 to 70% of the population on a voluntary basis.
To guarantee the necessary high quality in imaging and reporting, reference centres have been founded to inform, educate and control the quality of 92 involved screening units who are each responsible for about 125,000 women in their districts. Therefore, all radiographers, reporting physicians and involved physicians have to participate in well-defined educational courses and must stay at least one to four weeks in a reference centre to learn about screening background and handling, organisational work and quality assurance mechanisms.
The “Kooperationsgemeinschaft Mammographie” was founded both by the insurance companies and the “Regional Association of Statutory Health Insurance Physicians” (Kassenärztliche Vereinigung), as the highest organisational authority for all people and facilities that work in the programme. Each person and facility has to be accredited by a formal procedure.
How is the Screening Process Run?
During the process of mammographic screening (see related graph) the residents’ registration offices send the following information to the regional institution responsible for invitations or “Einladende Stelle”: first names, last names, former last names, address and birth date. The regional institution will generate a unique code from those data and will send an invitation to the nearest mammography unit for a screening according to parameters set by the screening unit. Typically those invitations are sent out about three to four weeks before the appointment will take place. The woman can now decide to attend or not to attend, at the specifically-mentioned date or at another date.
Once the woman arrives at the mammography unit, she is announced and asked about previous diseases or operations of the breast. After, the physical exam takes place and the woman is x-rayed on both sides of her breast. After the procedure, she leaves the unit. All data is transferred to the screening programme database, hosted by the Regional Association of Statutory Health Insurance Physicians.
Resultant images are then double- or triple-read. In case of a suspicious finding, a conference is held, chaired by the responsible physician who has a high level of experience in mammography. Should the suspicion not be solved by prior exams or interpretation of the images, the client is invited for a second look at a related assessment unit.
During that visit a special mammography, ultrasound or even biopsy is performed and the result is discussed with the patient. If a specimen was taken, an interdisciplinary conference is held and the results discussed between experts in mammography, senology, pathology and oncology as well as radiation therapy. If cancer is detected and proven by the related pathologist, the woman is transferred to a breast centre for further examination and treatment. The costs is reimbursed for the client’s visit on a quarterly basis about six months after contact with the client.
Challenges for the Screening Programme
I. Invitation System
As mentioned above, invitees are not obliged to respond to an invitation in either a positive or negative way. Therefore it will remain unpredictable how many people will attend the exam, wasting valuable time. Another organisational challenge is the administration of huge numbers of telephone calls from up to 10% of the invitees, who might ask for rescheduling or dropping the examination. No-shows are not prosecuted and instead sent a new invitation four weeks later.
After preliminary discussions with the clients in our institution, a higher response rate could be expected, if rescheduling would be possible for working women (50 to 65 years old). Therefore automated systems should accept calls and/or provide new appointments for those clients.
A second drawback will occur, if the notice of removal to the registration office is no longer obligatory. Another point is the vast variety of individual residents’ registration offices with different technologies. Those have already given rise to confusion about personal information. Thus, the basis for the invitation is endangered. There is really no workaround available.