ACR Bulletin

Covering topics relevant to the practice of radiology

Within Reach

Life-saving screening starts locally, with radiologists leading outreach efforts.
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If there’s a way to engage with the community to increase access, there is a financial justification for doing it.

—Syed F. Zaidi, MD
April 01, 2019

If an ounce of prevention is worth a pound of cure, a population health approach to delivering care is worth a bundle to radiology and the patients it serves. Connecting patients to appropriate healthcare screening may be the touchstone of widespread population health management (PHM), and at-risk patients in underserved communities need an investment in outreach.

“If you don’t practice proactive screening as part of PHM, patients will eventually show up in the system worse off and their care will come at a higher cost,” says Syed F. Zaidi, MD, vice president of clinical operations at Radiology Partners and chair of the ACR Commission on Patient and Family-Centered Care’s PHM Committee.

According to Zaidi, it is critical to engage in community health programs if you want to see a measurable increase in the health and wellness of your community. Recognizing the traits of an underserved population can help your program tailor community education and prevention strategies for lowering the rates of certain diseases.

Underserved populations in both rural and urban settings, who are most at risk for low rates of health screenings, share the following characteristics:

  • Little financial security
  • Less likely to exercise
  • More likely to have a poor diet
  • More likely to face transportation challenges
  • More likely to smoke

There must be a clear understanding of these social determinants of health to remove barriers to early detection and treatment.

Nearly two decades ago, the Institute of Medicine called for “a greater emphasis on public health interventions that involve communities.” To that end, lung, breast, and colorectal screenings have given radiologists a logical pathway to patients who may otherwise have difficulty accessing the healthcare system.

Identifying Connections

While breast cancer screening awareness is increasingly pervasive in underserved communities, lung cancer screening is still sorely underutilized. “We know screening for lung cancer works, and we know people aren’t having it done enough — even though it has been covered by insurance since 2015,” says Kim L. Sandler, MD, assistant professor of radiology and co-director of the lung screening program at Vanderbilt University Medical Center in Nashville.

With a local population that includes a significant number of people who smoke, Sandler and her colleagues in the radiology department are identifying women at high risk for lung cancer when patients come in for mammograms. “We know from the research that people who get screened for one type of cancer are much more likely to get screened for another type of cancer,” Sandler says. “So if you have a mammogram, you are much more likely to get checked for lung cancer or have a colonoscopy, and vice versa.”

The program targets women at high risk who are already in the system. The goal is to alert primary care providers before upcoming appointments with patients who are eligible for lung cancer screening — and to schedule that study during their visit. New marketing efforts are underway with outpatient imaging centers to promote the availability of lung cancer screening and to educate the public about the importance of early detection.

Cartoon image of a man holding a lung CT scanResearch has shown that screening not only improves survival rates, but can also greatly increase the treatment options for early-stage disease. “We really emphasize that the screening study doesn’t give you cancer,” Sandler says, addressing a common concern among patients. “We tell patients that screening allows us to detect disease at a stage where hopefully all you may need is minimally invasive surgery versus chemotherapy or radiation therapy.” The radiology department is also sensitive to some patients’ resistance to smoking cessation. “We tell them about the benefits of quitting smoking,” she says, “but we’re careful not to pass judgment and to let them know that we are only here to help.”

Convenience is also a persuasive factor in screening outreach. Transportation challenges and missed time from work are often deterrents for vulnerable populations. Sandler points to the accessibility of outpatient screening facilities — which are easier to reach, have free and ample parking, provide short visit times, and offer weekend and evening hours.

Partnering Locally

While identifying at-risk patients and offering convenient screening options improves population health from within a radiology group, comprehensive PHM outreach should extend to all available community resources. Learning more about the efforts of facilities already in place — faith centers, community centers, senior citizen centers, and so on — could help the outreach process.

There may also be opportunities to spread information through local TV stations and newspapers, to speak at health fairs, or to partner with local health centers to distribute print or web-based educational materials. This type of outreach is essential in communities with the most vulnerable populations, says Judy Yee, MD, FACR, chair of the ACR Colon Cancer Committee and chair of the department of radiology at Montefiore Health System and Albert Einstein College of Medicine in New York.

“We have BronxNet, a community TV network, which we use to talk about different types of available screening,” Yee says. “We actually go down to the studio and describe the disease, why it’s so important to get screened, and how we can help. It has been very well-received, is specific to the Bronx, and is bringing patients in to talk to their doctors.”

Radiologists take turns speaking, and there is no shortage of volunteers, Yee says. A breast imager, for example, will talk about breast cancer screening — usually aligned with Breast Cancer Awareness Month. Montefiore also holds community events on weekends to answer questions about the services it provides and to offer free screenings. The hospital collaborates with the local paper, which runs articles — not just ads — about the events and why local residents should attend.

The downstream health benefits of this type of community outreach are obvious, Yee notes, but it also builds a sense of trust of physicians within the community. “It’s important that they see our mission as helping patients in need and that our driving principle really is about social equality,” Yee says.

According to Yee, willingness and commitment are key to connecting with patients. “Our programs may not always roll out exactly as we hope because of funding or staffing shortfalls, but it’s never because of a lack of engagement by our physicians within the community,” she says.

Abating Barriers

“The radiology community needs to be an integral part of population health outreach,” says Efrén J. Flores, MD, officer of radiology community health improvement and equity at Massachusetts General Hospital (MGH). “By increasing access to services for underserved populations, you are promoting better healthcare for all patients.”

Engaging an underserved population with screening before a disease becomes evident leads to other preventative services — like keeping up to date on vaccinations or getting an annual flu shot, Flores says. Still, patients are often confused about which services are covered by their health insurance.

There is currently limited coverage for CT colonography, for example. “ACR has really taken the lead on supporting access to this,” Flores says. Given the widespread availability of CT, in some areas CT colonography could be more accessible than seeing a gastroenterologist. Furthermore, no sedation is required for CT colonography, and it can drive other cancer screening tests — such as mammography and lung cancer screening.”

Helping patients understand what is available to them is a challenge but can sometimes be accomplished through modest efforts. For example, the breast imaging department at MGH has translated consent forms into multiple languages. “It seems like a simple thing but it helps patients feel more comfortable with their care and more likely to have follow-up,” Flores says.

“We’ve also been working with community health clinics that serve a high number of Hispanic patients, who receive screening less frequently than other groups,” Flores notes. Through this partnership between radiology and primary care, patients receive lung cancer screening questionnaires when they come in for their annual screening mammograms. “We tabulate the information to see how many of those patients are eligible for lung cancer screening,” Flores says. “We give that information to the population health manager at that clinic so they can notify the patient’s primary care provider.”

Engaging patients at the time of their screening integrates radiologists into the healthcare value chain. Radiologists have a unique opportunity to advance their role in helping populations achieve health equity by partnering with stakeholders to engage patients in their own care — at the same time improving utilization of screening services and other health preventive services.

It is widely accepted that PHM can — and should — result in myriad downstream savings to the entire healthcare system, while at the same time raising the overall health of underserved populations. “Emphasizing preventive care over reactive care is both cost-effective and the right thing to do,” Flores points out.

“If there’s a way to engage with the community to increase access, there is a financial justification for doing it,” adds Zaidi. “You’re making the system sustainable.” Finding the initial point of engagement is the trick, he says.

According to Zaidi, “Once these patients are a part of the system, we can better manage their health and ensure a better future for the entire population. There are probably more underserved patients than we realize or talk about.” Fortunately, radiologists are well-positioned to take a leadership role in the health of their communities. “Through PHM outreach,” says Zaidi, “we can make sure people aren’t falling through the cracks.”

Author Chad Hudnall  senior writer, ACR Press