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Service Delivery Innovation Profile

Nurse Practitioner–Staffed Clinic Offers Same-Day, Comprehensive Appointments to Patients With Breast Symptoms, Leading to Faster Diagnosis and Lower Costs


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Snapshot

Summary

To improve the efficiency and timeliness of diagnosis and treatment for patients with symptomatic breast conditions, Virginia Mason Medical Center created a breast clinic co-located in a radiology department and staffed by an advanced registered nurse practitioner. Patients receive a comprehensive, same-day appointment in which the nurse practitioner takes a medical history, conducts a breast examination, and refers the patient as needed for immediate, onsite diagnostic testing and interpretation, including mammography, ultrasound, or image-guided biopsy. During the same visit, the nurse practitioner reviews the results with the patient, provides any needed education, and, if results are abnormal, refers the patient for a surgical consultation (available next to the clinic). The program has resulted in faster diagnosis, fewer physician visits and imaging studies, lower costs, enhanced efficiency for breast surgeons, and high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of a retrospective comparison of 2 cohorts of similar patients (100 seen in the clinic and 100 receiving traditional care), including evaluation of the speed of diagnosis, use of imaging tests and physician visits, and direct and indirect care costs; additional evidence includes post-implementation data on breast surgeon efficiency and patient satisfaction with the clinic.
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Developing Organizations

Virginia Mason Medical Center
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Date First Implemented

2008
October

Problem Addressed

Although most breast conditions end up being benign, the diagnostic process tends to be lengthy and inefficient (in part because busy surgeons often conduct the initial evaluation), leading to high costs and stress for patients who must endure long waits before finding out if they have cancer.
  • Many benign breast conditions: Each year, approximately 1.8 million women in the United States receive care for benign breast conditions, such as cysts, fibrocystic breast disease, and fibroadenomas.1 Roughly 90 percent of women who seek care for breast symptoms are ultimately determined to have a benign condition.2,3
  • Use of high-cost surgeons: Breast surgeons deliver the majority of breast care in the United States, even for benign conditions that can be effectively evaluated by a lower cost advance practice nurse without a surgical consultation.3,4 Like many health systems around the country, Virginia Mason Medical Center used breast and general surgeons to evaluate patients with breast symptoms before implementation of this program.
  • Resulting in unnecessary delays, tests, and patient stress: Women experiencing breast symptoms often must wait days or weeks before they can be seen by a surgeon, and they often undergo unnecessary diagnostic imaging tests after they do. As a result, they frequently endure a lengthy period of anxiety and stress as they wait to find out if they have cancer.3

What They Did

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Description of the Innovative Activity

Virginia Mason Medical Center created a breast clinic co-located in a radiology department and staffed by an advanced registered nurse practitioner. Patients with breast symptoms receive a comprehensive, same-day appointment in which the nurse practitioner takes a medical history, conducts a breast examination, and refers the patient for immediate, onsite diagnostic testing and interpretation. During the same visit, the nurse practitioner reviews the results with the patient, provides any needed education, and, if results are abnormal, refers the patient for a surgical consultation in an adjacent office. Key program elements include the following:
  • Marketing and referrals: Patients with breast symptoms self-refer to the clinic or are referred by primary care providers or by staff at the surgical practice. The medical center markets the breast center through various media, whereas area employers advertise its availability through internal communications.
  • Same-day appointment: Co-located in the medical center’s radiology department, the clinic operates from 7:00 a.m. to 5:00 p.m. 5 days a week. Virtually all referred patients receive a same-day appointment.
  • Nurse practitioner–led evaluation: Patients see an advanced registered nurse practitioner who conducts a medical history and breast examination, evaluates symptoms, and orders diagnostic tests that may include mammography or breast ultrasound, according to evidence-based protocols.
  • Onsite diagnostic testing: Because the breast clinic is located within the radiology department, most patients receive needed diagnostic tests within 1 hour. To facilitate rapid testing, the radiology department's schedule leaves several slots open each day to accommodate same-day appointments for breast clinic patients, and the department has radiologists available to read and interpret test results for clinic patients promptly.
  • Review of diagnosis and as-appropriate education: After testing and interpretation are completed, the nurse practitioner immediately meets with the patient to discuss the findings. The vast majority of women (approximately 90 percent) receive a confirmed diagnosis of benign breast disease. In these cases, the nurse practitioner provides relevant education and suggests a followup care schedule. Women who do not receive a confirmed diagnosis of benign breast disease undergo an image-guided biopsy, conducted either immediately or the following day in the radiology department. After this test is completed, the nurse practitioner explains the results, provides additional education as needed, and refers the patient for a surgical consultation if necessary (as described below).
  • Onsite surgical consultation: Women whose biopsy results are abnormal can see a breast surgeon in offices adjacent to the clinic. The timing of followup with the surgeon depends on the time to obtain biopsy results, which is usually a few days.
  • Shared information through electronic medical record: All care provided by the clinic is documented in the organization’s electronic medical record, thus facilitating the sharing of information among providers.

Context of the Innovation

Virginia Mason Medical Center in Seattle is a private, nonprofit, integrated health system that includes a 336-bed acute care medical center and a large, multispecialty group practice that employs approximately 450 physicians. The system handles roughly 800,000 outpatient visits and 17,000 hospital admissions each year. The impetus for this program came out of an annual meeting in which medical center representatives join with leaders of approximately 10 area health plans and employers to identify conditions that represent quality-improvement priorities for the community. Each identified condition becomes the subject of a “marketplace collaborative” that involves representatives from the medical center, an employer, and a health plan who develop and implement a quality-improvement initiative. In 2008, the group identified benign breast conditions as a target for improvement, based largely on the high incidence and costs associated with these conditions. At the same time, breast surgeons at Virginia Mason had expressed a desire to improve their efficiency and reduce care delays for patients.

Did It Work?

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Results

The program has resulted in faster diagnosis, fewer physician visits and imaging studies, lower costs, enhanced efficiency for breast surgeons, and high levels of patient satisfaction.
  • Faster diagnosis of benign conditions: Patients ultimately determined to have benign conditions received their final diagnosis in an average of 4 days at the clinic, much faster than the 16-day average for similar patients receiving traditional care.
  • Lower utilization: Breast clinic patients received fewer imaging studies and required fewer physician visits than those receiving traditional care, as outlined below:
    • Fewer imaging studies: The typical clinic patient had 1.02 imaging studies, well below the 1.31 tests for a patient receiving traditional care. A lower proportion of clinic patients underwent image-guided biopsy (10 percent versus 16 percent) and surgical biopsy (1 percent versus 6 percent).
    • Fewer physician visits: Clinic patients had fewer primary care physician visits related to breast symptoms than those receiving traditional care (an average of 0.28 physician visits per clinic patient versus 1.03 visits for those receiving traditional care) and were much less likely to visit a breast surgeon (an average 0.05 visits per clinic patient, compared with 0.23 visits for those receiving traditional care).
  • Lower costs: Direct medical costs for those seen in the clinic averaged $213, 19 percent below the $263 average for those receiving traditional care. Cost savings stemmed from use of a nurse practitioner (rather than a primary care doctor or surgeon) and less reliance on imaging studies. Cost savings for employers were estimated to be even higher ($316 per patient), due primarily to increases in productivity since clinic patients spent less time away from work.
  • Increased breast surgeon efficiency: The clinic increased the efficiency of breast surgeons by 37 percent. (This figure is based on an increase in the proportion of breast surgeon patients who actually require surgery.)
  • High patient satisfaction: During the first 3 months of clinic operations, 98 percent of patients rated their experience as “good” or “very good” (the top 2 scores on a 5-point scale).

Evidence Rating (What is this?)

Moderate: The evidence consists of a retrospective comparison of 2 cohorts of similar patients (100 seen in the clinic and 100 receiving traditional care), including evaluation of the speed of diagnosis, use of imaging tests and physician visits, and direct and indirect care costs; additional evidence includes post-implementation data on breast surgeon efficiency and patient satisfaction with the clinic.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Forming marketplace collaborative: Virginia Mason Medical Center created the aforementioned collaborative that included breast surgeons and radiologists from the medical center, the benefits director of a large area employer (the city of Seattle), and the medical director for that employer’s health plan. Virginia Mason Medical Center representatives invited employers and health plan leaders into the medical center to work directly with providers. Each of the three stakeholders had strong incentives to improve quality, affordability, and access by removing waste. Employers were willing to use their purchasing power to bring out the best in providers and health plans. Once employers were engaged in purchasing health care based on quality, other stakeholders fell into line quickly; the stakeholders began producing a breast patient “clinical value stream” based on the priorities of employers and according to their specifications for quality.
  • Holding rapid process improvement workshops: Using Toyota Lean methodology, collaborative participants held a series of rapid process improvement workshops. Over a period of several months, the group evaluated the current care process and designed a new one to allow patients with breast symptoms to have same-day access to a comprehensive evaluation and onsite diagnostic testing. In designing the process, the group sought to address five areas of concern for local employers: same-day access, rapid return to function, evidence-based care, high patient satisfaction, and affordable price.
  • Hiring nurse practitioner and medical assistant: During the design process, collaborative participants identified the need for appropriate staffing at the clinic. The medical center recruited and hired an advanced registered nurse practitioner with extensive experience in breast care, along with a medical assistant.
  • Remodeling space adjacent to radiology department: Several offices adjacent to the radiology department were relocated to make room for the breast clinic, which includes 2 examination rooms and a small waiting area (approximately 300 square feet).

Resources Used and Skills Needed

  • Staffing: The breast clinic is staffed by a full-time advanced registered nurse practitioner who has extensive experience with breast care, along with a full-time medical assistant.
  • Costs: Data on initial and ongoing costs are not available. Upfront expenses included remodeling to create space for the clinic within the radiology department, whereas ongoing costs consist primarily of the salary and benefits for the two full-time clinic staff.
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Funding Sources

Virginia Mason Medical Center
Clinic services are generally covered by reimbursement from third-party payers.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Consider specifics of market: A breast clinic may be an easier sell in markets with few breast surgeons and in fully integrated systems with employed specialists. In other areas, breast surgeons may become concerned that the center will reduce patient volumes.
  • Sell surgeons on benefits: To win surgeon support, emphasize the potential benefits of the clinic, including fewer delays (and less associated anxiety for patients) and higher efficiency (i.e., more time to see patients who require surgical treatment).
  • Include all stakeholders: The care redesign team should include representatives of all groups involved in delivering and paying for breast care, such as surgeons, radiologists, employers, and payers. This approach allows all stakeholders to provide input, and maximizes the odds that the new process will reflect actual workflows and win the support of clinicians.
  • Locate clinic in or near radiology department: To maximize efficiency and convenience for patients, the clinic should be located near imaging services and diagnostic equipment.
  • Build flexibility into radiology schedule: The radiology schedule should routinely leave several slots empty each day for breast clinic patients in need of same-day testing.
  • Hire right nurse practitioner: Nurse practitioners working in the clinic should have substantial experience with breast care and good interpersonal skills with patients. Finding such an individual can often be difficult; it took Virginia Mason Medical Center nearly 1 year to find the right person.

Sustaining This Innovation

  • Monitor and report on program's value: Collect, evaluate, and report information that demonstrates the program's value, including its impact on speed of diagnosis, direct care costs, employee productivity, surgeon efficiency, and patient satisfaction. Seeing this information will solidify the support of key stakeholders, including referring physicians, breast surgeons, and area employers.
  • Clearly define roles and expectations: Administrative responsibility for the clinic should be clearly defined, and the expectations and support from each of the involved clinical departments (e.g., radiology, surgery, primary care) should be explicit.

More Information

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Contact the Innovator

Carly Searles, ARNP
Virginia Mason Medical Center
Seattle, Washington
(206) 341-0696
E-mail: carly.searles@vmmc.org

Robert Mecklenburg, MD
Medical Director, Center for Health Care Solutions
Virginia Mason Medical Center
Seattle, Washington
(206) 341-1600
E-mail: robert.mecklenburg@vmmc.org

Innovator Disclosures

Ms. Searles and Dr. Mecklenburg reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Blackmore CC, Edwards JW, Searles C, et al. Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions. Health Aff. 2013;32(1):20-6. [PubMed]

Blackmore CC, Mecklenburg RS, Kaplan GS. At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality. Health Aff. 2011;30(9):1680-7. [PubMed]

Footnotes

1 Agency for Healthcare Research and Quality. Medical Expenditure Survey. Table 1: Number of people with care for selected conditions by type of service, United States, 2008. Available at: http://meps.ahrq.gov/mepsweb/data_stats
/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2008&Table=HCFY2008_CNDXP_A&_Debug
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2 Marchant DJ. Benign breast disease. Obstet Gynecol Clin North Am. 2002;29(1):1-20. [PubMed]
3 Blackmore CC, Edwards JW, Searles C, et al. Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions. Health Aff. 2013;32(1):20-6. [PubMed]
4 Rungruang B, Kelley JL 3rd. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011;54(1):110-24. [PubMed]
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Original publication: October 23, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.