Screening mammography in an integrated health care system: the Kaiser permanente experience

In this paper, we describe the attributes of a comprehensive approach to breast cancer screening possible in an integrated health care system. We define an integrated health care system as one in which comprehensive preventive and medical care is provided to a defined population, by a defined panel of providers, and in which this care can be tracked using automated electronic data systems. Guided by the Pathways Conceptual Framework, it is possible to identify and systematically address (through research and interventions) the multiple predisposing, enabling, and reinforcing factors at the individual and organizational level associated with each step along the screening process. This framework is helpful as both a planning and an evaluation tool, in identifying places in the screening and follow-up process that could benefit from concerted quality improvement efforts and in guiding an evaluation of those efforts. We describe examples from research and organizational programmatic efforts, and use the framework to point to additional areas for further investigation and potential organizational intervention. These examples use a variety of research methods, impact the breast cancer screening pathway in different places, and therefore show how it is possible to approach the broad issue of reduction of breast cancer mortality from multiple perspectives. Integrated health care systems, unlike more traditional academic settings, are well suited to supporting this full spectrum of research while also providing the context for its application.