BREAST CANCER SCREENING GUIDELINES Breast Cancer Screening Guidelines: Does Education to Healthcare Providers in an Outpatient Office Setting Increase Number of Screenings? By Maggie Dempsey Pennsylvania Western University 250 University Ave. California, PA 15419 A DNP Project Submitted to Pennsylvania Western University In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree November 2024 1 BREAST CANCER SCREENING GUIDELINES 2 Table of Contents Chapter 1: Overview of the Project……………………………………………………………….4 Chapter 2: Review of Literature…………………………………………………………………10 Chapter 3: Methodology…………………………………………………………………………14 Chapter 4: Results and Findings…………………………………………………………………18 Chapter 5: Discussion of Findings…………………………………………………………….…23 References……………………………………………………………………………………….26 Appendix A. Pretest and Posttest 10-Question Assessment………………………………..……30 Appendix B. Breast Cancer Screening Guidelines Google Slides Presentation……………...….36 BREAST CANCER SCREENING GUIDELINES 3 Abstract Breast cancer affects people all ages, genders, and races. The ways in which providers prevent and detect breast cancer have change significantly over the years. Healthcare providers have a number of resources to utilize to screen patients for breast cancer appropriately. However, providers do not always follow the guidelines that are recommended likely due to lack of knowledge. The purpose of this evidence-based quality improvement project was to increase healthcare provider knowledge about current breast cancer screening guidelines and recommendations. In August of 2024 over a two-week period, healthcare providers at a federally qualified health center look-alike were asked to participate in an evidence-based quality improvement project concerning breast cancer screening guidelines. Participants completed a pretest and posttest questionnaire to measure if there was an increase in knowledge after completing the presentation. Fifteen participants completed both the pretest and posttest. A paired-samples t-test was utilized to analyze data which resulted in a statistically significant finding. These results conclude that a breast cancer screening guidelines presentation helps to increase provider knowledge. Keywords: breast cancer screenings, guidelines, education, federally qualified health center, provider knowledge BREAST CANCER SCREENING GUIDELINES 4 Chapter 1: Overview of the Project Guidelines are tools that healthcare providers use frequently to help treat patients appropriately. Healthcare providers are fortunate to have guidelines at their disposal to help screen patients for multiple diseases. Breast cancer screening guidelines are being researched and updated often. A mammogram is a screening tool providers can use and educating healthcare providers about the current guidelines is an important way to help identify breast cancer early. Not all healthcare providers are aware of the most current guidelines available. Some newer providers are not educated on the topic, and some of the more experienced providers are using outdated guidelines. The American College of Obstetrics and Gynecology (ACOG), the United States Preventive Service Task Force (USPSTF), and the American Cancer Society (ACS) are common guidelines that healthcare providers use when treating patients. This Doctor of Nursing Practice (DNP) evidence-based practice project aimed to increase knowledge of staff and improve patient outcomes. About one in eight women will develop breast cancer in their lifetime, and it is the second leading cause of cancer death in women (ACS, 2023a). Since 1989 there has been a steady decline in the breast cancer death rate (ACS, 2023a). This decrease is believed to be related to increased awareness and screening methods (ACS, 2023a). One screening method that is sometimes underutilized is the mammogram. A mammogram takes an x-ray picture of the breast, and it is a tool that helps to identify breast cancer sometimes up to three years before it can be felt (Centers for Disease Control and Prevention, 2022). An educational Google Slides presentation summarized current breast cancer screening guidelines to help increase healthcare provider knowledge at a primary care office. Increase in BREAST CANCER SCREENING GUIDELINES 5 knowledge was measured by a pretest and posttest survey. Number of screenings documented at the primary care office before and after the presentation were documented and discussed. This project helped to extend prior research Rehman et al. (2022) conducted regarding healthcare professionals lacking knowledge about screening tools and breast cancer risk factors. Why has there been a decline in mammogram screening in women? Tsapatsaris et al. (2022) discussed barriers to breast cancer screening for women. This project helped to close the gap in literature by helping to increase adherence to current guidelines through an educational presentation. Background Context and Theoretical Framework Guidelines and recommendations regarding breast cancer change constantly. It is difficult for primary care providers to keep up with the changes. The people that suffer from missed screenings are the patients. There are a multitude of findings that support screening for breast cancer and encouraging patients to get yearly mammograms. However, more can be done to help educate providers and screen more women to ultimately prevent women from dying from breast cancer. The Donabedian Model of Quality Care framework was the theoretical framework the project followed. The three parts of the framework are: structure, process, and outcome (Donabedian, 1988). The structure stands for the place the project took place along with the providers and technology. The process stands for the intervention aimed at increasing provider knowledge of breast cancer screening guidelines. The outcome is measurement of effectiveness of the presentation and adhering to the recommendations summarized. The nursing theory used for this project was Jean Watson’s theory of Transpersonal Caring. The theory discusses how nursing involves promoting health and preventing illness BREAST CANCER SCREENING GUIDELINES 6 (Watson, 2012). If a person does become ill, then nurses care for the sick and try to restore health (Watson, 2012). Following guidelines regarding breast cancer screenings, is a way of promoting health and preventing illness. Problem Statement About one in every thirty-nine women diagnosed with breast cancer will die from breast cancer (ACS, 2023a). Without screening tools and treatment, that number would be much higher. If providers use breast cancer screening guidelines, this will help to identify disease and get treatment for patients sooner rather than later. It is not known why healthcare providers do not screen using the recommended breast cancer screening guidelines. Duffy et al. (2023) discussed the benefits of annual screenings and how missing one screening appointment increases the risk of dying from breast cancer. There are multiple reasons why women do not go for their annual breast cancer screening. First and foremost, they do not know their risk. Patients need their healthcare provider to encourage and advise them to proceed with a mammogram screening if they could benefit from it. In addition, do the healthcare providers know who is at risk or when to start screening? There have been multiple changes to breast cancer screening over the years. Certain guidelines recommend screening women with average risk for breast cancer starting at age 40 with mammograms every year (ACS, 2023b). Other guidelines recommend to screen women starting at age 40 and recommend mammograms every other year (USPSTF, 2024). At the proposed site, there are multiple missed opportunities when it comes to screening patients for breast cancer. Many providers only screen during preventative yearly exams. However, in reality providers can and should be screening for breast cancer during every patient encounter. Women are dying from breast cancer and there are ways in which this number can be BREAST CANCER SCREENING GUIDELINES 7 lowered. Barriers result in less women that are screened for breast cancer and result in poorer outcomes for patients and their families. Purpose of the Study The purpose of this evidence-based quality improvement project was to increase provider knowledge of current breast cancer screening recommendations at a federally qualified health center look-alike through an informational presentation. The proposed project used a pretest posttest design to measure the degree of change based on the informational presentation summarizing breast cancer screening recommendations. The goal of this project was to help to educate providers and increase recommended screening practices. The project took place at a federally qualified health center (FQHC) look-alike in Northeastern Pennsylvania. The target population was the group of health care providers at the FQHC look-alike. The informational presentation was distributed to the healthcare providers via work email and participation was optional and anonymous. Information obtained will help to contribute to the numerous other studies regarding breast cancer screening. Research Question The quality improvement project attempted to answer the following question: Does an informational presentation summarizing current breast cancer screening recommendations help to improve provider knowledge at a federally qualified health center look-alike? This project relates to the current problem of women not being screened for breast cancer. Healthcare providers are not aware of new guidelines and are not screening eligible women. Rationale for the Study Using a pretest posttest design was the best approach to achieve the goal of answering the research question. Stratton (2019) discussed how a pretest posttest design gives directionality. BREAST CANCER SCREENING GUIDELINES 8 This method is beneficial with quality improvement projects because one is able to test the dependent variable of knowledge before and after the intervention (Stratton, 2019). The pretest gave a baseline for what the participants knowledge level was prior to the informational presentation. The posttest was given after the presentation to see if there was an improvement in scores. Significance of the Study Why are women not being screened for breast cancer? Even with today's technology and treatment advances, about 43,000 women died from breast cancer in 2023 (ACS, 2023a). Jean et al. (2023) discusses the importance of evaluating barriers preventing women from obtaining mammograms. Barriers that prevent women from being screened for breast cancer include: language barriers, race, gender identity, religion, sexual orientation, and socioeconomic status (Jean et al., 2023). Utilizing a presentation to help clarify guidelines and teach providers, can be a way to evaluate one of the barriers. Whether or not a provider recommends a mammogram, is a barrier that needs to be overcome. Definitions of Terms Definition of terms used for this project can be found below. Breast Cancer Screenings: According to the American Cancer Society (2023b), screening for breast cancer includes using tests and exams to find disease in people who do not display symptoms. This project defines breast cancer screenings, as imaging, genetic tests, or physical exams to help detect breast cancer in asymptomatic patients. Provider: Merriam-Webster Dictionary (n.d.-a) defines provider as one that provides. BREAST CANCER SCREENING GUIDELINES 9 This project defines a provider as medical doctors, doctors of osteopathic medicine, nurse practitioners, physician assistants, licensed practical nurses, or registered nurses in a primary care setting that provide care to patients. Knowledge: Merriam-Webster (n.d.-b) states knowledge is gained through experience and is the condition of knowing something with familiarity. This project defines knowledge as the information that is obtained and utilized after an educational presentation about breast cancer screening. Federally Qualified Health Center: Rural Health Information Hub (n.d.) defines Federally Qualified Health Center (FQHC) as outpatient clinics. Under Medicare and Medicaid, a FQHC qualifies for certain reimbursement systems. For the purpose of this project, FQHC is defined as the outpatient primary care office where the project will take place. Breast cancer screening guidelines are frequently updated and adjusted. Healthcare providers should be aware of changes and educate patients accordingly. Educating providers about the current guidelines will ultimately help with early detection of breast cancer. Also, provider education will help to prevent over-screening. A Google Slides presentation discussing current guidelines, helped to educate providers. In order to determine if the presentation increased education regarding screening guidelines, a pretest and posttest were utilized. Breast cancer is a devastating disease that affects countless people every day. Increasing screening will help to decrease the number of people devastated by this disease. BREAST CANCER SCREENING GUIDELINES 10 Chapter 2: Review of Literature The Doctor of Nursing Practice (DNP) project focuses on using previous research and building upon that research to help bridge the gap. Breast cancer screenings and methods of improving adherence to current literature was the main focus of this DNP project. The purpose of this chapter is to review the existing literature regarding preventative screening guidelines and methods of educating healthcare providers. This quality improvement project aimed at implementing best practices as indicated in the research identified. The literature review was conducted using PubMed. Initial search consisted of keywords breast cancer and 516,628 results were found. The search was then filtered to only include articles within the last 5 years (2019-2024). This filter resulted in 134,077 articles. Next, screening guidelines were added to breast cancer and this resulted in 2,377 results. Finally, adding adherence to the above keywords resulted in 252 articles. Free full text filter and peer reviewed filters were used which resulted in 164 research articles to investigate for this literature review This chapter will be separated into barriers and review of the literature. The main problem regarding breast cancer screening relates to adherence to guidelines. The gap in research relates to the barriers that prevent healthcare providers from adhering to the guidelines. This DNP project helped to see if provider knowledge and awareness are one of the barriers. Rehman et al. (2022) performed an interventional study with 260 medical professionals. An educational session was utilized to educate the health professionals about breast cancer risks and guidelines (Rehman et al., 2022). A questionnaire was utilized for before and after to determine effectiveness of the educational session (Rehman et al., 2022). Results showed an increase in knowledge after the intervention (Rehman et al., 2022). BREAST CANCER SCREENING GUIDELINES 11 Friedman-Eldar et al. (2020) conducted a retrospective observational study between the years 2012 and 2015. Researchers examined women diagnosed with breast cancer for the first time at Kaplan Medical Center, Rehovot, Israel (Friedman-Eldar et al., 2020). Women were separated into two groups which included early-stage breast cancer and advanced breast cancer (ABC; Friedman-Eldar et al., 2020). The primary outcome included whether or not patients adhered to the guidelines in Israel during that time (Friedman-Eldar et al., 2020). Results showed that screening mammography reduced the likelihood of diagnosis at an advanced stage. However, there was a significant portion of women who presented with advanced disease even with following current recommended guidelines. Friedman-Eldar et al. (2020) discussed how extending the guidelines to include women younger than 50 would help with diagnosing at an earlier stage. Wehbe et al. (2023) performed a study to determine predictors of nonadherence to breast cancer screening guidelines among women. Researchers reviewed charts of women who received more than one screening mammogram in order to see if guidelines were followed related to breast cancer risk and breast density (Wehbe et al., 2023). Wehbe et al. (2023) utilize the American Cancer Society recommendations regarding yearly mammography and breast magnetic resonance imaging (MRI) for women considered high risk starting at age 30. Results showed that providers underutilized supplemental screening tools like a breast magnetic radiation imaging (MRI) for women who were at increased risk for breast cancer (Wehbe et al., 2023). Barriers to supplemental screening include lack of knowledge by the healthcare provider (Wehbe et al., 2023). Wehbe et al. (2023) suggested that the lack of standardized screening guidelines for women with dense breasts, may influence healthcare providers to order supplemental imaging. BREAST CANCER SCREENING GUIDELINES 12 A cross-sectional web-based survey was conducted in Minnesota to determine breast cancer screening practices among primary care providers (Blaes et al., 2020). The questionnaire focused on screening practices among women at increased risk for breast cancer (Blaes et al., 2020). Less than half of the providers recommended a breast MRI in addition to the screening mammography (Blaes et al., 2020). Researchers concluded that there is a need for increased education among healthcare providers (Blaes et al., 2020). To summarize, providers were not following current guidelines. A qualitative research project was conducted in Indonesia to determine the barriers to early detection of breast cancer (Icanervilia et al., 2023). Subjects included breast cancer patients, healthcare professionals, and healthy womens with no history of breast cancer (Icanervilia et al., 2023). Through in-depth interviews, researchers collected data to investigate barriers to the delay in breast cancer detection (Icanervilia et al., 2023). Barriers include public awareness, access to health services, enhancing the referral system, and strengthening the health facilities (Icanervilia et al., 2023). Nachtigal et al. (2020) surveyed healthcare providers in Wisconsin in 2018. Researchers used a 46-question survey about breast cancer screening among women of average risk (Nachtigal et al., 2020). Survey was sent to 1031 providers and 295 people responded. The majority of respondents chose U. S. Preventive Services Task Force (USPSTF) as very influential in regards to their decision making (Nachtigal et al., 2020). However, it was discovered that most of those providers were not following the USPSTF recommendations (Nachtigal et al., 2020). In addition, Nachtigal et al. (2020) concluded that healthcare providers in Wisconsin overestimate the usefulness of clinical and self-breast exams despite recommendations against them. BREAST CANCER SCREENING GUIDELINES 13 Chandra et al. (2023) investigated the effectiveness of an employer-based health program on increasing mammography adherence. The study included 318 women from a Texas-based company (Chandra et al., 2023). Researchers concluded that an employer-based health promotion program alone was insufficient in improving breast cancer screening. Determinants of mammogram adherence included access to healthcare coverage, those who disagree with belief that everything causes cancer, and those who perceive cancer screening as important (Chandra et al., 2023). The lack of association between increase in adherence to breast screening guidelines and an employer-based health promotion program, may indicate the absence of enough information or support (Chandra et al.,2023). Therefore, one can conclude more education needs to take place to help promote adherence to guidelines. Overall, the above research highlights the needs and the barriers regarding breast cancer screening and adhering to guidelines. The research discusses the importance of education. Educating the public about their risk for cancer is important to promote adherence. Educating healthcare providers about current and recommended guidelines will help to improve care given to patients. To overcome the barriers, it is important to continue to learn and grow as providers. Contradicting guidelines can cause confusion among providers. Therefore, knowing the research that supports the guidelines is important to share with patients. BREAST CANCER SCREENING GUIDELINES 14 Chapter 3: Methodology The focus of this quality improvement project was to increase healthcare provider knowledge about current breast cancer screening recommendations at a federally qualified health center look-alike in Northeastern PA. The project took place in August of 2024, and gained internal review board approval from both the Wright Center for Community Health and Pennsylvania Western University. This chapter is composed of how the project was carried out and the methodology used. Research Question The group of healthcare providers treat patients in the primary care setting. The pretest posttest design helped to see if the breast cancer screening guidelines presentation was effective at increasing knowledge of the participants. Knowledge refers to an increased understanding of breast cancer screening guidelines. The participants were recruited via work email. Google Slides was utilized for the breast cancer screening guidelines presentation. Google Forms was utilized for the pretest and posttest. Participation in the project was optional and the pretest and posttest responses were anonymous and kept secure. The initial email gave the purpose of the project and link to the pretest. Three days after sending the initial email, a follow-up email was sent with a link to the Google Slides presentation and posttest. Research Design and Methodology The pretest posttest design helped to answer the research question. This methodology was used as opposed to other designs because pretest and posttest design gives directionality and the student was able to test the dependent variable before and after the intervention (Stratton, 2019). The quantitative research design allowed the student to measure knowledge quantitatively by comparing the pretest and posttest scores. BREAST CANCER SCREENING GUIDELINES 15 The quasi-experimental design was chosen in order to evaluate the effectiveness of the educational presentation. Ledford and Gast (2014) discuss how the main advantage of the onegroup pretest-posttest is the opportunity to compare scores of participants before and after the treatment in the same group of participants. The educational Google Slides presentation was utilized as the intervention. The pretest and posttest scores were used to determine the effectiveness of the presentation. Population and Sample Selection The target population for this project were healthcare providers who worked in nine outpatient offices located throughout Northeastern PA. For the purpose of this study, healthcare providers included: 24 internal and family medicine attendings, 18 advanced practice providers, and 27 nurses. In order to increase the sample size, the project was also emailed to the internal medicine residents that participate within Graduate Medical Education program. Emails were addressed to the healthcare. Healthcare providers included the family and internal medicine attendings and residents, nurse practitioners, physician assistants, and nurses. Convenience sampling was used to enroll participants. Emails were sent to participants’ work email. The facility has an internal review board (IRB). IRB approval was obtained before the quality improvement project took place. The student completed necessary training courses and submit forms to IRBNet before the IRB scheduled meeting in order to obtain approval. All materials used for the project needed to gain approval as well. When the participant filled out the pretest, they were asked to create their own unique identifier. The unique identifier consisted of one letter and two numbers. The participants were asked to remember this and use their unique identifier for the posttest. This information was kept BREAST CANCER SCREENING GUIDELINES 16 secure in an Google Sheet. Three days after the pretest was emailed, the participant was then asked to complete the self-guided Google Slides presentation and posttest. The posttest results were documented in a secure Google Sheet. A third Google Sheet was utilized to complete the analysis of data after two weeks of data collection. A paired-samples t-test was performed to see if scores improved, decreased, or stayed the same after the educational presentation. Instrumentation or Sources of Data Validity and Reliability The pretest questionnaire (Appendix 1) was developed by the student, and had face validity only. Questions were reviewed and revised by the project mentor. Next, the questionnaire was submitted to the IRB. The pretest consisted of a series of questions measuring the healthcare provider's knowledge prior to the educational presentation. The posttest consisted of the same series of questions. Data Collection and Management Data collection included Google Forms and Google Sheets. The pretest and posttest were out of 10 total possible points. In addition, demographic information collected included: job title, gender, age, and education background. The participants' pretest score was compared to their posttest score. Statistical analysis was run on the data using a paired t-test. Alpha was set at 0.05. If the p value was less than 0.05, then this student could reject the null hypothesis and results could be considered statistically significant. Information is kept secure and anonymous. Results were analyzed while on a secure password protected network. Limitations Limitations include distributing the presentation through email. Some participants may not check email or only fill out the pretest. Participant completion of both the pretest and posttest BREAST CANCER SCREENING GUIDELINES is necessary to accurately compare results. The participants must also remember their unique identifier. Participants may forget the unique identifier they created which will make results difficult to analyze accurately. Timeframe is also a limitation. Two weeks is a short amount of time to complete the project. Also, the test being used to measure knowledge does not have established reliability. 17 BREAST CANCER SCREENING GUIDELINES 18 Chapter 4: Results and Findings The purpose of this evidence-based quality improvement project was to increase knowledge of healthcare providers about current breast cancer screening guidelines. Guidelines were summarized and placed into an informational Google Slides presentation. Healthcare providers were given the opportunity to participate in the quality improvement project from Monday August 12th, 2024 until Monday August 26th, 2024. One hundred fifty-two emails were sent to healthcare providers with information about the project and link to a pretest. Three days later, the same employees were emailed a link to the presentation and posttest. Thirty-two employees completed the pretest and 21 employees completed the posttest. Return rate for the pretest was 21% and 14% for the posttest. Fifteen respondents were used for final analysis. Fifty-two percent of the posttest responses were not utilized due to different unique identifier used between pretest and posttest. Data and results were analyzed using Google Sheets and XL Miner Application. XL Miner Application is free add-in software available to Google Sheets users. Sample Characteristics Table 1 shows the participant demographics. Fourteen females and one male completed both the pretest and posttest. Ages ranged from 28 to 56 and two respondents chose not to answer. Six of the participants were nurses. Five of the participants were nurse practitioners or physician assistants. Two of the participants were family medicine doctors and two were internal medicine doctors. Five of the participants had a high school diploma or a general educational development (GED) diploma. One of the participants had a bachelor’s degree. Three of the participants had a master’s degree, and six of the participants had a doctoral degree. Table 1 BREAST CANCER SCREENING GUIDELINES 19 Participant Demographics Characteristic n % Age 20-29 30-39 40-49 50+ Prefer not to answer 2 7 2 2 2 13.3 46.6 13.3 13.3 13.3 Gender Male Female 1 14 6.6 93.3 Profession Nurse Nurse Practitioner/ Physician Assistant Physician 6 5 40 33.3 4 26.6 Highschool / GED Bachelor’s Masters Doctorate 5 1 3 6 33.3 6.67 20 40 Education Results Figure 1 shows the individual’s pretest and posttest score. XL Miner Analysis application through Google Sheets was used to perform data analysis and descriptive statistics. A pairedsamples t-test was conducted in order to determine if the participants pretest score was significantly different from the posttest score. Table 2 shows the results of the paired-samples ttest. Average score of the pretest was 5.13, and average score of the posttest was 8.86. The standard deviation of the pretest was 2.53, and the standard deviation of the posttest was 1.80. Range of the pretest was 9, and range of the posttest was 7. Variance of the pretest was 6.40, and variance of the posttest was 3.26. Alpha was set a 0.05. P value was found to be 0.0001. Figure 1 Pretest Posttest Results BREAST CANCER SCREENING GUIDELINES 20 Pretest Posttest Results Questionaire Score 12 9 10 7 8 10 10 8 10 7 1010 8 10 8 6 6 9 8 5 2 2 1 2 10 9 5 3 4 10 5 6 9 7 33 0 A11 L56 X12 JB1 M12 C13 S56 T90 L22 D07 A10 A93 K17 A20 E14 Unique Identifer Pretest Score Posttest Score Note. The pretest results of participants are shown in pink and the posttest results of participants are shown in purple. The x-axis is the unique identifier and the y-axis is the questionnaire score. Table 2 Paired Sample t-test Pretest Posttest N Mean SD Range Variance 15 15 5.13 8.86 2.53 1.80 9 7 6.40 3.26 Significance p = 0.0001057 Electronic Health Record Data Upon completion of the quality improvement project, data was obtained with the help of the Clinical Quality Compliance and Reporting Manager at the facility. Table 3 shows data that was complied. Four weeks prior the quality improvement project (July 14th, 2024 – August 10th, 2024) 2,831 female patients between the ages of 40-74 were seen for appointments. Of those BREAST CANCER SCREENING GUIDELINES 21 2,831 patients, 1,598 women did not have a mammogram screening on file in the last 18 months. Of the 1,598 women, 578 women had a mammogram ordered during their visit. This resulted in 1,020 missed screenings. Data was also analyzed four weeks after the completion of the project between August 27th, 2024 and September 24th, 2024. During that time span, 3,139 women were seen for appointments. Of the 3,139 women, 1,829 patients did not have a mammogram on file for the last 18 months. Of the 1,829 women that were seen for an appointment, 548 women had a mammogram ordered. This resulted in 1,281 screenings that were missed. Table 3 Electronic Health Record Data Pre-Intervention Electronic Health Record Data Women Aged 40-74 Seen for Appointment 2831 No Mammogram on File 1598 Women who had mammogram ordered 578 Screenings missed 1020 Percentage of screenings completed 36.17% Percentage of screenings missed 63.80% Post-Intervention Electronic Health Record Data Women Aged 40-74 Seen for Appointment 3139 No Mammogram on File 1829 Women who had mammogram ordered 548 Screenings missed 1281 Percentage of screenings completed 30% Percentage of screenings missed 70% Data Limitations In order to keep results anonymous, emails were not collected. Participants were able to submit more than one pretest and posttest. In addition, for the majority of the project the pretest, presentation, and posttest could be accessed at the same time. Participants could have taken the pretest after the presentation which could have also affected the results. This could have been prevented by ending the pretest date when the posttest started. Small sample size is an additional limitation of this project and data analysis. Results may have been different with a larger sample BREAST CANCER SCREENING GUIDELINES 22 size. Sample size was likely influenced by staff on vacation and limited timeline to complete project. In regards to the electronic health records that were analyzed, limitations include mammograms not documented. Meaning, patients may have actually completed the mammogram, but it was not properly pulled into the system and documented appropriately. Also, many women have their mammograms ordered by their women’s health provider. Summary Overall, data analyzed comparing pretest and posttest scores were statistically significant using a paired-samples t-test. Average score of the 10-question pretest improved after participants completed the self-guided Google Slides presentation regarding breast cancer screening guidelines. We can infer that the participants gained a better understanding and increased knowledge of current guidelines and recommendations after completing the presentation. This data can be helpful to future projects that aim to increase knowledge of breast cancer screening guidelines and increase number of screenings. BREAST CANCER SCREENING GUIDELINES 23 Chapter 5: Discussion of Findings The purpose of this evidence-based quality improvement project was to increase provider knowledge through an educational presentation regarding breast cancer screening guidelines at a federally qualified health center look-alike. The project took place in August of 2024 over a twoweek period. This chapter will discuss findings of this project and how it relates to future practice regarding breast cancer screenings and recommendation. This chapter will cover summary of findings, implications, and recommendations for future practice. Summary of Findings Overall, the majority of the healthcare providers that participated in the project had improved scores after completing the presentation. Scores of the 10-question assessment improved significantly after completion of the Google Slides presentation regarding breast cancer screening guidelines. Fifteen participant responses were utilized for data analysis. Data analysis was completed using Google Sheets and XL Miner Application. The paired-samples ttest resulted in a p-value of less than 0.05. Data collected from the electronic health record showed there were multiple missed opportunities for mammograms. Yearly mammograms ordered prior to the quality improvement project were compared to the number of yearly mammograms ordered after the quality improvement project was completed. There was an increase in missed mammograms after the quality improvement project was completed. Implications Breast cancer is a disease that continues to devastate patients and their families. Screening patients on time and routinely could help to lessen this devastation. Education and knowledge are the keys to screening more patients. Results from this project have implications BREAST CANCER SCREENING GUIDELINES 24 for nursing practice. Providers demonstrated increased understanding of current breast cancer screening guidelines after completing the presentation. Thus, implementing a self-guided presentation into a yearly educational module required by providers can help to increase awareness of current guidelines and ultimately improve screening numbers. Limitations for this quality improvement include timeline for the project and small sample size. It took place over a two-week period which is a short amount of time. The project took place in August in which many providers were out of office on vacations. Due to time constraints and provider availability, an in-person presentation was not a realistic option. Future projects should include a larger cohort from multiple outpatient offices including women’s health facilities. Recommendations It is recommended that providers continue to utilize current guidelines and screening tools with every patient encounter. Healthcare providers should be aware which guideline they are using the research that supports the recommendations. Patients place an immense amount of trust in their clinician, and in return healthcare providers should make sure they are following evidence-based practice. The goal of clinicians is to provide quality care to all patients. Researchers need to further investigate why and how more patients can be screened. This quality improvement project helped to understand that knowledge and awareness of current guidelines are likely barriers that prevent more women from getting screened for breast cancer. Conclusion Overall, patients deserve to be treated by healthcare providers that utilize evidence-based guidelines and recommendations. Breast cancer screening tools and recommendations have BREAST CANCER SCREENING GUIDELINES 25 changed significantly over time. Education and knowledge are barriers that can prevent screenings. A presentation that summarizes these recommendations for providers can help to increase their knowledge and ensure they are up to date on current research. Learning more ways to help increase knowledge and awareness can ultimately help to increase screenings and help to detect breast cancer sooner rather than later. BREAST CANCER SCREENING GUIDELINES 26 References American Cancer Society. (2023a). Key statistics for breast cancer. https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breastcancer.html American Cancer Society. (2023b). 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Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center. Cancer Medicine, 12(14), 15482– 15491. https://doi.org/10.1002/cam4.6182 BREAST CANCER SCREENING GUIDELINES Appendix A Pretest and Posttest 10-Question Assessment 30 BREAST CANCER SCREENING GUIDELINES 31 BREAST CANCER SCREENING GUIDELINES 32 BREAST CANCER SCREENING GUIDELINES 33 BREAST CANCER SCREENING GUIDELINES 34 BREAST CANCER SCREENING GUIDELINES 35 BREAST CANCER SCREENING GUIDELINES Appendix B Breast Cancer Screening Guidelines Google Slides Presentation 36 BREAST CANCER SCREENING GUIDELINES 37 BREAST CANCER SCREENING GUIDELINES 38 BREAST CANCER SCREENING GUIDELINES 39 BREAST CANCER SCREENING GUIDELINES 40 BREAST CANCER SCREENING GUIDELINES 41 BREAST CANCER SCREENING GUIDELINES 42