Using individualised feedback to reduce recall rates from mammography screening

As part of the NHS Breast Screening Programme (NHSBSP), all women are invited for mammographic screening every three years between the ages of 50 and 70 years. Mammography involves use of an x-ray that aims to detect early signs of breast cancer. Around 4 out of 100 women are called back for additional imaging following screening mammography. Most women recalled are found not to have breast cancer. Being recalled can naturally provoke anxiety and it is important to avoid calling back too many women unnecessarily. However, this needs to be balanced with the risk of missing breast cancers.

Mammograms are examined (or ‘read’) by radiologists and radiographers who have undergone specialised training and continued assessment. Audits of mammography recall rates indicate that some readers tend to have higher recall rates whilst others tend to have lower recall rates. A recent improvement programme carried out in one mammography centre found that supporting individual mammography readers to review and reflect with a mentor on their individual practise using local data and reflecting on their own discrepant cases reduced mammography recall rates to an acceptable level.

Variations in recall rates in the Breast Screening Programme illustrates a common challenge in health care. Variations in the quality of health care cut across all healthcare systems and specialties. Some patients receive excellent care whilst others receive care which may fall below recommended standards. This is an important issue because it ultimately has a big impact on patient outcomes, experience and resource use. However, many healthcare professionals also struggle with concerns and uncertainty about whether the care they provide individually is good enough. Ideally, they would benefit from feedback on their performance. But there are practical problems. First, whilst individualised feedback can be reassuring and motivating, it can also be perceived as threatening and may not help improve care if badly delivered. Second, as most healthcare occurs within teams, it is often hard to gather and use data at an individual level. This PhD is about addressing these and other challenges to support individual health professionals in improving the quality of care they provide.

The availability and design of performance feedback has considerable potential to enhance “learning on the job” and support continuous development in professional practice. Although the need may be apparent, the practical challenges of establishing effective feedback within specific practice domains can be considerable and the required evidence-base dispersed across multiple disciplines, including medical education, psychology and implementation science.

The term ‘feedback’ is commonly used to describe the provision of knowledge of the results of behaviour or ‘knowledge of performance’. Within the psychological literature, for example, feedback has been defined as: “actions taken by external agents to provide information regarding some aspect of one’s task performance” and within healthcare, any “summary of clinical performance…over a specified period of time”. Synthesis of evidence from trials of audit and feedback in health care has identified small but potentially important improvements in professional practice. Furthermore, feedback was most effective when low baseline performance was present, it was delivered frequently, in multiple formats, including explicit targets and an action plan. Individualisation of feedback for healthcare professionals has been identified as important for actionable feedback and a marker of high performing medical centres. In practice, it is challenging to deliver given that much healthcare is delivered and assessed at team or organisational levels.

In response to calls for further research into the mechanisms or “active ingredients” of feedback interventions there is an opportunity to investigate the psychological mechanisms that may underpin improvement in personal professional practice resulting from enhanced feedback in naturalistic settings. Psychological theories of feedback, such as Control Theory, Feedback Intervention Theory and Goal Setting have historically been largely ignored in the design of audit and feedback trials in health care along with work psychology and human factors approaches that consider the role of feedback in the design of work and work systems. A robust system for learning from timely, individualised feedback on patient outcomes, may be particularly important in clinical settings requiring complex decision-making under conditions of uncertainty, such as mammography reading.

The aim of this PhD studentship is to investigate the mechanisms by which individualised feedback drives learning and improvement in mammography recalls using a mixed methods approach and multi-disciplinary perspective. There is considerable scope, for example, to test guidance for the design of effective feedback, developed from a multidisciplinary perspective. For example, what opportunities and resources exist for personalised feedback? What guidance/training should be provided to clinicians on how to receive and act upon feedback? How should the model for feedback be adapted according to clinical context and the stage of training or experience of clinicians? This thesis offers an opportunity to improve a key aspect of mammography services and hence improve experiences and outcomes for women who undergo screening.

Eligibility

You should hold a first degree equivalent to at least a UK upper second class honours degree, or suitable postgraduate degree in a health-related subject, psychology or social science. You will be enthusiastic, organised and motivated with experience in, or knowledge of healthcare services. Importantly, you will be committed to fully engaging with staff and patients and a wider multi-disciplinary team to conduct high-quality research that is of value to the NHS.

Candidates whose first language is not English must provide evidence that their English language is sufficient to meet the specific demands of their study. More details can be found here.

How to apply

Applicants should complete an online application form and attach the following documentation; 

• a full academic CV
• degree certificate and transcripts of marks
• Evidence that you meet the University's minimum English language requirements (if applicable).

To help us identify that you are applying for this scholarship project please ensure you provide the following information on your application form;

• Select PhD in Psychological Sciences as your programme of study
• Give the full project title and name the supervisors listed in this advert
• For source of funding please state you are applying for an NIHR funded scholarship