Organisational efforts to improve quality while reducing healthcare disparities: the case of breast cancer screening among Arab women in Israel.

OBJECTIVES (1) To improve quality and equity by increasing utilisation of mammography screening among Israeli Arab women. (2) To explore effectiveness of designing interventions with a combined top-down and bottom-up approach. DESIGN Retrospective study at two periods of time: 2004--intervention's preliminary stages; 2005--intervention's implementation. SETTING Maccabi Healthcare Services (MHS), an Israeli health plan serving 1.7 million members at study period; 7% of them are Arabs by 139 branches, 13 of which serve Arabs exclusively. MACRO-ORGANISATIONAL INTERVENTION (TOP DOWN): Development of a computerised Mammography Promotion System, phone contacts with non-respondents and intraorganisational reporting of screening rates. INTENSIVE INTERVENTION (BOTTOM UP): A local analysis of barriers to care and implementation of tailored solutions. This intervention was initiated and documented in three Arab branches, with spillover to the entire Arab sector. MEASURE DEFINITION: Biennial breast cancer (BC) screening of eligible women. Improvement measures Changes in BC screening rates in Arabs and comparisons with overall MHS BC screening rates for 2004 and 2005. RESULTS In 2005, average BC screening rates in Arab branches increased from 26.7% to 46.2% (73% improvement), while overall MHS screening rates increased from 49.0% to 63.1% (29% improvement). Analysis of the relative differences between 2004 and 2005 BC screening rates indicated statistically significant differences (p<0.006) in rates between the Arab and other branches. These results did not change after adjustment for branch size, region and branch average age. CONCLUSIONS Combined top-down interventions and bottom-up initiatives are effective for formulating programmes to reduce inequality.