Who gets repeat screening mammography: the role of the physician

Patient and physician characteristics affect adherence to screening mammography: A population-based cohort study

BACKGROUND

Screening mammograms are widely recommended biennially for women between the ages of 50 and 74. Despite the benefits of screening mammograms, full adherence to recommendations falls below 75% in most developed countries. Many studies have identified individual (obesity, smoking, socio-economic status, and co-morbid conditions) and primary-care physician parameters (physician age, gender, clinic size and cost) that influence adherence, but little data exists from large population studies regarding the interaction of these individual factors.

METHODS

We performed a historical cohort study of 44,318 Israeli women age 56-74 using data captured from electronic medical records of a large Israeli health maintenance organization. Univariate analysis was used to examine the association between each factor and adherence (none, partial or full) with screening recommendations between 2008-2014. Multivariate analysis was used to examine the significance of these factors in combination, using binary and multinomial logistic regression.

RESULTS

Among 44,318 women, 42%, 43% and 15% were fully, partially and non-adherent to screening recommendations, respectively. Factors associated with inferior adherence identified in our population included: smoking, obesity, low body weight, low socio-economic status, depression, diabetes mellitus and infrequent physician visits, while, women with ischemic heart disease, female physicians, physicians between the ages of 40 and 60, and medium-sized clinics were associated with higher screening rates. Most factors remained significant in the multivariate analysis.

CONCLUSIONS

Both individual and primary-care physician factors contribute to adherence to mammography screening guidelines. Strategies to improve adherence and address disparities in mammography utilization will need to address these factors.

Competitive testing of health behavior theories: how do benefits, barriers, subjective norm, and intention influence mammography behavior?

BACKGROUND

Competitive hypothesis testing may explain differences in predictive power across multiple health behavior theories.

PURPOSE

We tested competing hypotheses of the Health Belief Model (HBM) and Theory of Reasoned Action (TRA) to quantify pathways linking subjective norm, benefits, barriers, intention, and mammography behavior.

METHODS

We analyzed longitudinal surveys of women veterans randomized to the control group of a mammography intervention trial (n = 704). We compared direct, partial mediation, and full mediation models with Satorra-Bentler χ (2) difference testing.

RESULTS

Barriers had a direct and indirect negative effect on mammography behavior; intention only partially mediated barriers. Benefits had little to no effect on behavior and intention; however, it was negatively correlated with barriers. Subjective norm directly affected behavior and indirectly affected intention through barriers.

CONCLUSIONS

Our results provide empiric support for different assertions of HBM and TRA. Future interventions should test whether building subjective norm and reducing negative attitudes increases regular mammography.

Performance of a fail-safe system to follow up abnormal mammograms in primary care

OBJECTIVES

Missed and delayed breast cancer diagnoses are major sources of potential harm to patients and medical malpractice liability in the United States. Follow-up of abnormal mammogram results is an essential but challenging component of safe breast care. To explore the value of an inexpensive method to follow up abnormal test results, we examined a paper-based fail-safe system.

METHODS

We examined a fail-safe system used to follow up abnormal mammograms at a primary care practice at an urban teaching hospital. We analyzed all abnormal mammogram reports and clinicians' responses to follow-up reminders. We characterized potential lapses identified in this system and used regression models to identify patient, provider, and test result characteristics associated with such lapses.

RESULTS

Clinicians responded to fail-safe reminders for 92% of 948 abnormal mammograms. Clinicians reported that they were unaware of the abnormal result in 8% of cases and that there was no follow-up plan in place for 3% of cases. Clinicians with more years of experience were more likely to be aware of the abnormal result (odds of being unaware per incremental year in practice, 0.92; 95% confidence interval, 0.88-0.97) and were more likely to have a follow-up plan.

CONCLUSIONS

A paper-based fail-safe system for abnormal mammograms is feasible in a primary care practice. However, special care is warranted to ensure full clinician adherence and address staff transitions and trainee-related issues.

An assessment of American Indian women's mammography experiences

BACKGROUND

Mortality from breast cancer has increased among American Indian/Alaskan Native (AI/AN) women. Despite this alarming reality, AI/AN women have some of the lowest breast cancer screening rates. Only 37% of eligible AI/AN women report a mammogram within the last year and 52% report a mammogram within the last two years compared to 57% and 72% for White women. The experiences and satisfaction surrounding mammography for AI/AN women likely are different from that of women of other racial/ethnic groups, due to cultural differences and limited access to Indian Health Service sponsored mammography units. The overall goals of this study are to identify and understand the mammography experiences and experiential elements that relate to satisfaction or dissatisfaction with mammography services in an AI/AN population and to develop a culturally-tailored AI/AN mammography satisfaction survey.

METHODS AND DESIGN

The three project aims that will be used to guide this work are: 1) To compare the mammography experiences and satisfaction with mammography services of Native American/Alaska Native women with that of Non-Hispanic White, Hispanic, and Black women, 2) To develop and validate the psychometric properties of an American Indian Mammography Survey, and 3) To assess variation among AI/AN women's assessments of their mammography experiences and mammography service satisfaction. Evaluations of racial/ethnic differences in mammography patient satisfaction have received little study, particularly among AI/AN women. As such, qualitative study is uniquely suited for an initial examination of their experiences because it will allow for a rich and in-depth identification and exploration of satisfaction elements.

DISCUSSION

This formative research is an essential step in the development of a validated and culturally tailored AI/AN mammography satisfaction assessment. Results from this project will provide a springboard from which a maximally effective breast cancer screening program to benefit AI/AN population will be developed and tested in an effort to alter the current breast cancer-related morbidity and mortality trajectory among AI/AN women.

Does health status influence intention regarding screening mammography?

OBJECTIVE

We analyzed information surveyed from a community-based sample of Korean women older than 40 years of age to understand the relationships between health status and screening behavior.

METHODS

In a cross-sectional population-based study, a two-stage, geographically stratified household-based sampling design was used for assembly of a probability sample of women aged 40-69 years living in Gunpo in Korea, resulting in a total sample size of 503 women. The primary outcome variable for this analysis was the respondent's intention to obtain a mammogram. Predictor variables included health status and other factors known to influence the use of cancer screening, such as age, education, income, marital status and the presence of co-morbid illnesses. Health status was assessed by using the EuroQol (EQ-5D).

RESULTS

The median EQ visual analogue scale score was 75.0, ranging from 20 to 100. In bivariate analyses, the percentage of women reporting to have intention toward mammography use decreased with worsening health status. Women who had problems with mobility or anxiety/depression showed lower intention to undergo future screening mammography. Multivariate logistic regression confirmed that health status was significantly associated with intention toward mammography use. Anxiety or depression was an independent predictor of future screening mammography use.

CONCLUSIONS

Health status is significantly associated with intention regarding screening mammography use. Physicians or other health professionals should be aware that health status is an important component for health promotion, and should pay more attention to clients' possible vulnerability in screening mammography use due to their poor health status.

Correlates of repeat and recent mammography for women ages 45 to 75 in the 2002 to 2003 Health Information National Trends Survey (HINTS 2003)

BACKGROUND

Most national-level mammography data are for ever-had and most-recent screening. There are few national-level data on rates of repeat, on-schedule mammography, and on the prevalence and correlates of repeat mammography. It is also important to investigate the similarity of correlates for repeat and recent mammography.

METHODS

Analyses were from data for women ages 45 to 75 in the 2002 to 2003 Health Information and National Trends Survey (HINTS 2003; N = 1,581). The two dependent variables were self-report of repeat mammography (two exams on schedule, based on an every-other-year interval) and recent mammography only (one mammogram within the past 2 years).

RESULTS

The prevalence of recent mammography was 81.6% (95% confidence interval, 79.1-84.1) and for repeat mammography was 72.2% (95% confidence interval, 69.0-75.4). An access to care variable combining insurance coverage and regular source of care was the strongest sociodemographic correlate of both mammography indicators. Most other sociodemographic variables were not associated with mammography status. Five psychosocial/behavioral variables were associated with both mammography indicators (smoking status, attention to health information, knowledge of screening interval, worry about breast cancer, and recent mood status). Correlates were very similar for repeat and recent mammography.

CONCLUSIONS

Although access to care had the strongest association with mammography, psychosocial and behavioral variables did better as a group than the sociodemographic variables. A standard set of such variables should be considered for all national surveys.

Case-Finding for Depression Among Medical Outpatients in the Veterans Health Administration

OBJECTIVES

We sought to determine the rates and predictors of screening, screening positive, follow-up evaluation, and subsequent diagnosis of depression among medical outpatients.

RESEARCH DESIGN

This was a cross-sectional study using chart-review data from the Department of Veterans Affairs (VA) 2002 External Peer Review Program merged with administrative data.

SUBJECTS AND MEASURES

We studied a national sample of VA medical outpatients with no depression diagnosis or mental health visits in the past 6 months (n = 21,489) and used chart-review and administrative data to follow the chain of events from depression screening to diagnosis.

RESULTS

Overall, 84.9% of eligible patients (n = 18,245) were screened for depression in the past year. Of the 8.8% who screened positive, only 54.0% received follow-up evaluation and, of these, 23.6% (n = 204) subsequently were diagnosed with a depressive disorder (representing 1.1% of the originally screened sample). Patients who were younger, unmarried, and had more medical comorbidities were less likely to be screened; however, if screened, they were more likely to screen positive. Male gender and greater medical comorbidity were associated with decreased odds of follow-up evaluation after a positive screen. At the facility level, likelihood of depression screening was inversely associated with spending on teaching and research but positively associated with spending on mental health care.

CONCLUSIONS

VA's depression case-finding activities yielded relatively few positive cases, raising questions about cost-effectiveness. Targeted strategies may increase the value of case-finding among patients at greatest risk for depression and at more academically affiliated medical centers. Targeted efforts also are needed to ensure proper follow-up evaluation of suspected cases, particularly among male patients and those with increased medical comorbidity.

Mammography utilization in Canadian women aged 50 to 69: identification of factors that predict initiation and adherence

OBJECTIVE

To identify factors that predict initiation of mammography and adherence with biennial screening among Canadian women aged 50-69 years.

METHODS

Using data from a longitudinal panel of Canadian women interviewed in the National Population Health Survey (NPHS) in 1994/95 and 2 and 4 years later, we estimated the relative risks (RR) of mammography initiation and adherence according to socio-demographic, health and lifestyle characteristics.

RESULTS

Among 505 women with no history of mammography use at baseline, 23.0% and 41.4% initiated mammography by 2 and 4 years, respectively. Urban residence (RR = 2.85) was most strongly associated with initiation by 2 years; younger age (50-54) and lower education also predicted initiation by 2 years. Younger age, birthplace outside Canada, and having a recent (< 2 years) blood pressure check were associated with initiation by 4 years. Among 873 women reporting a recent (< 2 years) mammogram at baseline, 88.7% also reported a recent mammogram within 2 years while 73.0% reported one at both the 2- and 4-year follow-up. Being a non-smoker was the strongest predictor of maintaining adherence both at the 2- (RR = 1.18) and the 4-year (RR = 1.37) follow-up.

INTERPRETATION

Previously identified underserved groups of Canadian women (e.g., those with lower educational levels or born outside of Canada) were most likely to initiate mammography. Approximately 1 in 6 women aged 50 to 69 years remained never-users during follow-up, and fewer than half reported recent mammograms at all three survey cycles, suggesting the need to reinforce regular screening participation.

Measuring Sustained Mammography Use By Urban African-American Women

Although the numbers of African-American women who are 'ever' screened for breast cancer has increased, sustaining regular screening over a lifetime remains a problem. Face-to-face interviews about breast cancer screening were conducted with 576 African-American women from an east coast city. The well-screened index measuring adherence to breast cancer screening guidelines was developed and tested. This index incorporated a woman's past and present use of mammography plus her future intent to be screened. Respondents were dichotomized into well-screened and not well-screened groups. Social and psychological factors associated with sustained screening as measured by this index were then explored. In bivariate analyses, education, health insurance, usual source of care, chronicity and preference for provider ethnicity and gender were significantly different for the two groups. In the multivariate model, women who were well-screened were significantly more likely to report recent physician contact, Pap smear, dental visit, history of breast problems, and beliefs that screening should be done annually and that early detection improves outcomes. Women reporting poor health were less likely to be well-screened. The well-screened index can potentially be used for assessment by clinicians and for program evaluation; however further validation studies need to be conducted. Despite limited resources, the majority of these urban African-American women are building lifetime patterns of regular breast cancer screening. Focused efforts are needed to achieve sustained screening patterns in the 25% who are not regularly screened.

Repeat mammography: Prevalence estimates and considerations for assessment

Despite recent controversies in mammography efficacy, encouraging women to obtain regular screenings is still an important public health priority. Published articles about repeat or regular screening were reviewed to determine trends in rates of mammography adherence. A search of MEDLINE and PsycINFO from January 1990 to December 2001 identified 45 empirical articles of U.S. samples that reported, or provided sufficient data to calculate, the percentage of women 50 years of age and older who obtained 2 or more consecutive, on-schedule mammograms. Keywords used in the searches included pairing mammography with regular, repeat, adherence, compliance, annual, rescreen, and maintenance. The weighted average repeat mammography percentage across all eventually included studies (N = 37) was 46.1% (confidence interval: 39.4%, 52.8%). There was no substantial difference in the average repeat screening percentages comparing studies that collected data from 1995 to 2001 versus 1991 to 1994. Within each of 3 time periods of data collection (pre-1991, 1991-1994, 1995-2001), there was substantial variation in repeat rates. This variation appears to be due to several characteristics of study design and sampling, including the definition/methods of collecting data about the adherence measure, prior mammography status, and use of an upper age limit at recruitment. Consensus is needed regarding the definition of repeat mammography. National surveys must include items to assess repeat mammography in order to have estimates that accurately represent population-level rates. Although this study involved mammography, similar challenges in assessing prevalence rates can occur with other screening behaviors.

The effect of a stage-matched and tailored intervention on repeat mammography(1)

BACKGROUND

Our objective was to determine whether a tailored, stage-matched educational intervention, guided by the transtheoretical model (TTM), would increase rates of repeat-screening mammography. DESIGN SETTING/PARTICIPANTS: A total of 1324 women (N=1026 after attrition) aged 50 to 74 years were recruited from a staff-model health maintenance organization. Some of the women were not due for mammograms at the time of recruitment.

INTERVENTION

Women were randomly assigned to one of three intervention conditions: Group 1, no educational materials (usual care); Group 2, standard materials; and Group 3, stage-matched/tailored materials. Women in Groups 2 and 3 received a mailed education packet after both a baseline and a follow-up telephone interview. All women in Group 2 received the same materials regardless of differences in baseline mammography-related attitudes and behaviors. Each woman in Group 3 received materials based on her stage of adoption for mammography and TTM constructs.

MAIN OUTCOME

Using clinical records, repeat screening was defined as receipt of a second mammogram within 14 months after obtaining an initial postbaseline mammogram.

RESULTS

Women in Group 3 were more likely to obtain repeat-screening mammograms than women in Group 1 (44.2% vs 35.8%; adjusted rate ratio = 1.29, 95% confidence interval [CI]=1.11-1.46; adjusted rate difference = 0.06, 95% CI=-0.01-0.13). The screening percentage in Group 2 was intermediate (39.3%), and did not differ from either Group 3 or Group 1.

CONCLUSIONS

The effect of the stage-matched/tailored intervention was sustained for repeat screening, although no educational materials were delivered to coincide with the timing for a second mammogram. However, the stage-matched/tailored intervention was not sufficient to have a substantial impact on screening beyond the effect of standard educational materials. Future interventions may need to administer "booster" sessions to increase repeat screenings.

Breast and cervical cancer screening among women with physical disabilities

OBJECTIVE

This article reports findings from the National Study of Women with Physical Disabilities about rates of screening for breast and cervical cancer and factors associated with regular screening in a large sample of women with a variety of physical disabilities and a comparison group of women without disabilities.

DESIGN

Case-comparison study using written survey. Data were analyzed using measures of central tendency, chi 2 analysis, logistic regression, and risk using odds ratios.

SETTING

General community.

PARTICIPANTS

A total of 843 women, 450 with disabilities and 393 of their able-bodied friends, aged 18 to 65, who completed the written questionnaire. The most common primary disability type was spinal cord injury (26%), followed by polio (18%), neuromuscular disorders (12%), cerebral palsy (10%), multiple sclerosis (10%), and joint and connective tissue disorders (8%). Twenty-two percent had severe functional limitations, 52% had moderate disabilities, and 26% had mild disabilities.

MAIN OUTCOME MEASURES

Outcomes were measured in terms of frequency of pelvic exams and mammograms.

RESULTS

Women with disabilities tend to be less likely than women without disabilities to receive pelvic exams on a regular basis, and women with more severe functional limitations are significantly less likely to do so. No significant difference was found between women with and without disabilities, regardless of severity of functional limitation, in receiving mammograms within the past 2 years. Perceived control emerged as a significant enhancement factor for mammograms and marginally for pelvic exams. Severity of disability was a significant risk factor for noncompliance with recommended pelvic exams, but not mammograms. Race was a significant risk factor for not receiving pelvic exams, but not mammograms. Household income and age did not reach significance as risk factors in either analysis.

CONCLUSIONS

Women with physical disabilities are at a higher risk for delayed diagnosis of breast and cervical cancer, primarily for reasons of environmental, attitudinal, and information barriers. Future research should focus on the subpopulations that were not surveyed adequately in this study, women with disabilities who have low levels of education or income, or who are of minority status.