A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

The effect of conflicting versus consistent messaging on older women's support for breast cancer screening cessation

OBJECTIVE

Breast cancer over-screening is common in older women. Messaging about breast cancer screening cessation may reduce over-screening but the broader informational environment often emphasizes screening continuation. We aimed to examine the effect of receiving consistent messages about breast cancer screening cessation versus conflicting messages (i.e., receiving messages about screening cessation and screening continuation from different sources).

METHODS

In a two-wave survey experiment with 3809 women 65 + years from a U.S. population-based online panel, we randomized participants to a) no messages, b) consistent messages promoting screening cessation, or c) conflicting messages - a message promoting screening continuation followed by a message promoting screening cessation.

RESULTS

The conflicting message group had significantly lower support for screening cessation in a hypothetical older woman (mean 3.87 [SD 2.00] on 7-point scale, 95 % CI 3.76-3.97) compared with the consistent message group (mean 4.17 [SD 1.99], 95 % CI 4.08-4.28), but was still significantly higher than the control group (mean 2.68 [SD 1.87], 95 % CI 2.54-2.82, p's < 0.001). Message effects on self-screening intentions were similar. Participants reported low rates of confusion, distrust or ambivalence.

CONCLUSIONS

Messaging about screening cessation can significantly increase older women's support for screening cessation, with low rates of negative reactions, even if there are competing messages on continued screening.

PRACTICE IMPLICATIONS

Messaging about screening cessation can be incorporated into clinical discussions or used in conjunction with other interventions aimed at reducing over-screening.

Stakeholders' perceptions and experiences of factors influencing the commissioning, delivery, and uptake of general health checks: a qualitative evidence synthesis

BACKGROUND

General health checks are integral to preventive services in many healthcare systems. They are offered, for example, through national programmes or commercial providers. Usually, general health checks consist of several screening tests to assess the overall health of clients who present without symptoms, aiming to reduce the population's morbidity and mortality. A 2019 Cochrane review of effectiveness studies suggested that general health checks have little or no effect on either all-cause mortality, cancer or cardiovascular mortality or cardiovascular morbidity. These findings emphasise the need to explore the values of different stakeholder groups associated with general health checks.

OBJECTIVES

To identify how stakeholders (i.e. healthcare managers or policymakers, healthcare providers, and clients) perceive and experience general health checks and experience influencing factors relevant to the commissioning, delivery and uptake of general health checks. Also, to supplement and contextualise the findings and conclusions of a 2019 Cochrane effectiveness review by Krogsbøll and colleagues.

SEARCH METHODS

We searched MEDLINE (Ovid) and CINAHL (EBSCO) and conducted citation-based searches (e.g. reference lists, effectiveness review-associated studies and cited references in our included studies). The original searches cover the period from inception to August 2022. The results from the update search in September 2023 have not yet been incorporated.

SELECTION CRITERIA

We included primary studies that utilised qualitative methods for data collection and analysis. Included studies explored perceptions and experiences of commissioning, delivery and uptake of general health checks. Stakeholders of interest were healthcare managers, policymakers, healthcare providers and adults who participate (clients) or do not participate (potential clients) in general health checks. The general health check had to include screening tests for at least two diseases or risk factors. We considered studies conducted in any country, setting, and language.

DATA COLLECTION AND ANALYSIS

We applied a prespecified sampling frame to purposefully sample a variety of eligible studies. This sampling approach allowed us to capture conceptually rich studies that described the viewpoints of different stakeholder groups from diverse geographical regions and different settings. Using the framework synthesis approach, we developed a framework representing individual, intervention and contextual factors, which guided data extraction and synthesis. We assessed the methodological limitations of each study using an adapted version of the Critical Appraisals Skills Programme (CASP) tool. We applied the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess our confidence in each finding.

MAIN RESULTS

One hundred and forty-six studies met the inclusion criteria, and we sampled 36 of these for our analysis. While most of the studies were set in high-income countries in Europe, nearly a third (11/36) were set in culturally diverse middle-income countries across Eastern Europe, South and Southeast Asia, and Latin America. Sixteen sampled studies were conducted in primary and community healthcare settings, four in workplace settings and four in community settings. Included studies explored the perceptions and experiences of clients (n = 25), healthcare providers (n = 15) and healthcare managers or commissioners (n = 9). We grouped the findings at the individual level, intervention level and surrounding context. The findings at the individual level mainly reflect the client's perspective. General health checks helped motivate most clients to change their lifestyles. They were trusted to assess their health objectively, finding reassurance through professional confirmation (moderate confidence). However, those who feared negative results or relied on symptom-based care were more reluctant to attend (moderate confidence). Perceptions of disease, risk factors and prevention affected uptake (high confidence). Some clients felt an obligation to their families and society to maintain and improve their health through general health checks (moderate confidence). Healthcare providers played a crucial role in motivating participation, but negative experiences with unqualified providers discouraged attendance (moderate confidence). The availability and accessibility of general health checks and awareness systems played significant roles in clients' decision-making. Factors such as time and concerns that health insurance may not cover potential treatment costs influenced attendance (moderate confidence). The findings at the intervention level drew on the perspectives of all three stakeholder groups, with a strong focus on the healthcare provider's perspective. Healthcare providers and clients considered it essential that general health check providers were skilled and culturally competent (high confidence). Barriers to delivery included time competition with curative care, staff changes and shortages, resource limitations, technical issues, and reimbursement challenges (moderate confidence). Stakeholders thought innovative and diverse settings might improve access (moderate confidence). The evidence suggests that clients appreciated a comprehensive approach, with various tests. At the same time, healthcare providers deemed individualised approaches tailored to clients' health risks suitable, focusing on improving rather than abandoning general health checks (low confidence). The perspectives on the effectiveness of general health checks differed among healthcare commissioners, managers, providers, and clients (moderate confidence). Healthcare providers and clients recognised the importance of information, invitation systems, and educational approaches to create awareness of general health check availability and their respective advantages or disadvantages (moderate confidence). Clients considered explaining test results and providing recommendations as key elements of general health checks (low confidence). We have low or very low confidence in findings related to the contextual level and reasons for commissioning general health checks. The evidence suggests that cultural background, social norms, religion, gender, and language shape the perception of prevention and disease, thereby influencing the uptake of general health checks. Policymakers thought that a favourable political climate and support from various stakeholders are needed to establish general health checks.

AUTHORS' CONCLUSIONS

Despite the lack of effectiveness in the quantitative review, our findings showed that general health checks remain popular amongst clients, healthcare providers, managers and policymakers across countries and settings. Our data did not offer strong evidence on why these are commissioned, but it did point to these interventions being valued in contexts where general health checks have long been established. General health checks fulfil specific wants and needs, and de-implementation strategies may need to offer alternatives before a constructive debate can take place about fundamental changes to this widely popular or, at least, accepted service.

Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review

BACKGROUND

This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available.

METHODS

All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners). The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken.

RESULTS

A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making.

CONCLUSION

The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

Breast cancer screening among Medicare Advantage enrollees with dementia

BACKGROUND

The decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare.

METHODS

We conducted a pooled cross-sectional study of women with Alzheimer's disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid.

RESULTS

Mammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees.

CONCLUSIONS

Medicare beneficiaries age 65-74 with Alzheimer's disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer's disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.

Factors Influencing Primary Care Practitioners' Cancer Screening Recommendations for Older Adults: a Systematic Review

BACKGROUND

Primary care practitioners (PCPs) play a key role in cancer screening decisions for older adults (≥ 65 years), but recommendations vary by cancer type and jurisdiction.

PURPOSE

To examine the factors influencing PCPs' recommendations for breast, cervical, prostate, and colorectal cancer screening for older adults.

DATA SOURCES

MEDLINE, Pre-Medline, EMBASE, PsycINFO, and CINAHL, searched from 1 January 2000 to July 2021, and citation searching in July 2022.

STUDY SELECTION

Assessed factors influencing PCPs' breast, prostate, colorectal, or cervical cancer screening decisions for older adults' (defined either as ≥ 65 years or < 10-year life expectancy).

DATA EXTRACTION

Two authors independently conducted data extraction and quality appraisal. Decisions were crosschecked and discussed where necessary.

DATA SYNTHESIS

From 1926 records, 30 studies met inclusion criteria. Twenty were quantitative, nine were qualitative, and one used a mixed method design. Twenty-nine were conducted in the USA, and one in the UK. Factors were synthesized into six categories: patient demographic characteristics, patient health characteristics, patient and clinician psycho-social factors, clinician characteristics, and health system factors. Patient preference was most reported as influential across both quantitative and qualitative studies. Age, health status, and life expectancy were also commonly influential, but PCPs held nuanced views about life expectancy. Weighing benefits/harms was also commonly reported with variation across cancer screening types. Other factors included patient screening history, clinician attitudes/personal experiences, patient/provider relationship, guidelines, reminders, and time.

LIMITATIONS

We could not conduct a meta-analysis due to variability in study designs and measurement. The vast majority of included studies were conducted in the USA.

CONCLUSIONS

Although PCPs play a role in individualizing cancer screening for older adults, multi-level interventions are needed to improve these decisions. Decision support should continue to be developed and implemented to support informed choice for older adults and assist PCPs to consistently provide evidence-based recommendations.

REGISTRATION

PROSPERO CRD42021268219.

FUNDING SOURCE

NHMRC APP1113532.

Evaluating GPT as an Adjunct for Radiologic Decision Making: GPT-4 Versus GPT-3.5 in a Breast Imaging Pilot

OBJECTIVE

Despite rising popularity and performance, studies evaluating the use of large language models for clinical decision support are lacking. Here, we evaluate ChatGPT (Generative Pre-trained Transformer)-3.5 and GPT-4's (OpenAI, San Francisco, California) capacity for clinical decision support in radiology via the identification of appropriate imaging services for two important clinical presentations: breast cancer screening and breast pain.

METHODS

We compared ChatGPT's responses to the ACR Appropriateness Criteria for breast pain and breast cancer screening. Our prompt formats included an open-ended (OE) and a select all that apply (SATA) format. Scoring criteria evaluated whether proposed imaging modalities were in accordance with ACR guidelines. Three replicate entries were conducted for each prompt, and the average of these was used to determine final scores.

RESULTS

Both ChatGPT-3.5 and ChatGPT-4 achieved an average OE score of 1.830 (out of 2) for breast cancer screening prompts. ChatGPT-3.5 achieved a SATA average percentage correct of 88.9%, compared with ChatGPT-4's average percentage correct of 98.4% for breast cancer screening prompts. For breast pain, ChatGPT-3.5 achieved an average OE score of 1.125 (out of 2) and a SATA average percentage correct of 58.3%, as compared with an average OE score of 1.666 (out of 2) and a SATA average percentage correct of 77.7%.

DISCUSSION

Our results demonstrate the eventual feasibility of using large language models like ChatGPT for radiologic decision making, with the potential to improve clinical workflow and responsible use of radiology services. More use cases and greater accuracy are necessary to evaluate and implement such tools.

Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison

While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.

Evaluating ChatGPT as an Adjunct for Radiologic Decision-Making

BACKGROUND

ChatGPT, a popular new large language model (LLM) built by OpenAI, has shown impressive performance in a number of specialized applications. Despite the rising popularity and performance of AI, studies evaluating the use of LLMs for clinical decision support are lacking.

PURPOSE

To evaluate ChatGPT's capacity for clinical decision support in radiology via the identification of appropriate imaging services for two important clinical presentations: breast cancer screening and breast pain.

MATERIALS AND METHODS

We compared ChatGPT's responses to the American College of Radiology (ACR) Appropriateness Criteria for breast pain and breast cancer screening. Our prompt formats included an open-ended (OE) format, where ChatGPT was asked to provide the single most appropriate imaging procedure, and a select all that apply (SATA) format, where ChatGPT was given a list of imaging modalities to assess. Scoring criteria evaluated whether proposed imaging modalities were in accordance with ACR guidelines.

RESULTS

ChatGPT achieved an average OE score of 1.83 (out of 2) and a SATA average percentage correct of 88.9% for breast cancer screening prompts, and an average OE score of 1.125 (out of 2) and a SATA average percentage correct of 58.3% for breast pain prompts.

CONCLUSION

Our results demonstrate the feasibility of using ChatGPT for radiologic decision making, with the potential to improve clinical workflow and responsible use of radiology services.

"It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography

BACKGROUND

Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health.

METHODS

We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education).

RESULTS

Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation.

CONCLUSIONS

Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.