Mammography screening rates decline: a person-time approach to evaluation

OBJECTIVES: Early detection through mammography can reduce breast cancer mortality. This cohort study evaluated trends in mammography screening, demonstrating a person-time approach. METHODS: Included were women HMO members aged 50-69 from 1999 to 2002 who had not had breast cancer, dysplasia, fibrocystic disease, or implant. The amount of person-time covered by mammography as a percent of the time eligible for mammography screening (the prevention index (PI)) was calculated using electronic data. The denominator was the time during which the guidelines recommended that each participant should have been covered by a mammogram (every 24 months), excluding times when breast mass, abnormal mammogram, galactorrhea, or other breast disorders were under evaluation. The numerator was the time during which she was covered by a mammogram. RESULTS: The number of women who contributed person-time increased from 43,283 to 49,512 and the number of screening mammograms declined from 23,586 to 22,719. The overall PI for screening mammography declined from 67.0 (67% of eligible person-time was appropriately covered by a mammogram) to 62.5, and the proportion of women with no coverage during a given year increased 16%. CONCLUSIONS: This study shows a declining pattern of mammography screening using a person-time approach, a decline greater than that shown by methods that include diagnostic mammograms. The study highlights opportunities for use of the PI and quality improvement initiatives to improve breast cancer outcomes.     

Mammography rates for 20 community-based family practices in Ontario: a full practice audit

BACKGROUND: Many Canadian women 50 to 69 years of age do not have a mammogram within the recommended screening interval of every two years. Recent data suggest that over 50% of Canadian women did not have a time-appropriate mammogram and that not having a family physician was a significant factor associated with suboptimal screening. This study reviewed medical charts of 20 family physicians' practices to examine their mammography screening patterns. METHODS: Medical charts of all women between 52 and 71 years of age in 20 family practices were examined for mammography reports between September 2003 and June 2004. RESULTS: Across the 20 practices, 3,430 charts of eligible women 52 to 71 years of age were reviewed (mean per practice = 173 women; ranging from 38 to 385). The two-year time-appropriate mammography rate was 58.8%. The screening rates ranged from 25% to 76% across 20 practices. Four practices attained a 70% or greater time-appropriate screening rate. When we extended the time-appropriate frame to 36 months, the overall mammography rate increased to 70.0%. Practice size, method of remuneration for patient care, use of an electronic medical record, gender or age of physician, practice setting, use of Ontario Breast Screening Program (OBSP) were not found to be significantly associated with mammography screening rates. INTERPRETATION: Mammography rates within the recommended two-year interval for women who have a regular family physician are suboptimal. The rates for women in this study, all of whom have a family physician, were only slightly higher than those reported elsewhere for women without one. Further studies are required to uncover and overcome barriers to optimal mammography screening rates.     

Improving mammography recommendation: a nurse-initiated intervention

We attempted to improve our compliance with recommendations for screening mammography, according to the American Cancer Society (ACS) guidelines, for eligible women patients seen by family practice residents by using a multipart intervention designed to eliminate identified barriers of knowledge and behavior on the part of the residents. Copies of the ACS cancer screening guidelines were posted in all examination and conference rooms and were provided to all residents. The intervention addressing the behavioral barriers had three components: (1) identification by the nursing staff of eligible women who were overdue for a mammogram as they presented for care, (2) completion of a checklist by residents indicating whether a mammogram was or was not recommended and why, and (3) a nurse-initiated backup reminder system for patients who escaped the primary checklist system. An audit of 200 preintervention and 270 postintervention charts showed statistically and clinically significant increases in mammograms recommended or done. Similar statistically significant increases were found in a cohort of 111 charts of patients in both the pre- and the postintervention audits. Results indicate that an intervention designed to eliminate identified resident-dependent barriers to compliance with screening mammography guidelines can be effective in increasing recommended mammography rates.     

A two-step intervention of increase mammography among women aged 65 and older.

OBJECTIVES: This study evaluated a two-step intervention for mammography screening among older women. METHODS: Four hundred and sixty women, identified from physician practices, were randomized to a control or a two-step intervention (physician letter and peer counseling call) group. Women in the intervention group who obtained a mammogram received a grocery coupon. RESULTS: Over the 12 months of the study, more women in the intervention group than in the control group obtained mammograms (38% vs 16%). The most dramatic difference was in the higher odds that women in the intervention group would obtain a mammogram within 2 months (odds ratio = 10.5). CONCLUSIONS: The intervention significantly increased screening mammography. Future efforts must be multifaceted and incorporate the unique concerns of older women.     

Office Systems and Their Influence on Mammography Use in Rural and Urban Primary Care

CONTEXT: Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention. PURPOSE: Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization. METHODS: We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems. FINDINGS: Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets. CONCLUSIONS: Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.     

Mammography facility characteristics and repeat mammography use among Medicare beneficiaries

BACKGROUND: The goal of this study was to examine mammography facility characteristics and explore how such characteristics may impact repeat mammography use. METHODS: Mammography facility characteristics were obtained through a mailed a 21-item survey to Kansas mammography facilities. Medicare mammography claims were used to calculate facility-specific repeat mammography rates. Administrative data included female Kansas beneficiaries aged 65 years and older (N = 39,035) with a baseline mammogram during 1999. Beneficiaries with a mammography claim 12-18 months after their baseline mammogram were deemed to have had a repeat mammogram. RESULTS: Completed surveys were received from 90% (N = 79) of the 97 facilities serving >10 beneficiaries. Most facilities were in rural communities (58%), had an on-site radiologist (58%), and mailed mammography reminders to patients (63%). Extended hours of operation and the acceptance of self-referrals were uncommon (33% and 37%, respectively). Few facilities employed a quality improvement team (33%) or measured annual patient return rates (18%), but many measured patient satisfaction (57%). Of the beneficiaries, 61% had a repeat mammogram during the subsequent 12-18 months (range, 0% to 84%). Facilities notifying primary care providers of patients due for mammograms had higher repeat mammography rates. Multiple regression analyses found that higher repeat mammography rates were associated with facilities that accepted self-referrals, measured patient satisfaction, were in urban areas, and served a larger proportion of white beneficiaries. CONCLUSION: Mammography facility characteristics and repeat mammography rates vary widely. Although modifiable facility characteristics that may influence repeat mammography need additional study, results from this study indicate that mammography facilities are an opportunistic arena for quality improvement endeavors.     

A study of breast cancer detection practices and beliefs in black women attending public health clinics

In this study, breast cancer knowledge, beliefs and practices in low income black women were examined. First, focus groups were held with a total of 33 participants. Information gathered from the focus groups was used to develop a telephone survey which was partially based on the Health Belief Model (HBM) and administered to 92 subjects. Utilization rates of mammography and breast self-examination (BSE) were quite high; 66.3% of survey participants reported having at least one mammogram and 72.5% performed BSE. Because low-cost mammograms were available to the survey participants, these results suggest that women in this target population will utilize accessible and affordable mammograms. Several knowledge deficiencies that need to be addressed were also identified. Most of the health beliefs were not significantly associated with mammography or BSE utilization. Because the HBM has never been extensively tested on this population, its appropriateness as a behavior model for low-income women is examined. Implications for future research and interventions are discussed.     

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.     

Organizational Change: A Way to Increase Colon, Breast and Cervical Cancer Screening in Primary Care Practices

Screening tests for colon, cervical and breast cancer remain underutilized despite their proven effectiveness in reducing morbidity and mortality. Stone et al. concluded that cancer screening is most likely to improve when a health organization supports performance through organizational changes (OC) in staffing and clinical procedures. OC interventions include the use of separate clinics devoted to prevention, use of a planned care visit, designation of non-physician staff for specific prevention activities and continuous quality improvement interventions. Objectives To identify specific elements of OC interventions that increases the selected cancer screening rates. To determine to which extent practices bought into the interventions. Methods Eleven randomized controlled trials from January 1990 to June 2010 that instituted OC to increase cancer screening completion were included. Qualitative data was analyzed by using a framework to facilitate abstraction of information. For quantitative data, an outcome of measure was determined by the change in the proportion of eligible individuals receiving cancer screening services between intervention and control practices. The health prevention clinic intervention demonstrated a large increase (47%) in the proportion of completed fecal occult blood test; having a non-physician staff demonstrated an increase in mammography (18.4%); and clinical breast examination (13.7%); the planned care visit for prevention intervention increased mammography (8.8%); continuous quality improvement interventions showed mixed results, from an increase in performance of mammography 19%, clinical breast examination (13%); Pap smear (15%) and fecal occult blood test (13%), to none or negative change in the proportion of cancer screening rates. Conclusions To increase cancer screening completion goals, OC interventions should be implemented tailored to the primary care practice style. Interventions that circumvent the physicians were more effective. We could not conclude whether or not continuous quality techniques were effective. Further research is needed to evaluate cost-effectiveness of these interventions.     

Test-retest reliability of self-reported mammography in women veterans

BACKGROUND: Mammography self-report is used to monitor screening and evaluate intervention trends; however, few studies have examined reliability. METHODS: Reliability of self-reported lifetime number of mammograms, most recent mammogram date, and predictors of reliability were assessed using data from Project H.O.M.E. The study population was 2,494 women 52 years and over, listed in the U.S. National Registry of Women Veterans, with no history of breast cancer, who completed both baseline (2000-2002) and year 1 (2002-2003) surveys. RESULTS: Reliability of lifetime number of mammograms was 60.9% for exact consistency and 79.9% for consistency within one mammogram. Thirty-five percent was exactly consistent in reporting mammogram date; 55.6% was consistent within 3 months. Completing both surveys by mail and reporting fewer lifetime mammograms at baseline were positively associated with consistency of reporting lifetime number. White race/ethnicity, having a Bachelor's degree, reporting a health care provider's recommendation for a mammogram, having a screening mammogram, completing both surveys by mail, and being in the maintenance or action stages of change were associated with consistency in reporting date. CONCLUSIONS: Reliability varies with the measure of self-reported mammography. Likewise, predictors show different patterns of association with different definitions. Our findings call attention to the need for explicit definitions and measures of mammography use.     

Patient navigation to improve breast cancer screening in Bosnian refugees and immigrants

Refugee women have low breast cancer screening rates. This study highlights the culturally competent implementation and reports the outcomes of a breast cancer screening patient navigation program for refuge/immigrant women from Bosnia. Refugees/immigrant women from Bosnia age 40–79 were contacted by a Serbo-Croatian speaking patient navigator who addressed patient-reported barriers to breast cancer screening and, using individually tailored interventions, helped women obtain screening. The proportion of women up-to-date for mammography was compared at baseline and after 1-year using McNemar’s Chi-Square test. 91 Serbo-Croatian speaking women were eligible for mammography screening. At baseline, 44.0% of women had a mammogram within the previous year, with the proportion increasing to 67.0% after 1-year (P = 0.001). A culturally-tailored, language-concordant navigator program designed to overcome specific barriers to breast cancer screening can significantly improve mammography rates in refugees/immigrants.     

Tailored interventions to promote mammography screening: a meta-analytic review

OBJECTIVE: To evaluate the effectiveness of tailored interventions, designed to reach one specific person based on her unique characteristics, for promoting mammography use. METHOD: This systematic review used meta-analytic techniques to aggregate the effect size of 28 studies published from 1997 through 2005. Potential study-level moderators of outcomes (sample, intervention, and methodological characteristics) were also examined. RESULTS: A small but significant aggregate odds ratio effect size of 1.42 indicated that women exposed to tailored interventions were significantly more likely to get a mammogram (p<0.001). The type of population recruited and participants' pre-intervention level of mammography adherence did not significantly influence this effect. Tailored interventions that used the Health Belief Model and included a physician recommendation produced the strongest effects. Interventions delivered in person, by telephone, or in print were similarly effective. Finally, defining adherence as a single recent mammogram as opposed to regular or repeated mammograms yielded higher effect sizes. CONCLUSION: Tailored interventions, particularly those that employ the Health Belief Model and use a physician recommendation, are effective in promoting mammography screening. Future investigations should strive to use more standardized definitions of tailoring and assessments of mammography outcomes.     

Measuring the performance of screening mammography in community practice with Medicare claims data

BACKGROUND: Few studies have examined the outcomes of screening mammography in community practice, particularly the extent of false positive exams among older asymptomatic women. RESEARCH DESIGN: Subjects were female Medicare beneficiaries, age 67 or older, residing in one of eleven SEER areas, with no evidence of breast cancer. Medicare claims data were used to identify their screening mammograms over two time periods, 1993-1995 and 1996-1998, and to measure their use of follow-up diagnostic testing (diagnostic mammography, breast ultrasound and breast biopsy) within three months of the screening mammogram. RESULTS: There were significant differences among the rates of diagnostic testing for each age group (67-74; 75+ ) by year, but no clear trend toward higher or lower rates over time. Although rates of diagnostic testing differed significantly by geographic region in both time periods 1993-1995 and 1996-1998, estimates of specificity for all regions were within AHRQ clinical practice guidelines (specificity greater than 90%). Specificity significantly improved with the volume of the radiologist's practice for the latter time period (1996-1998) but not for the former (1993-1995). CONCLUSION: Medicare claims offer an accessible population-based source of data for mammography performance indicators. As such, they offer a low cost method for evaluating individual mammography practices as well as monitoring the impact of reimbursement policies, practice guidelines and laws mandating requirements for accrediting facilities.     

Repeat mammography among women over 50 years of age.

Mammography decreases mortality among women 50 years of age and older. Although recent surveys show that mammography use has increased since 1983, it continues to be underused by women at risk for breast cancer. The frequency of repeat screening at recommended intervals remains an important unanswered question. This record audit study included all visits from 1986 to 1988 for active female patients, 51-64 years of age, in a family medicine practice. The practice has a disproportionately black patient population, many of whom are on public assistance, characteristics associated with lower compliance with cancer screening guidelines. I reviewed medical records for a physician's recommendation for mammography and also for a radiology report documenting receipt of the mammogram. I also abstracted from the medical record the reason for mammography, a history of breast cancer risk factors, and sociodemographic information. In addition, I noted documentation of a clinical breast examination (CBE) and CBE results. Records for 150 patients were included in the analysis. The results indicate that repeat screening mammography is not common: 3% had three mammograms during the study period; 19% had two; 33% had one; and 44% had none. Physician recommendation for first-time mammography and clinical examination occurred with low frequency. As others report, mammography use is strongly associated with physician recommendation for a mammogram.     

Comparison of tailored interventions to increase mammography screening in nonadherent older women

BACKGROUND: Recent increases in mammography use have led to a decrease in mortality from breast cancer. METHODS: Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter. RESULTS: All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%. CONCLUSIONS: All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions.     

Tailored risk notification for women with a family history of breast cancer

BACKGROUND: Evidence indicates that although first-degree relatives of breast cancer cases are at increased risk of developing the disease themselves, they may be underutilizing screening mammography. Therefore, interventions to increase the use of mammography in this group are urgently needed. METHODS: A randomized two-group design was used to evaluate an intervention to increase mammography use among women (N = 901) with at least one first-degree relative with breast cancer. A statewide cancer registry was used to obtain a random sample of breast cancer cases who identified eligible relatives. The mailed intervention consisted of personalized risk notification and other theoretically driven materials tailored for high-risk women. RESULTS: An overall significant intervention effect was observed (8% intervention group advantage) in mammography at post-test. There was an interaction of the intervention with age such that there was no effect among women <50 years of age and a fairly large (20% advantage) effect among women 50+ and 65+. Health insurance, education, and having had a mammogram in the year before baseline assessment were positive predictors of mammography at post-test. Perceived risk, calculated risk, and relationship to index cancer case were not associated with mammography receipt. CONCLUSION: The intervention was successful in increasing mammography rates among high-risk women 50+ years of age. Further work is needed to determine why it was ineffective among younger women.     

Cost-effectiveness comparison of five interventions to increase mammography screening

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography. METHODS: There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness. RESULTS: Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened. CONCLUSIONS: A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.     

Improving access to mammograms through community-based influenza clinics. A quasi-experimental study

BACKGROUND: It is a national priority to increase breast-cancer screening among women aged > or = 50. Annual influenza clinics may represent an efficient setting in which to promote breast-cancer screening among older women. To our knowledge, this possibility has not previously been explored. OBJECTIVE: To examine whether offering women attending community-based influenza clinics the opportunity to receive a scheduling telephone call from a mammography facility will result in an increase in the number of mammograms performed over a 6-month period. METHODS: We used a quasi-experimental design with 6-month follow-up. A contemporaneous population-based survey provided a further control group for comparison. The sample group consisted of a total of 284 women attending nine community-based influenza clinics in a semirural county in Connecticut. All women were aged > or = 50 and reported no mammogram in the preceding 12 months. All women received informational literature on mammography. Experimental subjects were each asked if a radiology facility chosen by the subject could call her at home to schedule a mammogram. Mammograms performed were determined by hospital record for participants who received a scheduling call from a radiology facility, and by self-report for all other participants. RESULTS: Mammography use following access through influenza clinics was approximately twice that of women attending influenza clinics where access to mammography was not offered. Using three different assumptions regarding participants whose mammography status was unknown, the relative risks ranged between 1.6 and 2.1. For each assumption the results were statistically significant (chi(2)=8.51-12.2; p<0.001). CONCLUSIONS: Linking access to mammography at community-based influenza clinics can significantly increase the use of mammograms among women aged > or = 50. Further studies should seek to confirm these findings and determine the degree to which they can be replicated in a variety of communities. Enhancing preventive health practice through the bundling of services suggests a new strategy to exploit available interventions to improve health.     

Mammography-facility-based patient reminders and repeat mammograms for Medicare in New York State

BACKGROUND: Women who receive mammograms may fail to regularly return for repeat mammography. Many mammography facilities send annual patient reminders, but there are no large studies of their impact on overall mammography return rates, or by patient population subgroups. METHODS: Medicare claims data were used to identify New York women with claims for mammograms during a baseline and an 18-month follow-up period (1999-2000). Receipt of a second mammogram was examined in relation to whether the facility sends annual reminders, while controlling for other patient factors. RESULTS: Of 97,506 women studied, 76% attended facilities that send annual reminders. Of these women, 74% received a second mammogram within 18 months compared to 67% for other women. The impact of reminders was significant in all subgroups, but was less for women who were younger, minority, in Medicaid, in New York City or who received a diagnostic mammogram. In multivariate analysis, the adjusted odds ratio for return within 18 months if the facility uses reminders was 1.42 (95% CI 1.37-1.47). CONCLUSIONS: Annual patient reminders from mammography facilities are effective in increasing regular repeat mammography in Medicare women, although their impact is smaller in some groups. Facilities that do not currently send reminders should be encouraged to do so.