Beliefs and expectations of women under 50 years old regarding screening mammography

OBJECTIVE: Because shared decision making has been recommended for screening mammography by women under age 50, we studied women's decision-making process regarding the procedure. DESIGN: Qualitative research design using in-depth semi-structured interviews. PATIENTS: Sixteen white and African-American women aged 38 to 45 receiving care at a large New England medical practice. MEASUREMENTS AND MAIN RESULTS: We identified the following content areas in women's decision-making process: intentions for screening, motivating factors to undergo screening, attitudes toward screening mammography, attitudes toward breast cancer, and preferences for information and shared decision making. In our sample, all women had or intended to have a screening mammogram before age 50. They were motivated by the awareness of the recommendation to begin screening at age 40, knowing others with breast cancer, and a sense of personal responsibility for their health. Participants feared breast cancer and thought the benefits of screening mammography far outweighed its risks. Women's preferences for involvement in decision making varied from wanting full responsibility for screening decisions to deferring to their medical providers. All preferred the primary care provider to be the main source of information, yet the participants stated that their own providers played a limited role in educating them about the risks and benefits of screening and the mammography procedure itself. Most of their information was derived from the media. CONCLUSIONS: The women in this study demonstrated little ambivalence in their desire for mammography screening prior to age 50. They reported minimal communication with their medical providers about the risks and benefits of screening. Better information flow regarding mammography screening is necessary. Given the lack of uncertainty among women's perceptions regarding screening mammography, shared decision making in this area may be difficult to achieve.     

A randomized trial of three videos that differ in the framing of information about mammography in women 40 to 49 years old

OBJECTIVE: To assess the effect of providing structured information about the benefits and harms of mammography in differing frames on women's perceptions of screening. DESIGN: Randomized control trial. SETTING: General internal medicine academic practice. PARTICIPANTS: One hundred seventy-nine women aged 35 through 49. INTERVENTION: Women received 1 of 3 5-minute videos about the benefits and harms of screening mammography in women aged 40 to 49. These videos differed only in the way the probabilities of potential outcomes were framed (positive, neutral, or negative). MEASUREMENTS AND MAIN RESULTS: We measured the change in accurate responses to questions about potential benefits and harms of mammography, and the change in the proportion of participants who perceived that the benefits of mammography were more important than the harms. Before seeing the videos, women's knowledge about the benefits and harms of mammography was inaccurate (82% responded incorrectly to all 3 knowledge questions). After seeing the videos, the proportion that answered correctly increased by 52%, 43%, and 30% for the 3 knowledge questions, respectively, but there were no differences between video frames. At baseline, most women thought the benefits of mammography outweighed the harms (79% positive frame, 80% neutral frame, and 85% negative frame). After the videos, these proportions were similar among the 3 groups (84%, 81%, 83%, P =.93). CONCLUSIONS: Women improved the accuracy of their responses to questions about the benefits and harms of mammography after seeing the videos, but this change was not affected by the framing of information. Women strongly perceived that the benefits of mammography outweighed the harms, and providing accurate information had no effect on these perceptions, regardless of how it was framed.     

Self-referral for screening mammography

Patients can obtain screening mammograms without a physician's referral, leading to potential problems in clinical care. Because of the complexity of self-referral and the limitations of prior studies, we examined this phenomenon in a representative sample of mammography facilities. A questionnaire was given to all women obtaining mammograms at nine Connecticut mammography facilities during a 2-week period. Facilities included mobile sites, urban fixed sites, and rural fixed sites. Responses were categorized according to whether or not the woman had seen a primary care provider within the last year and whether or not she had received a recommendation to obtain a mammogram. The response rate was 62% (732 of 1,189), and the mean age of respondents was 58 years (range, 30–100 years). Self-referred women, defined as those without a recent visit to a primary care clinician and without a clinician's recommendation for a mammogram, constituted 6% of respondents. Self-referred women were significantly more likely to use mobile facilities (78% vs 33%, p  < .01) and be under 50 years of age (44% vs 28%, p = .02) compared with provider-referred women who had recently seen their provider. We conclude that younger women are obtaining screening mammograms without clear evidence of having seen their primary care provider in the previous year or having received a referral from their provider. Self-referral is especially common at mobile mammography facilities. Further study is needed to assess the clinical impact of self-referral on mass screening programs.     

Women's understanding of the mammography screening debate

BACKGROUND: The fractious public debate over mammography screening recommendations for women aged 40 to 49 years has received extensive attention in medical journals and in the press. OBJECTIVE: To learn how women interpret the mammography screening debate. METHODS: We mailed a survey to a random sample of American women 18 years and older, oversampling women of screening age (40-70 years). Sixty-six percent of women completed the survey (n = 503). MAIN OUTCOME MEASURES: The main outcome measures were women's reactions to the debate, their suggestion for the starting age for mammography screening, and their understanding of the source of the debate. RESULTS: Almost all women (95%) said that they had paid some attention to the recent discussion about mammography screening. Only 24% said the discussion had improved their understanding of mammography, while 50% reported being upset by the public disagreement among screening experts. Women's beliefs about mammography differed from those articulated by experts in the debate. Eighty-three percent believed that mammography had proven benefit for women aged 40 to 49 years, and 38% believed that benefit was proven for women younger than 40 years. Most women suggested that mammography screening should begin before age 40 years, while only 5% suggested a first mammogram should be performed at 50 years or older. In response to an open-ended question about why mammography has been controversial, 15% cited concerns about the potential harms of radiation and another 12% cited questions about efficacy. Nearly half (49%), however, identified costs as the major source of debate (eg, "Health maintenance organizations [HMOs] don't want to pay for mammography"). CONCLUSIONS: Most women paid attention to the recent debate about routine mammography screening for women aged 40 to 49 years, but many believed the debate was about money rather than the question of benefit. Policy makers issuing recommendations about implementation of large-scale mammography screening services need to consider how to effectively disseminate their message.     

Informed choice in mammography screening: a randomized trial of a decision aid for 70-year-old women

BACKGROUND: Many women who have participated in mammography screening are now approaching 70 years of age. These women are advised to consider both the benefits and harms of continuing to be screened. Doing so may be difficult for individual women, and there are no evaluated decision support tools to assist them. METHODS: To assess the effect of a decision aid (DA) about whether to continue or stop mammography screening for women aged 70 years, a population-based, randomized controlled trial was conducted in New South Wales, Australia. Women aged 70 years who had regularly participated in mammography screening were eligible to participate in the trial. Women received a DA providing balanced, quantitative information or standard information available from the screening program. The main outcomes were the percentage of women making an informed choice about whether to continue or stop screening and the percentage of women participating in the screening. RESULTS: Women who received the DA (the intervention group) were better informed than the control group (mean increase in knowledge score out of 10, 2.62 for the intervention group vs 0.68 for the control group; P < .001), and a significantly greater percentage made an informed choice (73.5% vs 48.8%; P < .001). The DA did not increase anxiety and slightly reduced decisional conflict. There was no difference in the percentage of women who participated in screening within 1 month. CONCLUSIONS: This DA increased knowledge and assisted women to make an informed choice. It did not alter participation in screening. The DA is an effective way to assist women to make a decision about continuing mammography screening and seems to be a feasible intervention within a population screening program.     

Is mammography painful? A multicenter patient survey

Anecdotal reports of pain experienced during mammography have been a source of anxiety and concern for some women considering screening. To determine what asymptomatic women actually experience during mammography, a survey of 1847 women was performed at seven breast-imaging centers. Women recorded their experience on a six-point scale ranging from no discomfort to severe pain. Eighty-eight percent of the women experienced no discomfort (49%) or mild discomfort (39%). Only 9% experienced moderate discomfort; 1%, severe discomfort; and 1%, moderate pain. No woman had pain so severe that it would make her reconsider having a mammogram again. The degree of discomfort was slightly greater in women who complained of breast tenderness within three days prior to the mammogram but was not strongly related to age, menstrual status, or week of the menstrual cycle. We conclude that in a vast majority of women mammography causes no or mild physical discomfort and that actual pain is an uncommon occurrence.     

Screening mammography for frail older women

OBJECTIVE: The potential benefits and harms of screening mammography in frail older women are unknown. Therefore, we studied the outcomes of a screening mammography policy that was instituted in a population of community-living nursing home-eligible women as a result of requirements of state auditors. We focused on the potential burdens that may be experienced. METHODS: Between January 1995 and December 1997, we identified 216 consecutive women who underwent screening mammography after enrolling in a program designed to provide comprehensive care to nursing home-eligible patients who wished to stay at home. Mammograms were performed at 4 radiology centers. From computerized medical records, we tracked each woman through September 1999 for performance and results of mammography, additional breast imaging and biopsies, documentation of psychological reactions to screening, as well as vital status. Mean follow-up was 2.6 years. RESULTS: The mean age of the 216 women was 81 years. Sixty-three percent were Asian, 91% were dependent in at least 1 activity of daily living, 49% had cognitive impairment, and 11% died within 2 years. Thirty-eight women (18%) had abnormal mammograms requiring further work-up. Of these women, 6 refused work-up, 28 were found to have false-positive mammograms after further evaluation, 1 was diagnosed with ductal carcinoma in situ (DCIS), and 3 were diagnosed with local breast cancer. The woman diagnosed with DCIS and 1 woman diagnosed with breast cancer were classified as not having benefited, because screening identified clinically insignificant disease that would not have caused symptoms in the women's lifetimes, since these women died of unrelated causes within 2 years of diagnosis. Therefore, 36 women (17%; 95% confidence interval [CI], 12 to 22) experienced burden from screening mammography (28 underwent work-up for false-positive mammograms, 6 refused further work-up of an abnormal mammogram, and 2 had clinically insignificant cancers identified and treated). Forty-two percent of these women had chart-documented pain or psychological distress as a result of screening. Two women (0.9%; 95% CI, 0 to 2) may have received benefit from screening mammography. CONCLUSION: We conclude that screening mammography in frail older women frequently necessitates work-up that does not result in benefit, raising questions about policies that use the rate of screening mammograms as an indicator of the quality of care in this population. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.     

The impact of physician compliance on screening mammography for older women

Screening mammography is underutilized, even for women older than 50 years for whom there is a general consensus that regular annual screening is appropriate and necessary. To evaluate reasons for this underutilization, we studied a random sample of 517 women in Los Angeles, Calif who were older than 50 years. All women were found to be underscreened, especially women older than 65 years. For example, approximately 35% of women 50 to 64 years old and 47% of women aged 65 years and older never had had even one mammogram. Analyses revealed that the most important factor that predicted whether a women ever had had a mammogram was whether her physician had talked to her about mammography. Women were between four and 12 times more likely, depending on their age group, to have had a mammogram at some time if their physicians discussed it with them. The discussions did not need to be lengthy or complex. These results indicate that physicians need to know that discussing screening mammography with their patients has a major impact on breast cancer screening behaviors.     

Determinants of colorectal cancer screening in women undergoing mammography

OBJECTIVES: Women who participate in screening for breast cancer are more likely to participate in screening for colorectal cancer. We studied such a motivated group of women to identify predictors of, and barriers to, participation in colorectal cancer screening by endoscopy. METHODS: We distributed surveys to 551 women > or = 50 yr of age while they were awaiting mammography at four sites in and around Boston, MA from June to September, 2000. The 40-question survey assessed knowledge, attitudes, and beliefs about, and behaviors toward, breast and colorectal cancer screening. Regression models were used to determine factors associated with having had sigmoidoscopy or colonoscopy. RESULTS: Seventy-nine percent of the women completed all or part of the survey. Half (221/438) reported ever having had sigmoidoscopy or colonoscopy. Of these, 93% did so at the recommendation of their primary care provider. Factors associated with participation in endoscopic screening included compliance with annual fecal occult blood testing, a family history of colorectal cancer, and indifference toward the gender of the doctor performing the endoscopy. CONCLUSIONS: Women undergoing mammography overwhelmingly cite the recommendation of their primary care provider as the reason for participating in colorectal cancer screening by endoscopy. Women who preferred a female endoscopist were less likely to have been screened. Whenever possible, primary care providers should offer women the choice of a female endoscopist for colorectal cancer screening.     

Increased patient concern after false-positive mammograms

OBJECTIVE: To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or true-negative vs false-positive) and to measure changes in health care utilization in the year after the mammogram. DESIGN: Cohort study. SETTING: Large health maintenance organization in New England. PATIENTS: Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram. MEASUREMENTS AND MAIN RESULTS: 1) Documentation in clinicians' notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non-breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P =.001). Documented concern increased with the intensity of recommended follow-up (P =.009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25). CONCLUSIONS: Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.     

Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization.

BACKGROUND: Despite the mortality benefits of breast cancer screening, not all women receive regular mammography. Such factors as age, socioeconomic status, and physician recommendation have been associated with greater use of screening. However, we do not know whether having an abnormal mammogram affects future screening. OBJECTIVE: To examine the effect of a false-positive mammogram on adherence to the next recommended screening mammogram. DESIGN: Prospective cohort study. SETTING: The breast cancer screening program at Group Health Cooperative, a health maintenance organization in Washington state. PATIENTS: 5059 women 40 years of age or older with no history of breast cancer or breast surgery who had false-positive (n = 813) or true-negative (n = 4246) index screening mammograms between 1 August 1990 and 31 July 1992. MEASUREMENTS: Screening rates and odds ratios for recommended interval screening up to 42 months after the index mammogram. RESULTS: After adjustment for differences in age; previous use of mammography; family history of breast cancer; exogenous hormone use; and age at menarche, first childbirth, and menopause, women with false-positive index mammograms were more likely than those with true-negative index mammograms to obtain their next recommended screening mammogram (odds ratio, 1.21 [95% CI, 1.01 to 1.45]). The relation between a false-positive mammogram and the likelihood of adherence to screening in the next recommended interval was strongest among women who had not previously undergone mammography (odds ratio, 1.66 [CI, 1.26 to 2.17]). CONCLUSIONS: Having a false-positive mammogram did not adversely affect screening behavior in the next recommended interval. Women with false-positive mammograms, especially those without previous mammography, were more likely to return for the next scheduled screening.     

Mammography use among women as a function of age and patient involvement in decision-making

OBJECTIVE: To assess the extent to which self-reported patient involvement in decision-making for initiation of mammography differs with age. DESIGN: Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement were evaluated. Prevalences were weighted and variances were adjusted using SUDAAN software to account for the complex, multistage sampling probability design of the NHIS. Logistic regression was used to evaluate the relative likelihood of self-reported involvement in the decision to have a mammogram within the preceding year as a function of age and other covariates. PARTICIPANTS: Mammography use was assessed among 3,863 NHIS female respondents 40 years of age or older. The analysis of decision-making was restricted to the subgroup of 1,064 women who reported a screening mammogram within the preceding year and who provided information on the other relevant variables. MEASUREMENTS AND MAIN RESULTS: The probability of reported mammography use within the preceding year declines among older groups of interviewees. Among women with a mammogram in the preceding year, the weighted percentage of women reporting active involvement in the decision (patient decision or decided jointly with a physician) declines from 51% among women 40 to 45 years of age to 19% among those aged 75 years or older. The adjusted odds ratio comparing the likelihood of participating in the decision to have a mammogram for the oldest women, compared with the youngest, was 0.31 (95% confidence interval 0.15 to 0.61). CONCLUSIONS: Older women are substantially less likely than younger women to report active involvement in the mammography decision-making process. Increased use of screening mammography among older women will require greater promotion by physicians. Other interventions, such as directed educational efforts, may also be needed to increase mammography demand among older women.     

Impact of same-day screening mammography availability: results of a controlled clinical trial

BACKGROUND: We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations. PATIENTS AND METHODS: Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group). MAIN OUTCOME MEASURES: Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography. RESULT: Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P<.001), increasing to 61% and 49% at 6 months (P<.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P<.001), women who were not employed (54% vs 36%; P<.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P<.001) within the last 5 years. CONCLUSIONS: Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.     

The relation between projected breast cancer risk, perceived cancer risk, and mammography use

BACKGROUND: Although the use of mammography on at regular intervals can save lives, not all women obtain the repeat mammography recommended in guidelines. OBJECTIVE: To assess the associations between routine mammography use, perceived cancer risk, and actual projected cancer risk. METHODS: We include women who were 45 to 75 years of age and who had responded to the 2000 National Health Interview Survey. Women who reported that they believed their risk of getting cancer in the future was "medium" or "high" were considered jointly as "medium/high-risk perception."Routine mammography use" was defined as having > or =3 mammograms in the previous 6 years. We used logistic regression to determine the independent relation between cancer risk perception, projected breast cancer risk, and routine mammography use. RESULTS: Of the 6,002 women who met our inclusion criteria, 63.1% reported routine mammography use. About 76% of women in the highest quartile of projected breast cancer risk reported routine mammography use, compared with only 68%, 64%, and 51% in the third, second, and first quartiles, respectively (P<.001 chi-square test for trend). After adjusting for indicators of access to care, sociodemographic and behavioral factors, and perceived cancer risk, women in the highest quartiles of projected cancer risk were significantly more likely to report routine mammogram use than women in the lowest quartile (odds ratio [OR] of women in third and fourth quartiles were 1.57 [1.24 to 1.99], and 2.23 [1.73 to 2.87] vs the lowest quartile, respectively). Women with a higher perceived cancer risk were significantly more likely to undergo routine mammography (adjusted OR: 1.29 [1.12 to 1.48] P=.001). Cancer risk perceptions tended to be higher among women who were younger age, obese, smokers, depressed, or reported one of the following breast cancer risk factors: family breast cancer history, prior abnormal mammogram, and early age at menarche. CONCLUSION: Actual and perceived risk were independent predictors of routine mammography use, suggesting that efforts to incorporate risk profiles into clinical decision making may need to involve more than just relaying information about projected risks to patients, but also to explore how risk perceptions can be affected by this information.     

Breast cancer screening in women aged 80 and older: results from a national survey

OBJECTIVES: To estimate the national rates of mammography screening in women aged 80 and older and examine the relationship between health status and screening within the previous 2 years. DESIGN: Population-based survey. SETTING: United States. PARTICIPANTS: Eight hundred eighty-two women aged 80 and older who responded to the 2000 National Health Interview Survey, representing an estimated 3.83 million noninstitutionalized women nationally. MEASUREMENTS: Screening mammography, disease burden, and functional status were assessed using a questionnaire. RESULTS: Of the 882 women, 41.5% were aged 85 and older; 19.6% had two or more significant diseases; and 12.1% were dependent in at least one activity of daily living (ADL). More than half (50.8%) had received a screening mammogram within the previous 2 years. Women with two or more significant diseases were less likely to have received screening than those without significant disease, but the difference was not statistically significant (43.9% vs 54.0%, P=.152). Women dependent in at least one ADL were less likely to receive screening mammography than women without functional impairment (37.2% vs 55.9%, P<.001). After adjustment, the likelihood of screening remained lower in women with two or more significant diseases (adjusted odds ratio (AOR)=0.63, 95% confidence interval (CI)=0.40-1.05) and in women with at least one ADL dependency (AOR=0.44, 95% CI=0.22-0.88). Of 294 women likely to have life expectancies of less than 5 years because of poor health, 39.4% received screening mammography. CONCLUSION: More than half of women aged 80 and older in the United States receive screening mammograms. Nearly 40% of women very unlikely to benefit because of poor health received screening mammography.     

Mammography and Papanicolaou smear use by elderly poor black women. The Harlem Study Team.

OBJECTIVE: To describe factors related to the use of mammography and Papanicolaou smears in low-income women aged 65 or more years to guide development of future interventions. DESIGN: A cross-sectional survey. SETTING AND PATIENTS: Elderly Black women attending a public hospital medical clinic. MEASUREMENTS: Information obtained in a face-to-face interview of a random sample of patients. RESULTS: Four-hundred and forty-five women (94%) consented to be interviewed; 74% reported a mammogram, and 85% reported a Papanicolaou smear in the past, although these early-detection tests were not obtained with any regularity after age 65. Concordance between self-reported screening use and blind chart review was more than 90%. The major reasons for non-use of both screening tests were that a physician hadn't recommended them or that the women didn't know they needed them. Levels of knowledge about breast and cervix cancer were low; 68% believed bumping or bruising the breast caused cancer, and only 25% knew that cancer risk increased with advancing age. In logistic regression models, health status, provider type, perceived benefit, life satisfaction, and knowledge of test intervals were each significantly associated with mammogram use. Age, health status, education, perceived susceptibility and benefit, life satisfaction, and knowledge of test intervals were independently related to Pap use (P < .05). CONCLUSION: This study illustrates that elderly, poor, minority women who are regular health-care users do use mammography and Pap smear screening services. Incorporating screening into routine primary care and physician and patient education could enhance the use of early cancer detection procedures in this age group.     

Predictors of varying levels of nonadherence to mammography screening in older women

OBJECTIVES: To identify predictors of varying levels of nonadherence to mammography screening in older women. DESIGN: Cross-sectional survey. Setting: Sixty community-based sites where seniors gather. PARTICIPANTS: Consecutive volunteer sample of 499 women aged 60 to 84 who had not received a mammogram within the previous year. MEASUREMENTS: Three levels of nonadherence (never had a mammogram (never), mammogram more than 2 years before (lapsed), and mammogram in the past 1 to 2 years (due/reference group)). These were based on a Transtheoretical Model and incorporated into the Adherence Model. Bivariate and multivariate multinomial logistic regression analysis was used for variables obtained. RESULTS: Two risk factors, having difficulty getting to a facility and not intending to ask a health provider for a mammogram, were predictive of the never and lapsed levels. Distinct risk factors for being in the never compared with the due level of nonadherence included being concerned about pain, not being enrolled in a health maintenance organization, not getting preventive checkups, and being only somewhat (versus very) likely to ask a physician for mammogram. In contrast, distinct risk factors for the lapsed compared with the due level of nonadherence included perceiving that no friends have routine mammograms and not having a provider referral. CONCLUSION: Some risk factors for not being up to date with mammography vary by the level of nonadherence. Interventions should be individualized to women's level of nonadherence and include common core strategies that encourage women to ask for a mammogram and to lessen the difficulty of getting to a screening facility.     

Redesigning Primary Care Processes to Improve the Offering of Mammography: The Use of Clinic Protocols by Nonphysicians

OBJECTIVE: To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN: A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING: Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS: A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION: Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS: Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50-75) or 2 years (if age 40-49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-to-date with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI -5%, 7%) in one of the control clinics and -2% (95% CI -3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-to-date with mammography increased over time and was consistent with a linear trend (p = .004). CONCLUSIONS: Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians' usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures.     

Differences in the quality of care for women with an abnormal mammogram or breast complaint

OBJECTIVE: To examine factors associated with variation in the quality of care for women with 2 common breast problems: an abnormal mammogram or a clinical breast complaint. DESIGN: Cross-sectional patient survey and medical record review. SETTING: Ten general internal medicine practices in the Greater Boston area. PARTICIPANTS: Women who had an abnormal radiographic result from a screening mammogram or underwent mammography for a clinical breast complaint (N=579). MEASUREMENTS AND MAIN RESULTS: Three measures of the quality of care were used: (1) whether or not a woman received an evaluation in compliance with a clinical guideline; (2) the number of days until the appropriate resolution of this episode of breast care if any; and (3) a woman’s overall satisfaction with her care. Sixty-nine percent of women received care consistent with the guideline. After adjustment, women over 50 years (odds ratio [OR], 1.58; 95% [CI], 1.06 to 2.36) and those with an abnormal mammogram (compared with a clinical breast complaint: OR, 1.75; 95% CI, 1.16 to 2.64) were more likely to receive recommended care and had a shorter time to resolution of their breast problem. Women with a managed care plan were also more likely to receive care in compliance with the guideline (OR, 1.72; 95% CI, 1.12 to 2.64) and have a more timely resolution. There were no differences in satisfaction by age or type of breast problem, but women with a managed care plan were less likely to rate their care as excellent (43% vs 53%, P<.05). CONCLUSIONS: We found that a substantial proportion of women with a breast problem managed by generalists did not receive care consistent with a clinical guideline, particularly younger women with a clinical breast complaint and a normal or benign-appearing mammogram. This work was supported by a grant from the Harvard Risk Management Foundation. Dr. Haas was the recipient of a Clinical Investigator Award from the National Institute of Child Health and Human Development (K08-HD01029) when this work was conducted.     

Mammography-related beliefs of older women. A survey of an HMO population

Although breast cancer risk increases with age, most studies show that mammography use decreases. A 15-minute telephone survey of 548 women health maintenance organization (HMO) members aged 65 to 74 who had not obtained a mammogram within the past year was undertaken to identify sociodemographic factors as well as knowledge, belief, and attitudinal characteristics associated with mammography history. Women who had never had a mammogram were less likely to have received a physician's recommendation and more likely to express negative attitudes about mammography, such as having a mammogram means "looking for trouble" and "makes me nervous." In addition, they expressed doubts about their need to have a mammogram and reported that "other problems" prevented them from having a mammogram. These results suggest that women who have never had a mammogram may require more intensive interventions to encourage them to obtain mammograms. In addition to receiving a mammography recommendation from their physicians, they might benefit from individual or small group educational sessions where negative attitudes about mammography could be explored and modified.