Gifford, Deidre S

While screening mammography remains the most effective method available to detect breast cancer early and reduce breast cancer mortality, rates of screening among women with Medicare in this State are low and have shown no improvement in the new millennium. In the two-year period from July 1999 to june 2001, 61.1% of women aged 50-69 with fee-for-service Medicare in Rhode Island had a mammogram, according to data from Medicare claims. There has been no improvement in that statistic in the intervening time. In the two-year period ending in March 2003, only 60.3% of such women had a claim for a mammogram. Rhode Island ranks approximately 20th in the nation, and last in New England in terms of the percentage of women with fee-for-service Medicare who are screened.1

There is virtually unanimous agreement among recommending bodies that women aged 50-69 should undergo periodic mammography screening.2 Sporadic controversies m the literature have centered on the appropriate age at which to initiate screening programs 3,4 and about methodologic flaws with some of the early randomized controlled trials5. Despite these controversies, the US Preventive Services Task Force (USPSTF) recently reconfirmed its recommendations for mammography screening. The USPSTF recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older. In addition, nearly all North American organizations support mammography screening, although the age of initiation and recommended screening interval may vary.2 While other screening modalities show promise, and may eventually prove to be more effective at early detection than mammography, it is currently the best available technology for finding cancers that are not palpable on clinical breast exam.

Given this consensus, how can we explain the significant proportion of older women who are not being screened in Rhode Island? Both clinical experience and the medical literature can provide insights into the barriers both physicians and their patients face in increasing the local rate of mammography screening:

* Lack of patient awareness: In national surveys of women, the barrier most commonly cited by women who have not been screened is lack of awareness of the necessity of screening.6

* Long waits for services: In Rhode Island, there are currently long waits at some facilities for a screening mammogram appointment. When there is a prolonged interval between the recommendation for the screening and the availability of an appointment, the likelihood of carrying through the test may diminish. Some studies have suggested that the availability of same-day appointments can increase the likelihood of screening taking place, especially among older women.7

* Cost: Medicare currently covers the cost of biennial mammography screening, and waives the Part B deductible. However, there is a small co-pay, between $15-20, which may present a barrier to some women.

* Pain and/or inconvenience of the test: Although this was cited as a barrier by only a small proportion of women in national surveys, some women may avoid mammograms because of the discomfort of breast compression, or embarrassment at the procedure itself.6

* Lack of clinician recommendation: A small proportion of women continue to report that they have not had the appropriate screening because a hcalthcare provider has not recommended it to them.6

* Difficulty integrating preventive care into acute care visits: Many women in this age group have multiple competing morbidities. Integrating all of the appropriate and recommended preventive services into acute care visits is challenging. Physician reimbursement structures do not reward or encourage counseling around preventive services.

Many of these barriers are not within the control of individual providers. Within the limitations of the current practice environment, what can we as clinicians do to maximize the percentage of our patients who receive the appropriate screening? Some provider groups in the state are able to achieve high rates of mammography compliance among their patients, while others have more difficulty. Clearly differences in patient mix are part of this, but the use of office systems which facilitate the ordering and follow-up of all screening tests, including mammography, has been shown to be very effective in enhancing screening.8

Many physicians who are part of the Rhode Island Physicians’ Quality Network are working to increase the level of screening among their patients. Below are several examples of practices being employed by Quality Network members which are consistent with the literature on maximizing screening, and which do not require significant investment of time or resources:

* Make tailored recommendations: Research suggests that women respond to screening recommendations more readily when the recommendation is tailored to their individual level of risk.9 Family history, nulliparity or first term pregnancy after age 30 and increasing age are all important risk factors for breast cancer. However, the majority of cancers occur in women with no known risk factor. Helping women to understand that they are at risk simply by virtue of their age and gender may increase the likelihood of their compliance with screening recommendations. Specifically addressing fears of pain or embarrassment in women who have not been screened may also increase the likelihood of compliance.

* Develop an office reminder system: The literature consistently cites office systems which remind providers to order screening and track results as factors that increase the likelihood of screening. Quality Partners has developed a simple mammography reminder system that allows you to track those patients who have not followed up on your recommendations for screening. (You can view the form at If you do not currently employ a preventive care flow sheet, these paper systems can serve as effective reminders of those tests that are due for individual patients. An example is available on our website.

* Facilitate appointment scheduling: Many offices do not have sufficient staff to schedule appointments with women as they leave the office. However, information about facility locations and current wait times for an appointment, including facilities with walk-in slots available, has been recently mailed to your office. Sharing wait time and walk-in information with patients may help them to expedite their appointment for a mammogram. If you need additional copies of our “Mammography Facility Wait Time Survey,” it is available at our web site or by calling us at Quality Partners.

* Recall patients who have not been seen in over a year: Many office billing systems allow identification of those women who have not been seen in over a year. Some offices choose to send a reminder to these patients to come in for a variety of preventive care services, mammography among them.

Breast cancer continues to be an important cause of morbidity and mortality among American women, second only to lung cancer as a cause of cancer-related death.2 Early detection through mammography is the best available method for reducing breast cancer mortality. In Rhode Island, current methods for recruiting women into screening are leaving a significant proportion of at-risk women out of the screening process. While barriers within the larger system may account for some of this, many physicians in Rhode Island are employing simple yet effective methods for increasing the rates of screening within their own practices.

If you are interested in learning more about any of the above techniques, or have a suggestion about ways to increase screening mammography in our State, please contact us at Quality Partners, 401-528-3200.

Copyright Rhode Island Medical Society Apr 2004

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