Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists

Motivators of Inappropriate Ovarian Cancer Screening: A Survey of Women and Their Clinicians

Background

This study examined why women and doctors screen for ovarian cancer (OC) contrary to guidelines.

Methods

Surveys, based on the Theoretical Domains Framework, were sent to women in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer and family physicians and gynecologists who organized their screening.

Results

Of 1264 Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer women, 832 (65.8%) responded. In the past 2 years, 126 (15.1%) had screened. Most of these (n = 101, 80.2%) would continue even if their doctor told them it is ineffective. For women, key OC screening motivators operated in the domains of social role and goals (staying healthy for family, 93.9%), emotion and reinforcement (peace of mind, 93.1%), and beliefs about capabilities (tests are easy to have, 91.9%). Of 531 clinicians 252 (47.5%) responded; a minority (family physicians 45.8%, gynecologists 16.7%) thought OC screening was useful. For gynecologists, the main motivators of OC screening operated in the domains of environmental context (lack of other screening options, 27.6%), and emotion (patient peace of mind, 17.2%; difficulty discontinuing screening, 13.8%). For family physicians,, the strongest motivators were in the domains of social influence (women ask for these tests, 20.7%), goals (a chance these tests will detect cancer early, 16.4%), emotion (patient peace of mind, 13.8%), and environmental context (no other OC screening options, 11.2%).

Conclusion

Reasons for OC screening are mostly patient driven. Clinician knowledge and practice are discordant. Motivators of OC screening encompass several domains, which could be targeted in interventions to reduce inappropriate OC screening.

The developing family doctor system: evidence from the progress of the family doctor signing service from a longitudinal survey (2013-2016) in Pudong New Area, Shanghai

Background

The family doctor system is a vital part of China’s national medical and health system reform. Evidence of the degree of implementation of the family doctor system is required to assist managers and policy makers in Pudong with resource allocation planning. This study analyzed changes in indicators (family doctor team construction, contracted medical services, health management services and so on) over time to evaluate the progress of the family doctor system in Pudong.

Methods

We used a cross-sectional design with an online questionnaire survey to collect 3-year (2013–2016) consecutive data. The online questionnaires were completed by the doctors responsible for information reporting in each community health service center of Pudong. The data were sorted, and the indices calculated and analyzed using descriptive statistics and statistical tests.

Results

The proportion of registered general practitioners increased each year, from 50.8% in 2013 to 66.5% in 2016; this difference was statistically significant (P = 0.000). The number of family doctors per 10,000 permanent residents rose each year, from 1.7 in 2013 to 2.1 in 2016. The rate of contracted household residents was 55.7% in 2013 and increased to 71.7% in 2016, with the difference being significant in different years (P = 0.012). Analysis of referral services showed the people times of contracted residents transferring to higher-level hospitals from family doctors increased each year, from 172,734 in 2013 to 341,615 in 2016; differences among different regions were statistically significant for 2013–2016. The rate of health screening for contracted residents also increased each year, with statistically significant differences in different years (P = 0.000). The rate of health assessment interventions for contracted residents rose each year, with statistically significant differences in different years (P = 0.003).

Conclusions

The family doctor signing service in Pudong made headway in general practitioner availability, contract service rate of household residents, and providing health management services. However, problems included family doctor shortages and limited supporting policies, especially in rural and suburban areas compared with urban divisions. Increasing the enrollment rate of family doctors and speeding up the implementation of “contract service fees” are key tasks for the sustainable development of the family doctor system in Pudong.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01353-0.

Cervical Cancer Screening and Prevention in 78 Sexually Transmitted Disease Clinics-United States, 2014-2015

BACKGROUND

Human papillomavirus (HPV) infections cause approximately 30,700 cancers annually among US men and women, cervical cancer being the most common. Human papillomavirus vaccination is recommended routinely for US girls and boys at age 11 to 12 years, and for those not previously vaccinated, through age 26 and 21 years for women and men, respectively. Our objective was to assess current cervical cancer screening and HPV vaccination practices among sexually transmitted disease (STD) clinics in the United States.

METHODS

We surveyed a geographically diverse convenience sample of US STD clinics identified by members of the National Coalition of STD Directors within 65 state, territorial, and local jurisdictions. An online multiple-choice survey about clinical services was administered to clinic directors or designees during October 2014 to February 2015.

RESULTS

Survey respondents included 78 clinics from 46 states and territories. Of these clinics, 31 (39.7%) offered both cervical cancer screening and HPV vaccination, 6 (7.7%) offered cervical cancer screening only, 21 (26.9%) offered HPV vaccination only, and 20 (25.6%) offered neither cervical cancer prevention service. Among those not offering the service, the most commonly reported barrier to cervical cancer screening was time constraints (25/41, 61.0%); for HPV vaccination it was reimbursement (11/26, 42.3%).

CONCLUSIONS

By early 2015, in a geographically diverse group of 78 STD clinics, 39.7% provided nationally recommended HPV vaccination and cervical cancer screening, whereas 25.6% provided neither. Further research could identify strategies for STD clinics to reduce HPV-associated cancers by increasing provision of HPV vaccination and cervical cancer screening services, particularly among medically underserved populations.

Scrutinizing screening: a critical interpretive review of primary care provider perspectives on mammography decision-making with average-risk women

CONTEXT

A decision to undertake screening for breast cancer often takes place within the primary care setting, but current controversies such as overdiagnosis and inconsistent screening recommendations based on evolving evidence render this a challenging process, particularly for average-risk women. Given the responsibility of primary care providers in counseling women in this decision-making process, it is important to understand their thoughts on these controversies and how they manage uncertainty in their practice.

OBJECTIVE

To review the perspectives and approaches of primary care providers regarding mammography decision-making with average-risk women.

DESIGN AND METHODS

This study is a critical interpretive review of peer-review literature that reports primary care provider perspectives on mammography screening decision-making. Ovid MEDLINE®, Ovid PsycInfo, and Scopus databases were searched with dates from 2002 to 2017 using search terms related to mammography screening, uncertainty, counseling, decision-making, and primary health care providers.

RESULTS

Nine articles were included following a review process involving the three authors. Using an inductive and iterative approach, data were grouped into four thematic categories: (1) perceptions on the effectiveness of screening, screening initiation age, and screening frequency; (2) factors guiding primary care providers in the screening decision-making process, including both provider and patient-related factors, (3) uncertainty faced by primary care providers regarding guidelines and screening discussions with their patients; and (4) informed decision-making with average-risk women, including factors that facilitate and hinder this process.

DISCUSSION

The discussion of results addresses several factors about the diversity of perspectives and practices of physicians counseling average-risk women regarding breast cancer screening. This has implications for the challenge of understanding and explaining evidence, what should be shared with average-risk women considering screening, the forms of knowledge that physicians value to guide screening decision-making, and the consent process for population-based screening initiatives. Within the data, there was little attention placed on how physicians coped with uncertainty in practice. Given the dual responsibility of physicians in caring for both individuals and the larger population, further research should probe more deeply into how they balance their duties to individual patients with those to the larger population they serve.

Linking physician attitudes to their breast cancer screening practices: A survey of US primary care providers and gynecologists

Despite changes to breast cancer screening guidelines intended to decrease screening in younger and older women, mammography rates remain high. We investigated physician attitudes towards screening younger and older women. Surveys were mailed to US primary care providers and gynecologists between May and September 2016 (871/1665, 52.3% adjusted response rate). We assessed physician (1) attitudes towards screening younger (45-49years) and older (75+ years) women and (2) recommendations for routine mammography. We used exploratory factor analysis to identify underlying themes among physician attitudes and created measures standardized to a 5-point scale. Using multivariable logistic regression models, we examined associations between physician attitudes and screening recommendations. Attitudes identified with factor analysis included: potential regret, expectations, and discordant guidelines (referred to as potential regret), patient-related hazards due to screening, physician limitations and uncertainty, and concerns about rationing care. Gynecologists had higher levels of potential regret compared to internists. In adjusted analyses, physicians with increasing potential regret (1-point increment on 5-point scale) had higher odds of recommending mammography to younger (OR 8.68; 95% CI 5.25-14.36) and older women (OR 4.62; 95% CI 3.50-6.11). Increasing concern for patient-related hazards was associated with decreased odds of recommending screening to older women (OR 0.68; 95% CI 0.56-0.83). Physicians were more motivated by potential regret in recommending screening for younger and older women than by concerns for patient-related hazards in screening. Addressing physicians' most salient concerns, such as fear of missing cancer diagnoses and malpractice, may present an important opportunity to improving delivery of guideline-concordant cancer screening.

Linking Reminders and Physician Breast Cancer Screening Recommendations: Results From a National Survey

PURPOSE

Physician reminders have successfully increased rates of mammography. However, considering recent changes to breast cancer screening guidelines that disagree on the optimal age to start and stop mammography screening, we sought to examine the extent to which reminders have been deployed for breast cancer screening targeting younger and older patients.

METHODS

A mailed survey was sent to a national sample of 2,000 primary care physicians between May and September 2016. Physicians were asked whether they received reminders to screen women in various age groups (40 to 44, 45 to 49, and ≥ 75 years), the organizational screening guidelines they trusted most, and whether they recommended routine breast cancer screening to average-risk women in the different age groups. Using regression models, we assessed the association between reminders and physician screening recommendations, controlling for physician and practice characteristics, and evaluated whether the association varied by the guidelines they trusted.

RESULTS

A total of 871 physicians responded (adjusted response rate, 52.3%). Overall, 28.9% of physicians reported receiving reminders for patient ages 40 to 44 years, 32.5% for patient ages 45 to 49 years, and 16.5% for patient ages ≥ 75 years. Receiving reminders significantly increased the likelihood of physicians recommending mammography screening. In adjusted analyses, 84% (95% CI, 77% to 90%) of physicians who received reminders recommended screening for women ages ≥ 75 versus 65% (95% CI, 62% to 69%) of those who did not receive reminders. The associations between reminders and screening recommendations remained consistent regardless of which guidelines physicians reported trusting.

CONCLUSION

Reminders were significantly associated with increases in physician screening recommendations for mammography, underscoring the need for careful implementation in scenarios where guidelines are discordant.

When Guidelines Conflict: A Case Study of Mammography Screening Initiation in the 1990s

BACKGROUND

Cancer screening guidelines communicate important information to patients and physicians regarding the costs and benefits of screening. Currently, guideline recommendations from major organizations conflict regarding the age of mammography screening initiation. To understand current and future U.S. mammography screening patterns we study age-mammography patterns from the 1990s, another period of conflicting guideline recommendations.

METHODS

We examine mammography use rates by single year of age to understand compliance with guideline-recommended initiation ages in the 1990s. Mammography test use data was taken primarily from the 1991 to 2001 Behavioral Risk Factor Surveillance System. The analytic sample included all women 35 to 54 years of age.

RESULTS

We found a discrete 8.7-percentage point increase in mammography use precisely at age 40 and a much smaller 1.6-percentage point increase in mammography use at age 50. These findings varied by insurance status, with the insured experiencing a large, discrete increase primarily at age 40 and the uninsured experiencing notable discrete increases at ages 40 and 50.

CONCLUSION

Physicians and patients converged primarily on the age 40 mammography screening threshold during the 1990s. Prices, along with guidelines, were key determinants of the age of screening initiation, with the insured responding to age 40 coverage and cost-sharing reductions and the uninsured affected by guidelines and public funding tied to the age 50 threshold. The policy factors underlying these results, recent ACA coverage increases, and ACA cost-sharing requirements imply that a substantial number of women will continue to receive mammography screening in their 40s.