Patient compliance in mobile screening mammography

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Availability of prior mammograms affects incomplete report rates in mobile screening mammography

PURPOSE

Mobile mammography can improve access to screening mammography in rural areas and underserved populations. We evaluated the frequency of incomplete reports in mobile mammography screening and the relationships between prior mammograms and recall rates.

METHODS

The frequency of incomplete mammogram reports, the subgroups of those needing prior comparison mammograms, recalls for additional imaging, and availability of prior mammograms of a mobile screening mammography unit were compared with fixed site mammography from January 1, 2007 through December 31, 2009. All mobile unit mammograms were full field digital mammography (FFDM). Differences between rates of recall, incomplete reports, and availability of prior mammograms were calculated using the Chi-Square statistic.

RESULTS

Of 2640 mobile mammography cases, 21.9% (578) reports were incomplete, versus 15.2% (7653) (p ≤ 0.001) of 50325 fixed site reports. Of incomplete cases, recall for additional imaging occurred among 8.3% (218) of mobile mammography reports versus 11.3% (5708) (p ≤ 0.001) of fixed site reports. Prior mammograms were needed among 13.6% (360) of mobile mammography versus 3.9% (1945) (p ≤ 0.001) of fixed site reports. Mobile mammography recall rate varied with availability of prior mammograms: 16.0% (54) when no prior mammograms, 7.6% (127) when prior mammograms were elsewhere but unavailable and 5.9% (37) when prior FFDM were immediately available (p ≤ 0.001).

CONCLUSIONS

Incomplete reports were more frequent in mobile mammography than the fixed site. The availability of prior comparison mammograms at time of interpretation decreased the rate of incomplete mammogram reports. Recall rates were higher without prior comparison mammograms and lowest when comparison FFDM mammograms were available.

Mobile mammography in underserved populations: analysis of outcomes of 3,923 women

Mobile health units are increasingly utilized to address barriers to mammography screening. Despite the existence of mobile mammography outreach throughout the US, there is a paucity of data describing the populations served by mobile units and the ability of these programs to reach underserved populations, address disparities, and report on outcomes of screening performance. To evaluate the association of variables associated with outcomes for women undergoing breast cancer screening and clinical evaluation on a mobile unit. Retrospective analysis of women undergoing mammography screening during the period 2008-2010. Logistic regression was fitted using generalized estimating equations to account for potential repeat annual visits to the mobile unit. In total, 4,543 mammograms and/or clinical breast exams were conducted on 3,923 women with a mean age of 54.6, 29 % of whom had either never been screened or had not had a screening in 5 years. Age < 50 years, lack of insurance, Hispanic ethnicity, current smoking, or having a family relative (<50 years of age) with a diagnosis of cancer were associated with increased odds of a suspicious mammogram finding (BIRADS 4,5,6). Thirty-one breast cancers were detected. The mobile outreach initiative successfully engaged many women who had not had a recent mammogram. Lack of insurance and current smoking were modifiable variables associated with abnormal screens requiring follow up.

Use of BI-RADS 3-probably benign category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial

PURPOSE

To determine (a) how often the Breast Imaging Reporting and Data System (BI-RADS) category 3 was used in the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), either at the time of screening mammography or after work-up, (b) how often subjects actually returned for the recommended follow-up examination, and (c) the rate and stages of any malignancies subsequently found in subjects for whom short-term interval follow-up was recommended.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board at all institutions where subjects were enrolled. All subjects participating in DMIST gave informed consent and the study was HIPAA-compliant. A total of 47,599 DMIST-eligible and evaluable subjects, all of whom consented to undergo both digital and screen-film mammography, were included in this analysis. Cases referred for short-term interval follow-up based on digital, screen-film, or both imaging examinations were determined. Compliance with the recommendations and the final outcome (malignancy diagnosis at biopsy or no malignancy confirmed through follow-up) of each evaluable case were determined.

RESULTS

A total of 1114 of the 47,599 (2.34%) subjects had tumors assigned a BI-RADS 3 category and were recommended to undergo short-interval follow-up. In this study, 791 of 1114 (71%) of the subjects were compliant with the recommendation and returned for short-interval follow-up. Of the women who did not return for short-interval follow-up, 70% (226 of 323) did return for their next annual mammography. Among all subjects whose tumors were assigned a BI-RADS 3 category either at screening mammography or after additional work-up, nine of 1114 (0.81%) were found to have cancer. Of the nine biopsy-proved cancers, six were invasive cancers and three were ductal carcinoma in situ stage Tis-T1c. The invasive cancers were all less than 2 cm in size.

CONCLUSION

In DMIST, radiologists used the BI-RADS 3 classification infrequently (2.3% of patients). Tumors assigned a BI-RADS 3 category had a low rate of malignancy. The relatively high rate of noncompliance with short-interval follow-up recommendations (323 of 1114, or 29%) supports prior recommendations that radiologists thoroughly evaluate lesions before placing them in this category.

Costs of Achieving High Patient Compliance After Recall from Screening Mammography

OBJECTIVE

The purpose of our study was to document the hidden costs in achieving high recall patient compliance from an off-site screening mammography program.

MATERIALS AND METHODS

This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases.

RESULTS

For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was $4,724 divided by 30,286 screening patients, or 16 cents per screening patient.

CONCLUSION

The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.

Digital Mammography: Current Capabilities and Obstacles

Digital mammography represents an exciting new technology for breast imaging and possibly breast screening. The decoupling of functional components in digital mammography translates into potential operational efficiencies compared with screen-film mammography (SFM). Digital mammography is a platform for advanced applications not possible with traditional SFM. However, for digital mammography to replace SFM in daily clinical practice, operational and clinical hurdles will have to be overcome.

Breast imaging flow models

Economically efficient and clinically effective breast imaging can be achieved through combinations and permutations of four fundamental breast imaging flow models: (1) the traditional flow model, (2) the online flow model, (3) the women's imaging flow model, and (4) the combination-care flow model. The structure, strengths, and weaknesses of these four individual breast imaging flow models are described and compared.

Can case management be used to facilitate diagnostic testing in publicly funded breast cancer screening programs?

The earlier breast cancer can be diagnosed and treated, the better the odds for survival. The literature has shown many of the barriers to timely diagnosis are not individual behaviors but problems in delivery of health care. Case management has been suggested to facilitate diagnostic testing and treatment. Models of case management exist in other practice settings but have not always been rigorously described or evaluated. Determining optimal models for case management has been established federally as a research priority to ensure medically underserved women are promptly diagnosed and treated. One model has been developed and pilot-tested in this setting. This article will describe elements of case management and the characteristics of a publicly funded screening program that make use of case management to facilitate timeliness of diagnostic testing different from case management in other settings. These differences have implications for successfully implementing case management in public programs.

Informing patients of diagnostic mammography results: mammographer's opinions

PURPOSE

The authors' purpose was to determine mammographers' practices and attitudes regarding disclosing results of diagnostic mammograms to patients.

MATERIALS AND METHODS

In 1995, the authors mailed a questionnaire to 500 members of the Society of Breast Imaging; 399 (80%) responded to the survey.

RESULTS

Three-quarters of respondents stated that mammographers should disclose results to their patients, and approximately half were already doing so (52% for normal results, 51% for abnormal results). A sizable minority (25%) said that not telling patients was the best practice and identified several barriers to direct disclosure, including lack of time. Although bivariate analysis showed direct disclosure to be more common among female mammographers, the sex difference did not persist in multivariate analysis. In both bivariate and multivariate analyses, reading more than 100 mammograms per week and having a radiology practice in a university or academic setting were each strongly associated with direct disclosure.

CONCLUSION

Implementation of the Mammography Quality Standards Reauthorization Act of 1998 may not require a major change in mammographers' current practice. It remains critical to establish systems that help radiologists disclose results and communicate with referring physicians efficiently and effectively.

Patient satisfaction with screening mammography: online vs off-line interpretation

RATIONALE AND OBJECTIVES

The purpose of this study was to determine patient satisfaction with online and off-line methods of interpreting screening mammograms and to determine those characteristics that most influence patient preferences.

MATERIALS AND METHODS

A survey consisting of 17 questions assessing satisfaction and demographics was distributed to women whose screening mammograms were read in one of two ways at the same facility: (a) the "online" method, in which all additional requested studies are completed and results are immediately communicated, and (b) the "off-line" method, in which mammograms are read in batches the next day, results are communicated at a later time, and patients return for diagnostic studies. To ensure statistical power, at least 174 surveys were collected from each group.

RESULTS

Of 192 women whose mammograms were interpreted online, 188 (97%) responded, and of 247 women whose mammograms were interpreted off-line, 181 (73%) responded. Overall mean satisfaction with the mammographic experience and with the time it took to receive results differed significantly between the two groups (P < .002). Analysis of the subgroup of very satisfied respondents disclosed that 92% of patients in the online group and 59% of patients in the off-line group were very satisfied with their mammography experience. If allowed to choose the method of interpretation, 97% of patients in the online group and 91% of patients in the off-line group would choose online interpretation.

CONCLUSION

Patients preferred online mammographic interpretation of screening studies.

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.