Mammography result notification letters: are they easy to read and understand?

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.

Breast Density Awareness and Knowledge in a Mammography Screening Cohort of Predominantly Hispanic Women: Does Breast Density Notification Matter?

BACKGROUND

New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited.

METHODS

Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40-60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information.

RESULTS

Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09-0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16-0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08-0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59-4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas.

CONCLUSIONS

DBN increases BD awareness disproportionately across sociodemographic groups.

IMPACT

Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.

Organization Communication Factors and Abnormal Mammogram Follow-up: a Qualitative Study Among Ethnically Diverse Women Across Three Healthcare Systems

BACKGROUND

Regular mammogram screening for eligible average risk women has been associated with early detection and reduction of cancer morbidity and mortality. Delayed follow-up and resolution of abnormal mammograms limit early detection efforts and can cause psychological distress and anxiety.

OBJECTIVE

The goal of this study was to gain insight from women's narratives into how organizational factors related to communication and coordination of care facilitate or hinder timely follow-up for abnormal mammogram results.

DESIGN

We conducted 61 qualitative in-person interviews with women from four race-ethnic groups (African American, Chinese, Latina, and White) in three different healthcare settings (academic, community, and safety-net).

PARTICIPANTS

Eligible participants had an abnormal mammogram result requiring breast biopsy documented in the San Francisco Mammography Registry in the previous year.

APPROACH

Interview narratives included reflections on experience and suggested improvements to communication and follow-up processes. A grounded theory approach was used to identify themes across interviews.

KEY RESULTS

Participants' experiences of follow-up and diagnosis depended largely on communication processes. Twenty-one participants experienced a follow-up delay (> 30 days between index mammogram and biopsy). Organizational factors, which varied across different institutions, played key roles in effective communication which included (a) direct verbal communication with the ability to ask questions, (b) explanation of medical processes and terminology avoiding jargon, and (c) use of interpretation services for women with limited English proficiency.

CONCLUSION

Health organizations varied in their processes for abnormal results communication and availability of support staff and interpretation services. Women who received care from institutions with more robust support staff, such as bilingual navigators, more often than not reported understanding their results and timely abnormal mammogram follow-up. These reports were consistent across women from diverse ethnic groups and suggest the value of organizational support services between an abnormal mammogram and resolution for improving follow-up times and minimizing patient distress.

Engaging patients and families in pediatric radiology

While patient and family-centered care (PFCC) is currently a hot topic in medicine, it has long been a specific focus of pediatrics. The concept of PFCC includes a change in culture where physicians and patients move away from paternalism and instead view patients and families as partners in care. Although there are many ways in which adult-focused radiologists can learn from pediatric radiologists as leaders in PFCC, there remain many opportunities for improvement for all radiologists.

Impact of Improved Screening Mammography Recall Lay Letter Readability on Patient Follow-Up

PURPOSE

In the setting of abnormal results on screening mammography, the Mammography Quality Standards Act mandates that patients receive a mailed "recall" lay letter informing them to return for additional follow-up imaging. The language used in this letter should be "easily understood by a lay person." In February 2019, the authors' institution revised the language of its recall lay letter to the sixth grade reading level. The purpose of this study was to analyze the effect of improved readability on patient follow-up rates.

METHODS

In this retrospective study, data from all screening mammograms at a single institution with BI-RADS category 0 assessments excluding technical recalls between February 2018 to February 2019 (pre-intervention group) and February 2019 to February 2020 (post-intervention group) were reviewed. The primary outcome measure was the percentage of patients in each intervention group who returned for their diagnostic follow-up examination within 60 days (the standard recommended by the Centers for Disease Control and Prevention). Univariate and multivariate logistic regression was done to estimate odds ratios and 95% confidence intervals for follow-up within 60 days.

RESULTS

This study included 1,987 patients in the pre-intervention group and 2,211 patients in the post-intervention group. The patient follow-up rate within 60 days increased from 90.1% (1,790 of 1,987) in the pre-intervention group to 93.9% (2,076 of 2,211) in the post-intervention group (P < .001). When controlling for imaging site, patients in the post-intervention group had 1.96-fold increased odds of returning for a diagnostic follow-up examination within 60 days (95% confidence interval, 1.52-2.53).

CONCLUSIONS

Revising an institution's recall lay letter to a lower reading grade level significantly improved timely patient follow-up.

A Qualitative Study of Spanish-Speakers' Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital

BACKGROUND

Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown.

OBJECTIVE

This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital.

DESIGN

Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings.

PARTICIPANTS

Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN.

APPROACH

Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN.

KEY RESULTS

Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up.

CONCLUSIONS

Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.

Communication Practices of Mammography Facilities and Timely Follow-up of a Screening Mammogram with a BI-RADS 0 Assessment

RATIONALE AND OBJECTIVES

The objective of this study was to evaluate the association of communication practices with timely follow-up of screening mammograms read as Breast Imaging Reporting and Data Systems (BI-RADS) 0 in the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

MATERIALS AND METHODS

A radiology facility survey was conducted in 2015 with responses linked to screening mammograms obtained in 2011-2014. We considered timely follow-up to be within 15 days of the screening mammogram. Generalized estimating equation models were used to evaluate the association between modes of communication with patients and providers and timely follow-up, adjusting for PROSPR site, patient age, and race and ethnicity.

RESULTS

The analysis included 34,680 mammography examinations with a BI-RADS 0 assessment among 28 facilities. Across facilities, 85.6% of examinations had a follow-up within 15 days. Patients in a facility where routine practice was to contact the patient by phone if follow-up imaging was recommended were more likely to have timely follow-up (odds ratio [OR] 4.63, 95% confidence interval [CI] 2.76-7.76), whereas standard use of mail was associated with reduced timely follow-up (OR 0.47, 95% CI 0.30-0.75). Facilities that had standard use of electronic medical records to report the need for follow-up imaging to a provider had less timely follow-up (OR 0.56, 95% CI 0.35-0.90). Facilities that routinely contacted patients by mail if they missed a follow-up imaging visit were more likely to have timely follow-up (OR 1.65, 95% CI 1.02-2.69).

CONCLUSIONS

Our findings support the value of telephone communication to patients in relation to timely follow-up. Future research is needed to evaluate the role of communication in completing the breast cancer screening episode.

How do breast imaging centers communicate results to women with limited English proficiency and other barriers to care?

Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

The PAADRN study: a design for a randomized controlled practical clinical trial to improve bone health

INTRODUCTION

To describe the rationale and design of an NIH funded randomized controlled trial: the Patient Activation after DXA Result Notification (PAADRN) study. The aim of this trial is to evaluate the effect that a direct mailing of Dual-Energy X-ray Absorptiometry (DXA) results from bone density testing centers to patients will have on patients' knowledge, treatment and self-efficacy.

METHODS

We will enroll approximately 7500 patients presenting for DXA at three study sites, the University of Iowa, the University of Alabama at Birmingham, and Kaiser Permanente of Atlanta, Georgia. We will randomize providers (and their respective patients) to either the intervention arm or usual care. Patients randomized to the intervention group will receive a letter with their DXA results and an educational brochure, while those randomized to usual care will receive their DXA results according to standard practice. The seven discrete outcomes are changes from baseline to 12-weeks and/or 52-weeks post-DXA in: (1) guideline concordant pharmacologic and non-pharmacologic therapy; (2) knowledge of DXA results; (3) osteoporosis-specific knowledge; (4) general health-related quality of life; (5) satisfaction with bone-related health care, (6) patient activation; and, (7) osteoporosis-specific self-efficacy.

CONCLUSION

This trial will offer evidence of the impact of a novel approach-direct-to-patient mailing of test results-to improve patient activation in their bone health care. The results will inform clinical practice for the communication of DXA and other test results.

Urban women's preferences for learning of their mammogram result: a qualitative study

Research suggests that communication of mammogram results is flawed for many low-income ethnic minority women. This study conducted four focus groups with low-income inner-city minority women (n = 34). The goals of our project were: (1) to elucidate women's experiences learning of their result; (2) to elicit their preferences as to how this communication could be improved; and (3) to gather information to help inform the development of a new tool for communicating mammogram results. Salient themes included dissatisfaction with result communication; difficulty elucidating the meaning of a typical results notification letter; a preference for direct verbal communication of results and for print materials that included pictures, testimonials, and an action plan including a hotline to call with questions; and a strong interest in advance education about the likelihood of having to return for additional follow up. Video and other programs to inform patients before the test about what happens after may improve patient satisfaction and enhance women's understanding of their personal result and follow up plan.