Mammography Self-Report and Mammography Claims

Utilization of Mammography During the Last Year of Life Among Older Breast Cancer Survivors

Background: Mammography is generally recommended for breast cancer survivors. However, discussion is ongoing about stopping surveillance mammography when life expectancy is <5-10 years as the benefit of screening might be diminished toward the end of life. The utilization pattern of mammography in the last year of life among this population has not been well studied. Methods: We identified 58,736 females diagnosed with breast cancer between January 2002 and December 2015, who died at the age of at least 67, from the SEER-Medicare database. We examined the utilization patterns of mammography during their last year of life and investigated factors associated with the use of mammography at the end of life using a multivariable logistic regression model. Results: Overall, 28.5% of the patients received mammography during the last year of life. Multivariable logistic regression showed that older age (OR = 0.31, 95% CI = 0.29-0.34, p < 0.001 for 95 vs. 85 years old), more advanced cancer stage (OR = 0.22, 95% CI = 0.20-0.24 p < 0.001 for distant vs. localized disease), and higher comorbidity score (OR = 0.92, 95% CI = 0.91-0.93, p < 0.001 for every 1-point increase) were associated with less mammography use. Age was nonlinearly associated with mammography use, with a steady proportion of patients receiving a mammography until approximately age 80 and then a sharp decrease thereafter. Conclusion: This population-based study found that a sizable proportion of older breast cancer survivors received mammography during the last year of life.

Screening Mammography Utilization Among Female Medicare Beneficiaries and Breast Cancer Survivors in 2002-2016

Background: The use of screening mammography varies by patient characteristics. This study examined the annual mammography utilization trends among female Medicare beneficiaries and breast cancer survivors, overall and by beneficiary characteristics. Materials and Methods: This retrospective, serial cross-sectional study used the 2002-2016 Medicare Current Beneficiary Survey (MCBS), including fee-for-service female Medicare beneficiaries who resided in community settings and who completed the survey (n = 53,788, weighted n = 206,259,890). Self-reported mammography utilization and breast cancer history were identified through the survey. Annual trends in the proportion of using mammography were examined using simple linear regression models, overall and by beneficiary's age, race, geographic region, and count of comorbidities. Multivariable models with generalized estimating equations were used to examine factors associated with mammography utilization. Results: Overall, the mammography utilization trends significantly decreased during the 2002-2016 period for both cohorts (p = 0.004 for female beneficiaries from 50.85% in 2002 to 40.55% in 2016 and p = 0.041 for breast cancer survivors from 68.36% in 2002 to 55.21% in 2016). Among female beneficiaries, trends also significantly decreased in different age groups, Whites, residential regions (Midwest, South, West, Metro, and Nonmetro), and count of comorbid conditions (all p < 0.05). Trends also declined among the breast cancer survivors who were ≥70 years old, ≥40 years old, and in South region (all p < 0.05). Beneficiary's demographic and socioeconomic factors, comorbidity, smoking, and health status were associated with the likelihood of screening mammography utilization among female beneficiaries; however, such associations were limited among breast cancer survivors. Conclusions: In 2002-2016, the overall trends in mammography use among female Medicare beneficiaries and breast cancer survivors declined significantly. Variations in mammography use among different subgroups were observed.

Using Public Claims Data for Neighborhood Level Epidemiologie Surveillance of Breast Cancer Screening: Findings from Evaluating a Patient Navigation Program in Chicago's Chinatown

OBJECTIVES

This study was designed to evaluate a patient navigation program undertaken with our community partners in Chicago's Chinatown. Inadvertently, the study collected data on two biannual mammography screening cycles that coincided almost exactly with implementation of the Affordable Care Act (ACA) in Illinois.

METHODS

The study uses claims data to profile mammography screening rates for residents of an 18 zip code, 398 census tract area on Chicago's near south and southwest side. Patient addresses were geocoded from biannual (August 2011 to July 2103 and August 2103 to July 2015) Illinois Medicaid and Illinois Breast and Cervical Cancer Program (IBCCP) claims. Screening rates are presented separately for low-income women ages 40 to 49 and 50 to 64 years. We compare change between 16 tracts with greater than 20% Chinese ancestry, 85 tracts with 1% to 20% Chinese ancestry, and 297 tracts with less than 1% Chinese ancestry.

RESULTS

There were more than 65,000 low-income women age 40 to 64 in the study area (mammogram patients were 63% Black, 23% Hispanic, 10% White, 2.5% Asian, and 2.5% other/unknown race and ethnicity). The increase in screening was greatest in Chinatown, although mean rates were not significantly different across the three areas (p = .07).

DISCUSSION

Our results demonstrate large increases in mammography screening after ACA implementation in 20132014. The greatest increase occurred in the Chinatown patient navigation program area. The study provides a template for programs aimed at using public community-area data to evaluate programs for improving access to care and health equity.

Lack of validity of self-reported mammography data

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Screening mammography use in older women according to health status: a systematic review and meta-analysis

Background

The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective

The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources

We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection

We included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis

ORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.

Main outcomes and measures

The primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.

Results

Of 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).

Conclusion

Greater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

The Role of Socioeconomic Status and Health Care Access in Breast Cancer Screening Compliance Among Hispanics

OBJECTIVES

Considerable disparities in breast cancer screening exist between Hispanic and non-Hispanic white (NHW) women. Identifying and quantifying the factors contributing to these racial-ethnic disparities can help shape interventions and policies aimed at reducing these disparities. This study, for the first time, identified and quantified individual-level sociodemographic and health-related factors that contribute to racial-ethnic disparities in breast cancer screening using the nonlinear Blinder-Oaxaca decomposition method.

METHODS

Analysis of the retrospective pooled cross-sectional Medical Expenditure Panel Survey data from 2000 to 2010 was conducted. Women aged 40 years and older were included in the study. Logistic regressions were used to estimate racial-ethnic disparities in breast cancer screening. Nonlinear Blinder-Oaxaca decomposition method was used to identify and quantify the contribution of each individual-level factor toward racial-ethnic disparities.

RESULTS

Based on the unadjusted analyses, Hispanic women had lower odds of receiving mammogram screening (MS) (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.69-0.80) and breast cancer screening (OR: 0.75; 95% CI: 0.70-0.81) as compared with NHW women. However, the relationship reversed in adjusted analyses, such that Hispanic women had higher odds of receiving MS (OR: 1.27; 95% CI: 1.16-1.40) and breast cancer screening (OR: 1.28; 95% CI: 1.17-1.40) as compared with NHW women. The Blinder-Oaxaca decomposition estimated that improving insurance status, access to care, education, and income will considerably increase screening rates among Hispanic women.

CONCLUSIONS

The study projects that improving health care access and health education will considerably increase breast cancer screening compliance among Hispanic women. Policies like the Affordable Care Act, and patient navigation and health education interventions, might considerably reduce screening disparities in the Hispanic population.

Self-Report Versus Medical Record for Mammography Screening Among Minority Women

Self-report is the most common means of obtaining mammography screening data. The purpose of this study was to assess the accuracy of minority women's self-reported mammography by comparing their self-reported dates of mammograms with those in their medical records from a community-based randomized control trial. We found that out of 192 women, 116 signed the Health Information Portability and Accountability Act form and, among these, 97 had medical records that could be verified (97 / 116 = 83.6%). Ninety-two records matched where both sources confirmed a mammogram; 48 of 92 (52.2%) matched perfectly on self-reported date of mammogram. Complexities in the verification process warrant caution when verifying self-reported mammography screening in minority populations. In spite of some limitations, our findings support the usage of self-reported data on mammography as a validated tool for other researchers investigating mammography screening among minority women who continue to have low screening rates.

The Effect of the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations on Mammography Rates

OBJECTIVE

To examine the effect of a change in U.S. Preventive Services Task Force (USPSTF) screening guidelines on mammography rates in the United States.

PRINCIPAL FINDINGS

In 2010, the year following the change in guidelines, 12-month mammography prevalence among women aged 40-49 years fell by 2.09 percentage points (95 percent confidence interval [CI]: -2.87 to -1.31) from 54.63 percent in 2008. For women aged 50-74 years, and aged 75 years and older, 12-month screening rates were 2.21 (95 percent CI: -2.65 to -1.77) and 3.60 (95 percent CI: -4.48 to -2.70) percentage points lower than those in 2008. In 2012, for women aged 40-49 years, 12-month prevalence fell to 52.51 percent, a decline of 2.12 percentage points (95 percent CI: -2.79 to -1.32) relative to screening rates prior the USPSTF announcement. For women aged 50-74 years and aged 75 years and older screening rates were 2.45 (95 percent CI: -2.96 to -2.07) and 5.71 (95 percent CI: -6.61 to -4.81) percentage points lower, respectively, in 2012 than in 2008.

CONCLUSION

This study demonstrates an immediate and lasting reduction in the rates of breast cancer screening among women of all age groups after the 2009 revision of screening guidelines by the USPSTF.

Predicting Incongruence between Self-reported and Documented Colorectal Cancer Screening in a Sample of African American Medicare Recipients

Assessments of colorectal cancer (CRC) screening rates typically rely on self-reported screening data, which are often incongruent with medical records. We used multilevel models to examine health-related, socio-demographic and psychological predictors of incongruent self-reports for CRC screening among Medicare-insured African Americans (N = 3,740). Results indicated that living alone decreased, and income increased, the odds of congruently self-reporting endoscopic CRC screening. Being male and having greater number of comorbidities decreased, and having less than a high school education increased, the odds of congruently self-reported fecal occult blood tests. Living alone, age and income had the most robust effects across classifications into one of four mutually exclusive categories defined by screening status (screened/unscreened) and congruence of self-reports. The results underscore the clinical importance of gathering socio-demographic data via patient interviews, and the relevance of these data for judging the veracity of self-reported CRC screenings behaviors.

Recent trends in adherence to continuous screening for breast cancer among Medicare beneficiaries

OBJECTIVE

The aim of this study is to examine recent trends in adherence to continuous screening, especially the rate of subsequent screening mammography following an initial screening before and after the U.S. Preventive Services Task Force (USPSTF) revised its guidelines on breast cancer in November 2009.

METHODS

We retrospectively analyzed Medicare fee-for-service claims data to: 1) compare rate of subsequent screening mammography over 27 month periods for 317,150 women screened in either 2004 or 2009; and 2) examine patterns of subsequent screening by age and race.

RESULTS

When adjusted for age, race, state of residence, county-level covariates, and clustered on ordering provider, the rate of subsequent screening decreased in 2009 relative to 2004 (OR=0.75; 95% CI: 0.74-0.76). Adjusted odds ratios are similar for alternative follow-up windows (15 months, 0.71; 24 months, 0.70; 30 months 0.75). The decline was mostly attributable to women 75 and older who are now less likely to return for a subsequent screening. Although USPSTF guidelines call for 24 months, approximately half of women continue screening at 12-month intervals in both cohorts.

CONCLUSIONS

The rate of subsequent screening mammography has declined after 2009. Older women seem to follow the revised USPSTF guideline, but confusion by physicians and patients about competing guidelines may be contributing to these findings.

Validating self-reported mammography use in vulnerable communities: findings and recommendations

BACKGROUND

Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past 2 years) at about 70% to 80% regardless of race or residence. We examined the potential extent of overreporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use.

METHODS

Using venue-based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n = 2,200) and to provide consent to view their medical record. Of the 1,909 women who screened eligible for medical record review, 1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n = 1,221). We compared the self-reported responses from the survey with the imaging reports found in the medical record (documented). To account for missing data, we conducted multiple imputations for key demographic variables and report standard measures of accuracy.

RESULTS

Although 73% of women self-reported a mammogram in the last 2 years, only 44% of self-reports were documented. Overreporting of mammography use was observed for all three ethnic groups.

CONCLUSIONS

These results suggest considerable overestimation of prevalence of use in these vulnerable populations.

IMPACT

Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities.

Mammography utilization among Black and White Medicare beneficiaries in high breast cancer mortality US counties

BACKGROUND

Disparities in US breast cancer mortality between older Black and White women have increased in the last 20 years. Regular mammography use is important for early detection and treatment: its utilization among older Blacks especially in counties with high Black mortality is of interest, but its extent and determinants are unknown.

METHODS

We used Medicare claims for Black and White women 65–74 years old in 203 counties with the highest Black breast cancer mortality. Outcomes over 6 years were as follows: ever mammogram, i.e., C 1 screening mammogram, and regular mammogram, i.e., C 3 mammograms. With logistic regressions, we examined the independent effect of race on screening controlling for individual- and county-level factors.

RESULTS

Of 406,602 beneficiaries, 17 % were Black. Ever and regular mammogram was significantly lower among Blacks (51.6 vs. 56.9 %; 32.9 vs. 43.1 %, respectively). Controlling for covariates, including use of cervical cancer screening, flu shots, or lipids tests, Black women were more likely to have ever mammogram (OR 1.23, CI 1.20–1.25), but not regular mammogram (OR 0.95, CI 0.93–0.97) than White women. County-level managed care penetration was negatively associated with ever and regular mammograms.

CONCLUSIONS

In Medicare enrollees from these counties, breast cancer screening was low. Black women had same or better odds of screening than White women. Some health care factors, e.g., managed care, were negatively associated with screening. Further studies on the determinants of mammography utilization in older women from these counties are warranted.

Health literacy and cancer screening: a systematic review

OBJECTIVE

To evaluate published evidence about health literacy and cancer screening.

METHODS

Seven databases were searched for English language articles measuring health literacy and cancer screening published in 1990-2011. Articles meeting inclusion criteria were independently reviewed by two investigators using a standardized data abstraction form. Abstracts (n=932) were reviewed and full text retrieved for 83 articles. Ten articles with 14 comparisons of health literacy and cancer screening according to recommended medical guidelines were included in the analysis.

RESULTS

Most articles measured health literacy using the S-TOFHLA instrument and documented cancer screening by self-report. There is a trend for an association of inadequate health literacy and lower cancer screening rates, however, the evidence is mixed and limited by study design and measurement issues.

CONCLUSION

A patient's health literacy may be a contributing factor to being within recommended cancer screening guidelines.

PRACTICE IMPLICATIONS

Future research should: be conducted using validated health literacy instruments; describe the population included in the study; document cancer screening test completion according to recommended guidelines; verify the completion of cancer screening tests by medical record review; adjust for confounding factors; and report effect size of the association of health literacy and cancer screening.

Accuracy of self-reported cervical and breast cancer screening by women with intellectual disability

This study examines the accuracy of self-report of cervical and breast cancer screening by women with intellectual disability (n  =  155). Data from face-to-face interviews and medical records were analyzed. Total agreement, sensitivity, specificity, positive predictive value and negative predictive value were calculated. Total agreement between self-report and medical record on receipt of both procedures was 75% for Pap test and 87% for mammography. Self-reported Pap tests and mammography showed >90% sensitivity, but specificity was low for both procedures (41% for Pap test, 30% for mammogram), indicating overreporting of receipt of Pap tests and mammography similar to women without disabilities. Clinicians and researchers are cautioned to corroborate self-reported data with other sources for patients and research participants with intellectual disability.

Mammography rates after the 2009 US Preventive Services Task Force breast cancer screening recommendation

OBJECTIVE

To measure the impact of the 2009 US Preventive Services Task Force (USPSTF) breast cancer screening recommendation, which recommended against routine screening for women aged 40 to 49 and stated that there was "insufficient evidence" to recommend screening for women aged 75 and older, on mammography rates.

METHODS

Self-reported mammography rates were calculated using the 2006-2010 Medical Expenditure Panel Surveys (n=29,857). The paper reports mammography rates by age group (40 to 49, 50 to 74, and 75 and older), adjusted for age, race/ethnicity, socioeconomic status, and region. The study was performed at Emory University in Atlanta, Georgia, USA in 2012.

RESULTS

Differences in mammography rates between 2010 and earlier years were not significant. Among women aged 40-49, biennial mammography rates declined by -0.5 percentage points between 2006 to 2009 and 2010 (95% confidence interval [CI]: -3.0 to 1.9; p=0.67). Among women aged 50-74, rates declined by -0.07 percentage points (95% CI: -1.8 to 1.7; p=0.93). Among women aged 75 years and older, rates declined by -0.1 percentage points (95% CI: -4.2 to 3.9; p=0.94).

CONCLUSION

The revision to the USPSTF breast cancer screening recommendation did not affect screening patterns.

Self-reported cancer screening among elderly Medicare beneficiaries: a rural-urban comparison

PURPOSE

We examined the rural-urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening.

METHODS

Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural-urban disparity and rurality's independent impact on cancer screening, controlling for patient, and area factors.

RESULTS

From urban, large rural, small rural, and isolated rural areas, the rates for mammogram last year were 53%, 52%, 45%, and 44%, respectively. They were 56%, 50%, 48%, and 43% for CRC screening, respectively. After controlling for patient and area level characteristics, rurality is significantly associated with CRC screening, but not mammogram.

CONCLUSIONS

We found rural-urban disparities for both mammogram and CRC screenings. Patient and area factors totally eliminated the rural-urban disparity for mammogram but not CRC screening. Health promotions to improve cancer screening should focus more on small and isolated rural areas.

Methodological issues in using multiple years of the Medicare current beneficiary survey

BACKGROUND

The analysis presented in this paper examines the multi-year capacity of the Medicare Current Beneficiary Survey (MCBS).

METHODS

We systematically reviewed the literature for methodological approaches in research using multiple years of the MCBS and categorized the studies by study design, use of survey sampling weights, and variance adjustments. We then replicated the approaches in an empirical demonstration using functional status (activities of daily living (ADL) and 2005-2007 MCBS data.

RESULTS

In the systematic review, we identified 22 pooled, 17 repeated cross-sectional, and 17 longitudinal studies. Less than half of these studies explicitly described the weighting approach or variance estimation. In the empirical demonstration, we showed that different study designs and weighting approaches will yield statistically different estimates.

CONCLUSION

There is a variety of methodological approaches when using multiple years of the MCBS, and some of them provide biased results. Research needs to improve in describing the methods and preferred approaches for using these complex data.

Geographic access and the use of screening mammography

BACKGROUND

Screening mammography rates vary geographically and have recently declined. Inadequate mammography resources in some areas may impair access to this technology. We assessed the relationship between availability of mammography machines and the use of screening.

METHODS

The location and number of all mammography machines in the United States were identified from US Food and Drug Administration records of certified facilities. Inadequate capacity was defined as <1.2 mammography machines per 10,000 women age 40 or older, the threshold required to meet the Healthy People 2010 target screening rate. The impact of capacity on utilization was evaluated in 2 cohorts: female respondents age 40 or older to the 2006 Behavioral Risk Factor Surveillance System survey (BRFSS) and a 5% nationwide sample of female Medicare beneficiaries age 65 or older in 2004-2005.

RESULTS

About 9% of women in the BRFSS cohort and 13% of women in the Medicare cohort lived in counties with <1.2 mammography machines per 10,000 women age 40 or older. In both cohorts, residence in a county with inadequate mammography capacity was associated with lower odds of a recent mammogram (adjusted odds ratio in BRFSS: 0.89, 95% CI: 0.80-0.98, P < 0.05; adjusted odds ratio in Medicare: 0.86, 95% CI: 0.85-0.87, P < 0.05), controlling for demographic and health care characteristics.

CONCLUSION

In counties with few or no mammography machines, limited availability of imaging resources may be a barrier to screening. Efforts to increase the number of machines in low-capacity areas may improve mammography rates and reduce geographic disparities in breast cancer screening.

Misconceptions about breast lumps and delayed medical presentation in urban breast cancer patients

BACKGROUND

Despite current recommendations for women to be screened for breast cancer with mammography every 1 to 2 years, less than half of all newly diagnosed breast cancers are initially detected through screening mammography. Prompt medical attention to a new breast symptom can result in earlier stage at diagnosis, yet many patients delay seeking medical care after becoming aware of a breast symptom.

METHODS

In a population-based study of breast cancer, we examined factors potentially associated with patient delay in seeking health care for a breast symptom among 436 symptomatic urban breast cancer patients (146 white, 197 black, and 95 Hispanic). Race/ethnicity, socioeconomic status, health care access and utilization, and misconceptions about the meaning of breast lumps were the key independent variables.

RESULTS

Sixteen percent of patients reported delaying more than 3 months before seeking medical advice about breast symptoms. Misconceptions about breast lumps and lacking a regular provider, health insurance, and recent preventive care were all associated with prolonged patient delay (P < 0.005 for all). Misconceptions were much more common among ethnic minorities and women of lower socioeconomic status.

CONCLUSION

Reducing patient delay and disparities in delay will require educating women about the importance of getting breast lumps evaluated in a timely manner and providing greater access to regular health care.

Mammography use among Black women: the role of electronic medical records

BACKGROUND AND AIMS

Accurately documenting mammography use is essential to assess quality of care for early breast cancer detection in underserved populations. Self-reports and medical record reports frequently result in different accounts of whether a mammogram was performed. We hypothesize that electronic medical records (EMRs) provide more accurate documentation of mammography use than paper records, as evidenced by the level of agreement between women's self-reported mammography use and mammography use documented in medical records.

METHODS

Black women aged 40-75 were surveyed in six primary care sites in Boston, Massachusetts (n = 411). Survey data assessed self-reported mammography prevalence within 2 years of study entry. Corresponding medical record data were collected at each site. Positive predictive value (PPV) of self-report and kappa statistics compared data agreement among sites with and without EMRs. Logistic regression estimated effects of site and patient characteristics on agreement between data sources.

RESULTS

Medical records estimated a lower prevalence of mammography use (58%) than self-report (76%). However, self-report and medical record estimates were more similar in sites with EMRs. PPV of self-report was 88% in sites with continuous access to EMRs and 61% at sites without EMRs. Kappa statistics indicated greater data agreement at sites with EMRs (0.72, 95% CI 0.56-0.88) than without EMRs (0.46, 95% CI 0.29-0.64). Adjusted for covariates, odds of data agreement were greatest in sites where EMRs were available during the entire study period (OR 4.31, 95% CI 1.67-11.13).

CONCLUSIONS

Primary care sites with EMRs better document mammography use than those with paper records. Patient self-report of mammography screening is more accurate at sites with EMRs. Broader access to EMRs should be implemented to improve quality of documenting mammography use. At a minimum, quality improvement efforts should confirm the accuracy of paper records with supplemental data.

Bias associated with self-report of prior screening mammography

BACKGROUND

Self-reported screening behaviors from national surveys often overestimate screening use, and the amount of overestimation may vary by demographic characteristics. We examine self-report bias in mammography screening rates overall, by age, and by race/ethnicity.

METHODS

We use mammography registry data (1999-2000) from the Breast Cancer Surveillance Consortium to estimate the validity of self-reported mammography screening collected by two national surveys. First, we compare mammography use from 1999 to 2000 for a geographically defined population (Vermont) with self-reported rates in the prior two years from the 2000 Vermont Behavioral Risk Factor Surveillance System. We then use a screening dissemination simulation model to assess estimates of mammography screening from the 2000 National Health Interview Survey.

RESULTS

Self-report estimates of mammography use in the prior 2 years from the Vermont Behavioral Risk Factor Surveillance System are 15 to 25 percentage points higher than actual screening rates across age groups. The differences in National Health Interview Survey screening estimates from models are similar for women 40 to 49 and 50 to 59 years and greater than for those 60 to 69, or 70 to 79 (27 and 26 percentage points versus 14, and 14, respectively). Overreporting is highest among African American women (24.4 percentage points) and lowest among Hispanic women (17.9) with non-Hispanic White women in between (19.3). Values of sensitivity and specificity consistent with our results are similar to previous validation studies of mammography.

CONCLUSION

Overestimation of self-reported mammography usage from national surveys varies by age and race/ethnicity. A more nuanced approach that accounts for demographic differences is needed when adjusting for overestimation or assessing disparities between populations.

Access to mammography screening in a large urban population: a multi-level analysis

Objective

To understand area-based sociodemographics, physician and medical practice characteristics, and community indicators associated with mammography use in Los Angeles County. An earlier multi-level analysis by Gumpertz et al. found that distance to the nearest mammography facility helped explain the higher proportion of Latinas diagnosed with late stage breast cancer compared with non-Latina Whites in Los Angeles County. Our study examined whether Latinas also have lower rates of mammography use.

Methods

We used a multi-level spatial modeling approach to examine individual and community level associations with mammography use among a diverse group of women aged 40–84 years in Los Angeles County. To build our multi-level spatial data set, we integrated five data sources: (1) 2001 California Health Interview Survey (CHIS) data, (2) 2001 Food and Drug Administration (FDA) certified mammography facility data, (3) 2003 LA Transit Authority data, (4) 2000 US Decennial Census data, and (5) 2001 Community Tracking Study (CTS) Physician’s Survey data.

Results

Our study confirmed for Los Angeles County many associations for mammography use found in other locations. An unexpected finding was that women with limited English proficiency (predominantly Latina) were significantly more likely to have had a recent mammogram than English-proficient women. We also found that, after controlling for other factors, mammography use was higher in neighborhoods with a greater density of mammography facilities.

Conclusion

Women with limited English proficiency were especially likely to report recent mammography in Los Angeles. This unexpected finding suggests that the intensive Spanish-language outreach program conducted by the Every Woman Counts (EWC) Program in low-income Latina communities in Los Angeles has been effective. Our study highlights the success of this targeted community-based outreach conducted between 1999 and 2001. These are the same populations that Gumpertz et al. identified as needing intervention. It would be useful to conduct another study of late-stage diagnosis in Los Angeles County to ascertain whether increased rates of mammography have also led to less late-stage diagnosis among Latinas in the neighborhoods where they are concentrated in Los Angeles.

Cancer screening in a middle-aged general population: factors associated with practices and attitudes

BACKGROUND

The aim of this study was to identify factors associated with cancer screening practices and with general attitudes toward cancer screening in a general population.

METHODS

Mailed survey of 30-60 year old residents of Geneva, Switzerland, that included questions about screening for five cancers (breast, cervix uteri, prostate, colon, skin) in the past 3 years, attitudes toward screening, health care use, preventive behaviours and socio-demographic characteristics. Cancer screening practice was dichotomised as having done at least one screening test in the past 3 years versus none.

RESULTS

The survey response rate was 49.3% (2301/4670). More women than men had had at least one cancer screening test in the past 3 years (83.2% vs 34.5%, p < 0.001). A majority of women had had a cervical smear (76.6%) and a mammography (age 30-49: 35.0%; age 50 and older: 90.3%); and 55.1% of men 50-60 years old had been screened for prostate cancer. Other factors associated with screening included older age, higher income, a doctor visit in the past 6 months, reporting a greater number of preventive behaviours and a positive attitude toward screening. Factors linked with positive attitudes included female gender, higher level of education, gainful employment, higher income, a doctor visit in the past 6 months and a personal history of cancer.

CONCLUSION

Attitudes play an important role in cancer screening practices among middle-aged adults in the general population, independent of demographic variables (age and sex) that determine in part screening recommendations. Negative attitudes were the most frequent among men and the most socio-economically disadvantaged. The moderate participation rate raises the possibility of selection bias.

Race and the validity of self-reported cancer screening behaviors: development of a conceptual model

BACKGROUND

Many estimates of cancer screening are based on self-reported screening behavior. There is growing concern that self-reported screening measures may be less accurate among members of racial and ethnic minority groups. This would have considerable implications for research on racial and ethnic disparities in cancer screening.

OBJECTIVES

To review the literature on the relationship between race/ethnicity and the accuracy of self-reported cancer screening behavior and develop a conceptual framework that would provide a deeper understanding of factors underlying this relationship.

METHODS

We developed a conceptual framework drawing from diverse literatures including validation studies examining the accuracy of self-reported cancer screening behaviors and articles on survey response bias.

RESULTS AND CONCLUSIONS

Evidence suggests that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that overreporting may be particularly problematic. Research conducted in other areas suggests that these sources of measurement error may stem from cognitive and motivational processes and that they can be moderated by question wording and data collection characteristics. At this point, however, the quality of the evidence is not strong and more research is needed before definitive conclusions can be drawn.

Do managed care plans' tiered networks lead to inequities in care for minority patients?

This study examined whether specialists designated as meeting efficiency thresholds in an insurance company's performance network were less likely than non-designated specialists to treat minority patients insured by that company. Claims data were used to identify patients treated by specialists. Claimants' race/ethnicity status was self-reported to the insurer at enrollment. In large part, minority patients appeared to be evenly distributed across the performance network, with the exception of Asian/Pacific Islanders, who appeared to be more likely to be treated by nondesignated physicians than by designated "good-performing" specialists.

Challenges for multilevel health disparities research in a transdisciplinary environment

Numerous factors play a part in health disparities. Although health disparities are manifested at the level of the individual, other contexts should be considered when investigating the associations of disparities with clinical outcomes. These contexts include families, neighborhoods, social organizations, and healthcare facilities. This paper reports on health disparities research as a multilevel research domain from the perspective of a large national initiative. The Centers for Population Health and Health Disparities (CPHHD) program was established by the NIH to examine the highly dimensional, complex nature of disparities and their effects on health. Because of its inherently transdisciplinary nature, the CPHHD program provides a unique environment in which to perform multilevel health disparities research. During the course of the program, the CPHHD centers have experienced challenges specific to this type of research. The challenges were categorized along three axes: sources of subjects and data, data characteristics, and multilevel analysis and interpretation. The CPHHDs collectively offer a unique example of how these challenges are met; just as importantly, they reveal a broad range of issues that health disparities researchers should consider as they pursue transdisciplinary investigations in this domain, particularly in the context of a large team science initiative.

Ethnic differences in the use of regular mammography: the multiethnic cohort

Women's regular use of mammography over a 6 year interval was examined among women aged 45-75 in the Hawaii and Los Angeles Multiethnic Cohort (MEC). The analyses included 81,722 African American, Japanese, Latina, Native Hawaiian, and White females using self-reported mammography history from 1993 to 1998. Ninety-one percent of MEC women reported ever having a mammogram, however only 36% reported regular annual and 48% reported regular biennial mammography over the interval. Mammography was lowest among women who were obese, had a high school education or less, or who were aged 70 and over. Regular mammography use during follow-up was low compared to prior studies reporting on recent mammography. African American, Latina, and Native Hawaiian women had significantly lower annual and biennial mammography use compared to White women even after controlling for age, education, family history, body mass index and hormone therapy indicating that gaps exist in mammography that remain unexplained by known predictors of screening behavior.

Preventive services use among women seen by gynecologists, general medical physicians, or both

OBJECTIVE

To estimate how preventive services and counseling differ for women seen by general medical physicians and gynecologists, and whether seeing both types of physicians had a greater impact on delivery of gender-specific and gender-neutral preventive care than by either type of physician alone.

METHODS

Using data from the 2000 National Health Interview Survey, we studied the association of provider type with Pap tests, tobacco use screening, and exercise and diet counseling among women 18-64 years (n=7,317), and these services along with clinical breast examinations, mammograms, and colon cancer screening among women aged 50-64 years (n=1,551). We modeled care using multivariable logistic regression and used propensity score techniques to limit selection bias from choice of provider.

RESULTS

In the study sample, 15% were seen by general medical physicians, 62% by gynecologists, and 23% by both. Overall rates of gender-specific services (Pap test, clinical breast examination, mammography) were high (88-95%), whereas gender-neutral services were low (23-53%). Patients of gynecologists only were more likely to have Pap tests (adjusted relative risk [RR] 1.26, 95% confidence interval [CI] 1.24-1.27), tobacco use screening (adjusted RR 1.08, 95% CI 1.02-1.14), mammography (adjusted RR 1.25, 95% CI 1.20-1.28), and clinical breast examination (adjusted RR 1.25, 95% CI 1.19-1.29). In general, combined gynecologist and general care did not increase the likelihood of preventive care. Propensity score analyses confirmed these results.

CONCLUSION

Patients of gynecologists receive more preventive services compared with patients of general medical physicians, although rates of gender-neutral services were low regardless of provider type. These findings validate gynecologists' roles as providers of basic preventive care services but demonstrate that considerable room exists to improve delivery of preventive care to women.

Accuracy of self-reported cancer-screening histories: a meta-analysis

BACKGROUND

Survey data used to study trends in cancer screening may overestimate screening utilization while potentially underestimating existing disparities in use.

METHODS

We did a literature review and meta-analysis of validation studies examining the accuracy of self-reported cancer-screening histories. We calculated summary random-effects estimates for sensitivity and specificity, separately for mammography, clinical breast exam (CBE), Pap smear, prostate-specific antigen testing (PSA), digital rectal exam, fecal occult blood testing, and colorectal endoscopy.

RESULTS

Sensitivity was highest for mammogram, CBE, and Pap smear (0.95, 0.94, and 0.93, respectively) and lowest for PSA and digital rectal exam histories (0.71 and 0.75). Specificity was highest for endoscopy, fecal occult blood testing, and PSA (0.90, 0.78, and 0.73, respectively) and lowest for CBE, Pap smear, and mammogram histories (0.26, 0.48, and 0.61, respectively). Sensitivity and specificity summary estimates tended to be lower in predominantly Black and Hispanic samples compared with predominantly White samples. When estimates of self-report accuracy from this meta-analysis were applied to cancer-screening prevalence estimates from the National Health Interview Survey, results suggested that prevalence estimates are artificially increased and disparities in prevalence are artificially decreased by inaccurate self-reports.

CONCLUSIONS

National survey data are overestimating cancer-screening utilization for several common procedures and may be masking disparities in screening due to racial/ethnic differences in reporting accuracy.

Studying prescription drug use and outcomes with medicaid claims data: strengths, limitations, and strategies

Medicaid claims and eligibility data, particularly when linked to other sources of patient-level and contextual information, represent a powerful and under-used resource for health services research on the use and outcomes of prescription drugs. However, their effective use poses many methodological and inferential challenges. This article reviews strengths, limitations, challenges, and recommended strategies in using Medicaid data for research on the initiation, continuation, and outcomes of prescription drug therapies. Drawing from published research using Medicaid data by the investigators and other groups, we review several key validity and methodological issues. We discuss strategies for claims-based identification of diagnostic subgroups and procedures, measuring and modeling initiation and persistence of regimens, analysis of treatment disparities, and examination of comorbidity patterns. Based on this review, we discuss "best practices" for appropriate data use and validity checking, approaches to statistical modeling of longitudinal patterns in the presence of typical challenges, and strategies for strengthening the power and potential of Medicaid datasets. Finally, we discuss policy implications, including the potential for the research use of Medicare Part D data and the need for further initiatives to systematically develop and optimally use research datasets that link Medicaid and other sources of clinical and outcome information.

Disparities in preventive procedures: comparisons of self-report and Medicare claims data

Background

Racial/ethnic disparities are assessed using either self-report or claims data. We compared these two data sources and examined contributors to discrepancies in estimates of disparities.

Methods

We analyzed self-report and matching claims data from Medicare Beneficiaries 65 and older who participated in the Medicare Current Beneficiary Survey, 1999–2002. Six preventive procedures were included: PSA testing, influenza vaccination, Pap smear testing, cholesterol testing, mammography, and colorectal cancer testing. We examined predictors of self-reports in the absence of claims and claims in the absence of self-reports.

Results

With the exception of PSA testing, racial/ethnic disparities in preventive procedures are generally larger when using Medicare claims than when using patients' self-report. Analyses adjusting for age, gender, income, educational level, health status, proxy response and supplemental insurance showed that minorities were more likely to self-report preventive procedures in the absence of claims. Adjusted odds ratios ranged from 1.07 (95% CI: 0.88 – 1.30) for PSA testing to 1.83 (95% CI: 1.46 – 2.30) for Pap smear testing. Rates of claims in the absence of self-report were low. Minorities were more likely to have PSA test claims in the absence of self-reports (1.55 95% CI: 1.17 – 2.06), but were less likely to have influenza vaccination claims in the absence of self-reports (0.69 95% CI: 0.51 – 0.93).

Conclusion

These findings are consistent with either racial/ethnic reporting biases in receipt of preventive procedures or less efficient Medicare billing among providers with large minority practices.