Post on 31-Mar-2015
Barriers to Screening Mammography in an Urban Family
Medicine Residency Clinic
Bonnie H. Kwok, MPH, MD (c)
University of Wisconsin School of Medicine and Public Health
Wisconsin Health Improvement and Research Partnerships Forum
September 15, 2011
Topics to be Covered
• Purpose• Background• Literature Review• Methods• Results• Discussion• Next Steps
Research Goals1) To evaluate the barriers to breast cancer screening by mammography
2) To measure the effectiveness of an outreach program for breast cancer screening at Wingra clinic
3) To identify “missed opportunities” for screening patients at Wingra clinic
BackgroundBreast Cancer• Rank: 2nd leading cause of cancer death in US women• Incidence: 230,480 (2011)¹• Deaths: 40,970 (2007)²• Recent changes: screening mammogram every 2 years for
women ages 50-74• National screening rate: 71% (2008)³
¹National Cancer Institute at NIH, ²CDC, ³CDC
Wingra Clinic• Urban family medicine residency clinic • FQHC in South Madison• Diverse patient population
• Ethnically• 22.6% Hispanic/Latino• 22.1% African-American/Black• 6% Asian
• Geographically
Background
Breast Cancer Screening in 2009 P
erce
nta
ge
scre
ened
Screening test
Literature review
Literature search• Papers published in PubMed from 2006-2010• Search terms (MeSH and Keywords):
• mammography, mammogram, delivery of healthcare, quality improvement, preventive health services, barriers, and screening
Significant barriers at the patient, provider and structural levels
Patient Barriers to Screening Mammography
Variables• Race/ethnicity• Language• Insurance• BMI • Age • Family history of breast cancer • Smoking
Provider Barriers
Provider barriers• Lack of time, training, skill, and awareness• Lack of continuity with patient• Financial barriers• Cultural barriers• Assignment of higher priority to other health concerns/competing
demands• Physician fatigue• Negative attitude about breast cancer screening and mammography
Structural and Mammography-related Barriers
Structural barriers• Cost or lack of insurance• Failure to recall that patient is due for exam/lack of reminders• Poor documentation and charting within office• Lack of follow-up Barriers related to mammography • Patient reluctance/fear/anxiety• Challenges/delays to scheduling mammogram• Preparation by patients for procedure/adherence• Unpleasantness of procedure• Referrals (additional consultation)• Lack of direct access to mammography
HypothesesWe hypothesize that:
1) Several demographic factors are associated with failure to receive services:• Black, Hispanic, and Asian race/ethnicity• Primary language other than English• Insurance type (public and uninsured)
2) Outreach• Those who receive outreach services are more likely to be screened
3) Missed opportunities
The likelihood of having a screening mammogram ordered is increased if:• Seeing one’s own PCP • Provider receives a staff reminder in EMR• Health maintenance visit
Methods~10,000 Wingra patients in UW HealthLink
Inclusion criteria
9471) Female 2) Ages 50-743) Active Wingra patients4) Have a Wingra PCP
41) Breast cancer2) Double mastectomy3) Hospice4) Diagnostic
mammography5) Deceased
35 no longer Wingra patients
912 eligible patients
“Overdue”“Not due” or “Due soon”
512 (56.1%) Screened 400 (43.9%) Unscreened
Excluded Excluded
Results
Results
ResultsP
erce
nta
ge
scre
ened
Insurance type
Outreach and Missed Opportunities
Telephone outreach to “overdue” and “due soon” patients• 3 rounds of calls + 1 mailed letter• Interpreter services available
Missed opportunities:
Chart review of patient visits between May 9 – June 21, 2011
Visits n=142, Patients n=96• Primary Care Physician• Staff reminder• Health maintenance visit
Limitations and Challenges• Quality of data
• Small sample size for “Other” race/ethnicity (Asian, American Indian, Alaska Native, Native Hawaiian and other Pacific Islander)
(n=65 screened, n=37 unscreened)• Loss to follow-up
• Recent implementation of electronic ordering • Limited time and support from research staff• Only 1 staff member to conduct all outreach calls• Residency clinic
Discussion
Key Points:• Barriers – patient, provider, structural
• Insurance – having no insurance or public insurance• Race/ethnicity – minorities
What I learned:• Evidence-based guidelines for cancer screening • EMR data• Clinical duties vs. research responsibilities• Family medicine
Keep Calm and Carry On
• Analyze data from first round of outreach• Analyze “Missed Opportunities” data• Continue outreach • Begin patient focus groups
• Agree to getting a mammogram → Mammogram scheduled → No show
Acknowledgements
• Kirsten Rindfleisch, MD• Jon Temte, MD, PhD• Wingra clinic staff
• Shereen Vakili• UWSMPH Department of Family Medicine
• Ron Prince• Patrick Kwok, MFSA
Questions?
“Who ever thought up the word “mammogram”? Every time I hear it, I think I’m supposed to put my breast in an envelope and send it to someone.”
Jan King
Bonnie H. Kwok, MPH, MD (c)University of Wisconsin School of Medicine and Public Healthbkwok@wisc.edu