Estimating Breast Cancer Overdiagnosis After Screening Mammography Among Older Women in the United States.

BACKGROUND: Overdiagnosis is increasingly recognized as a harm of breast cancer screening, particularly for older women. OBJECTIVE: To estimate overdiagnosis associated with breast cancer screening among older women by age. DESIGN: Retrospective cohort study comparing the cumulative incidence of breast cancer among older women who continued screening in the next interval with those who did not. Analyses used competing risk models, stratified by age. SETTING: Fee-for-service Medicare claims, linked to the SEER (Surveillance, Epidemiology, and End Results) program. PATIENTS: Women 70 years and older who had been recently screened. MEASUREMENTS: Breast cancer diagnoses and breast cancer death for up to 15 years of follow-up. RESULTS: This study included 54 635 women. Among women aged 70 to 74 years, the adjusted cumulative incidence of breast cancer was 6.1 cases (95% CI, 5.7 to 6.4) per 100 screened women versus 4.2 cases (CI, 3.5 to 5.0) per 100 unscreened women. An estimated 31% of breast cancer among screened women were potentially overdiagnosed. For women aged 75 to 84 years, cumulative incidence was 4.9 (CI, 4.6 to 5.2) per 100 screened women versus 2.6 (CI, 2.2 to 3.0) per 100 unscreened women, with 47% of cases potentially overdiagnosed. For women aged 85 and older, the cumulative incidence was 2.8 (CI, 2.3 to 3.4) among screened women versus 1.3 (CI, 0.9 to 1.9) among those not, with up to 54% overdiagnosis. We did not see statistically significant reductions in breast cancer-specific death associated with screening. LIMITATIONS: This study was designed to estimate overdiagnosis, limiting our ability to draw conclusions on all benefits and harms of screening. Unmeasured differences in risk for breast cancer and differential competing mortality between screened and unscreened women may confound results. Results were sensitive to model specifications and definition of a screening mammogram. CONCLUSION: Continued breast cancer screening was associated with greater incidence of breast cancer, suggesting overdiagnosis may be common among older women who are diagnosed with breast cancer after screening. Whether harms of overdiagnosis are balanced by benefits and for whom remains an important question. PRIMARY FUNDING SOURCE: National Cancer Institute.

Comparative Effectiveness of Digital Breast Tomosynthesis and Mammography in Older Women.

BACKGROUND: Digital breast tomosynthesis (DBT) has become a prevalent mode of breast cancer screening in recent years. Although older women are commonly screened for breast cancer, little is known about screening outcomes using DBT among older women. OBJECTIVE: To assess proximal screening outcomes with DBT compared to traditional two-dimensional(2-D) mammography among women 67-74 and women 75 and older. DESIGN: Cohort study. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 67 years and older with no history of prior cancer who received a screening mammogram in 2015. MAIN MEASURES: Use of subsequent imaging (ultrasound and diagnostic mammography) as an indication of recall, breast cancer detection, and characteristics of breast cancer at the time of diagnosis. Analyses used weighted logistic regression to adjust for potential confounders. KEY RESULTS: Our study included 26,406 women aged 67-74 and 17,001 women 75 and older who were screened for breast cancer. Among women 75 and older, the rate of subsequent imaging among women screened with DBT did not differ significantly from 2-D mammography (91.8 versus 97.0 per 1,000 screening mammograms, p=0.37). In this age group, DBT was associated with 2.1 additional cancers detected per 1,000 screening mammograms compared to 2D (11.5 versus 9.4, p=0.003), though these additional cancers were almost exclusively in situ and stage I invasive cancers. For women 67-74 years old, DBT was associated with a higher rate of subsequent imaging than 2-D mammography (113.9 versus 100.3, p=0.004) and a higher rate of stage I invasive cancer detection (4.7 versus 3.7, p=0.002), but not other stages. CONCLUSIONS: Breast cancer screening with DBT was not associated with lower rates of subsequent imaging among older women. Most additional cancers detected with DBT were early stage. Whether detecting these additional early-stage cancers among older women improves health outcomes remains uncertain.

Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States.

BACKGROUND: Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs. METHODS: We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation. RESULTS: Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually. CONCLUSIONS: The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.

Dense Breast Notification Laws, Education, and Women's Awareness and Knowledge of Breast Density: a Nationally Representative Survey.

BACKGROUND: To date, 38 states have enacted dense breast notification (DBN) laws mandating that mammogram reports include language informing women of risks related to dense breast tissue. OBJECTIVE: Nationally representative survey to assess the association between residing in a state with a DBN law and women's awareness and knowledge about breast density, and breast cancer anxiety. DESIGN: Internet survey conducted in 2018 with participants in KnowledgePanel®, an online research panel. PARTICIPANTS: English-speaking US women ages 40-59 years without a personal history of breast cancer who had received at least one screening mammogram (N = 1928; survey completion rate 68.2%). MAIN MEASURES: (1) Reported history of increased breast density, (2) knowledge of the increased risk of breast cancer with dense breasts, (3) knowledge of the masking effect of dense breasts on mammography, and (4) breast cancer anxiety. KEY RESULTS: Women residing in DBN states were more likely to report increased breast density (43.6%) compared with women residing in non-DBN states (32.7%, p < 0.01, adjusted odds ratio, 1.70, 95% CI,1.34-2.17). Interaction effect between DBN states and education status showed that the impact of DBN on women's reporting of dense breasts was significant for women with greater than high school education, but not among women with a high school education or less (p value = 0.01 for interaction). Only 23.0% of women overall knew that increased breast density was associated with a higher risk of breast cancer, and 68.0% of women understood that dense breasts decreased the sensitivity of mammography. There were no significant differences between women in DBN states and non-DBN states for these outcomes, or for breast cancer-related anxiety. CONCLUSIONS: State DBN laws were not associated with increased understanding of the clinical implications of breast density. DBN laws were associated with a higher likelihood of women reporting increased breast density, though not among women with lower education.

Association of State Dense Breast Notification Laws With Supplemental Testing and Cancer Detection After Screening Mammography.

OBJECTIVES: To evaluate the association of state dense breast notification (DBN) laws with use of supplemental tests and cancer diagnosis after screening mammography. METHODS: We examined screening mammograms (n = 1 441 544) performed in 2014 and 2015 among privately insured women aged 40 to 59 years living in 9 US states that enacted DBN laws in 2014 to 2015 and 25 US states with no DBN law in effect. DBN status at screening mammography was categorized as no DBN, generic DBN, and DBN that mandates notification of possible benefits of supplemental screening (DBN+SS). We used logistic regression to examine the change in rate of supplemental ultrasound, magnetic resonance imaging, breast biopsy, and breast cancer detection. RESULTS: DBN+SS laws were associated with 10.5 more ultrasounds per 1000 mammograms (95% CI = 3.0, 17.6 per 1000; P = .006) and 0.37 more breast cancers detected per 1000 mammograms (95% CI = 0.05, 0.69 per 1000; P = .02) compared with no DBN law. No significant differences were found for generic DBN laws in either ultrasound or cancer detection. CONCLUSIONS: DBN legislation is associated with increased use of ultrasound and cancer detection after implementation only when notification of the possible benefits of supplemental screening is required.

Thrombophilia testing in the inpatient setting: impact of an educational intervention.

BACKGROUND: Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients. METHODS: During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention. RESULTS: Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls. CONCLUSION: A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.

Breast Density Notification Legislation and Breast Cancer Stage at Diagnosis: Early Evidence from the SEER Registry.

BACKGROUND: Twenty-eight states have passed breast density notification laws, which require physicians to inform women of a finding of dense breasts on mammography. OBJECTIVE: To evaluate changes in breast cancer stage at diagnosis after enactment of breast density notification legislation. DESIGN: Using a difference-in-differences analysis, we examined changes in stage at diagnosis among women with breast cancer in Connecticut, the first state to enact legislation, compared to changes among women in control states. We used data from the Surveillance, Epidemiology, and End Results Program (SEER) registry, 2005-2013. PARTICIPANTS: Women ages 40-74 with breast cancer. INTERVENTION: Breast density notification legislation, enacted in Connecticut in October of 2009. MAIN MEASURE: Breast cancer stage at diagnosis. KEY RESULTS: Our study included 466,930 women, 25,592 of whom lived in Connecticut. Legislation was associated with a 1.38-percentage-point (95 % CI 0.12 to 2.63) increase in the proportion of women in Connecticut versus control states who had localized invasive cancer at the time of diagnosis, and a 1.12-percentage-point (95 % CI -2.21 to -0.08) decline in the proportion of women with ductal carcinoma in situ at diagnosis. Breast density notification legislation was not associated with a change in the proportion of women in Connecticut versus control states with regional-stage (-0.09 percentage points, 95 % CI -1.01 to 1.02) or metastatic disease (-0.24, 95 % CI -0.75 to 0.28). County-level analyses and analyses limited to women younger than 50 found no statistically significant associations. LIMITATIONS: Single intervention state, limited follow-up, potential confounding from unobserved trends. CONCLUSIONS: Breast density notification legislation in Connecticut was associated with a small increase in the proportion of women diagnosed with localized invasive breast cancer in individual-level but not county-level analyses. Whether this finding reflects potentially beneficial early detection or potentially harmful overdiagnosis is not known. Legislation was not associated with changes in regional or metastatic disease.

A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.

PURPOSE: Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. DESIGN: Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. RESULTS: The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). CONCLUSIONS: We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

Colorectal Cancer Screening in the Era of the Affordable Care Act.

BACKGROUND: The Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use. OBJECTIVE: To evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA. DESIGN: Repeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA. PARTICIPANTS: Adults 50-64 with private health insurance and adults 65-75 with Medicare. MAIN MEASURES: Self-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening. KEY RESULTS: Our study included 8617 adults aged 50-64 and 3761 adults aged 65-75. MEPS response rates ranged from 58 to 63%. Among adults aged 50-64, 18.9-20.9% received a colonoscopy in the survey year, 0.59-2.1% received a sigmoidoscopy, and 7.9-10.4% received an FOBT. For adults aged 65-75, 23.6-27.7% received a colonoscopy, 1.3-3.2% a sigmoidoscopy, and 13.5-16.4% an FOBT. In adjusted analyses, among participants aged 50-64, there was no increase in yearly rates of colonoscopy (-0.28 percentage points, 95% CI -2.3 to 1.7, p = 0.78), sigmoidoscopy (-1.1%, 95% CI -1.7 to -0.46, p = <0.001), or FOBT (-1.6%, 95% CI -3.2 to -0.03, p = 0.046) post-ACA. For those aged 65-75, rates of colonoscopy (+2.3%, 95% CI -1.4 to 6.0, p = 0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p = 0.58) and FOBT (-0.65, 95% CI -4.1 to 2.8, p = 0.72) did not increase. Among those aged 65-75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p = 0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p = 0.043). CONCLUSIONS: Eliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.

Fulfilling outpatient medicine responsibilities during internal medicine residency: a quantitative study of housestaff participation with between visit tasks.

BACKGROUND: Internal Medicine residents experience conflict between inpatient and outpatient medicine responsibilities. Outpatient "between visit" responsibilities such as reviewing lab and imaging data, responding to medication refill requests and replying to patient inquiries compete for time and attention with inpatient duties. By examining Electronic Health Record (EHR) audits, our study quantitatively describes this balance between competing responsibilities, focusing on housestaff participation with "between visit" outpatient responsibilities. METHODS: We examined EHR log-in data from 2012-2013 for 41 residents (R1 to R3) assigned to a large academic center's continuity clinic. From the EHR log-in data, we examined housestaff compliance with "between visit" tasks, based on official clinic standards. We used generalized estimating equations to evaluate housestaff compliance with between visit tasks and amount of time spent on tasks. We examined the relationship between compliance with between visit tasks and resident year of training, rotation type (elective or required) and interest in primary care. RESULTS: Housestaff compliance with logging in to complete "between visit" tasks varied significantly depending on rotation, with overall compliance of 45% during core inpatient rotations compared to 68% during electives (p = 0.01). Compliance did not significantly vary by interest in primary care or training level. Once logged in, housestaff spent a mean 53 min per week logged in while on electives, compared to 55 min on required rotations (p = 0.90). CONCLUSIONS: Our study quantitatively highlights the difficulty of attending to outpatient responsibilities during busy core inpatient rotations, which comprise the bulk of residency at our institution and at others. Our results reinforce the need to continue development and study of innovative systems for coverage of "between visit" responsibilities, including shared coverage models among multiple residents and shared coverage models between residents and clinic attendings, both of which require a balance between clinic efficiency and resident ownership, autonomy and learning.

A National study of burdensome health care costs among non-elderly Americans.

BACKGROUND: Rising health care costs and increased cost sharing have resulted in significant medical expenses for many Americans. The goal of this study was to describe the prevalence of and risk factors for burdensome health care costs among non-elderly Americans. METHODS: This was a cross sectional study of a nationally representative sample of non-elderly Americans. We used survey data previously collected by the Kaiser Family Foundation. We used logistic regression to identify key risk factors for burdensome health care costs and to assess whether risk factors differ according to age within our study population. For analyses comparing younger and middle-aged adults, we compared participants ages 18-39 (younger Americans) to those ages 40-64 (middle-aged Americans). RESULTS: Our study population included 5,493 participants. Twenty seven percent of participants reported difficulty paying medical bills, a prevalence that did not differ by age. Low income, lack of health insurance, and poor health were independently associated with difficulty paying medical bills after controlling for demographic covariates. Both younger and middle-aged adults were likely to experience burdensome health care costs at low incomes. At moderate incomes, risk fell for middle-aged adults, but remained high for younger adults (ORmiddle-age 1.40, 95% CI 1.12-1.75, ORyounger 2.48, 95% CI 1.73-3.57, p value for interaction 0.004). Younger adults without insurance were at risk for accruing burdensome costs compared to their insured counterparts (OR 2.61, 95% CI 1.96-3.47). Middle-aged adults without insurance, though, had an even higher risk (OR 3.82, 95% CI 2.93-4.97, p value for interaction 0.037). CONCLUSIONS: Both younger and middle-aged adults commonly report difficulty paying medical bills. Younger adults remain vulnerable to burdensome medical costs even when earning moderate incomes. Middle-aged adults, however, are more likely to encounter burdensome costs when uninsured. These findings suggest that younger and middle-aged adults experience distinct vulnerabilities and may benefit differentially from health reform efforts intended to expand coverage and limit out-of-pocket expenses.

Digital Interventions to Support Lung Cancer Screening: A Systematic Review.

INTRODUCTION: Lung cancer remains a leading cause of cancer-related deaths globally. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce lung cancer mortality, but its adoption in the U.S. has been limited. Digital interventions have the potential to improve uptake of LCS. This systematic review aims to summarize the evidence for the effectiveness of digital interventions in promoting LCS. METHODS: A systematic search of three electronic databases (PubMed, Embase, and Medline) was conducted to identify studies published between January 2014 and May 2023. Studies were reviewed and abstracted between February 2023 and July 2023. Outcomes related to knowledge, decision-making and screening were measured. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. RESULTS: Of 1,979 screened articles, 30 studies were included in this review. Digital interventions evaluated included decision aids (n=20), electronic health record (EHR)-based interventions (n=7), social media campaigns and mobile applications (n=3). Decision aids were the most commonly studied digital interventions, with most studies showing improved knowledge (13/13) and reduced decisional conflict (7/9) but most did not show a substantial change in screening use. Fewer studies tested clinician-facing or multi-level interventions. DISCUSSION: Digital interventions, particularly decision aids, have shown promise in improving knowledge and the quality of decision-making around LCS. However, few interventions have been shown to substantially alter screening behavior and few clinician-facing or multi-level interventions have been rigorously tested. Further research is needed to develop effective tools for engaging patients in LCS, to compare the efficacy of different interventions, and evaluate implementation strategies in diverse healthcare settings.

Lung cancer screening use among screening-eligible adults with disabilities.

BACKGROUND: Lung cancer screening (LCS) use among adults with disabilities has not been well characterized. We estimated the prevalence of LCS use by disability types and counts and investigated the association between disability counts and LCS utilization among LCS-eligible adults. METHODS: We used cross-sectional data from the 2019 Behavioral Risk Factor Surveillance System, Lung Cancer Screening Module. Based on the 2013 US Preventive Services Task Force criteria for LCS, the sample included 4407 LCS-eligible adults, aged 55-79 years, with current or former (quit smoking in the past 15 years) tobacco use history of at least 30 pack-years. Disability types included limitations in hearing, vision, cognition, mobility, self-care, and independent living. We also categorized respondents by number of disabilities (no disability, 1 disability, 2 disabilities, 3+ disabilities). We utilized descriptive statistics and multivariable logistic regression analyses to determine the association between disability counts and the receipt of LCS (yes/no) in the past 12 months. RESULTS: In 2019, 16.4% of LCS-eligible adults were screened for lung cancer. Overall, 49.6% of participants had no disability, and 14.5% had >3 disabilities. Mobility was the most prevalent disability type (35.4%), followed by cognitive impairment (18.2%) and hearing (16.6%). LCS was more prevalent in adults with disability in self-care versus no disability in self-care (24.0% vs. 15.5%, p = 0.01), disability in independent living versus no disability in independent living (22.2% vs. 15.4%, p = 0.02), and cognitive impairment disability versus no cognitive impairment (22.1% vs. 15.3%, p = 0.03). The prevalence rates of LCS among groups of LCS-eligible adults with different disability counts were not significant (p = 0.17). CONCLUSIONS: Despite the lack of clinical guidelines on LCS among individuals with disabilities, some individuals with disabilities are being screened for lung cancer. Future research should address this knowledge gap to determine clinical benefit versus harm of LCS among those with disabilities.

Incarceration and screen-detectable cancer diagnosis among adults in Connecticut.

Although incarcerated adults are at elevated risk of dying from cancer, little is known about cancer screening in carceral settings. This study compared stage-specific incidence of screen-detectable cancers among incarcerated and recently released people with the general population, as a reflection of screening practices. We calculated the age- and sex-standardized incidence ratios (SIR) for early- and late-stage cancers for incarcerated and recently released adults compared to the general Connecticut population between 2005 and 2016. Our sample included 143 cancer cases among those incarcerated, 406 among those recently released, and 201 360 in the general population. The SIR for early-stage screen-detectable cancers was lower among incarcerated (SIR = 0.28, 95% CI = 0.17 to 0.43) and recently released (SIR = 0.69, 95% CI = 0.51 to 0.88) individuals than the general population. Incidence of late-stage screen-detectable cancer was lower during incarceration (SIR = 0.51, 95% CI = 0.27 to 0.88) but not after release (SIR = 1.32, 95% CI = 0.93 to 1.82). Findings suggest that underscreening and underdetection of cancer may occur in carceral settings.

Evaluating ChatGPT's Accuracy in Providing Screening Mammography Recommendations among Older Women: Artificial Intelligence and Cancer Communication.

Abstract Objective: The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography through age 74. Guidelines vary as to whether or not they recommended mammography screening to women aged 75 and older. This study aims to determine the ability of ChatGPT to provide appropriate recommendations for breast cancer screening in patients aged 75 years and older. Methods: 12 questions and 4 clinical vignettes addressing fundamental concepts about breast cancer screening and prevention in patients aged 75 years and older were created and asked to ChatGPT three consecutive times to generate 3 sets of responses. The responses were graded by a multi-disciplinary panel of experts in the intersection of breast cancer screening and aging . The responses were graded as 'appropriate', 'inappropriate', or 'unreliable' based on the reviewer's clinical judgment, content of the response, and whether the content was consistent across the three responses . Appropriateness was determined through a majority consensus. Results: The responses generated by ChatGPT were appropriate for 11/17 questions (64%). Three questions were graded as inappropriate (18%) and 2 questions were graded as unreliable (12%). A consensus was not reached on one question (6%) and was graded as no consensus. Conclusions: While recognizing the limitations of ChatGPT, it has potential to provide accurate health care information and could be utilized by healthcare professionals to assist in providing recommendations for breast cancer screening in patients age 75 years and older. Physician oversight will be necessary, due to the possibility of ChatGPT to provide inappropriate and unreliable responses, and the importance of accuracy in medicine.

It Takes a Village: An Interdisciplinary Approach to Preparing Internal Medicine Residents to Care for Patients at the Intersection of Women's Health, Gender-Affirming Care, and Health Disparities.

Objective: To create an interdisciplinary curriculum to teach key topics at the intersection of women's health, gender-affirming care, and health disparities to internal medicine (IM) residents. Materials and Methods: A core team of faculty from IM, Obstetrics and Gynecology, and Surgery partnered with faculty and fellows from other disciplines and with community experts to design and deliver the curriculum. The resulting curriculum consisted of themed half-day modules, each consisting of three to four inter-related topics, updated and repeated on an ∼3-year cycle. Health equity was a focus of all topics. Module delivery used diverse interactive learning strategies. Modules have been presented to ∼175 residents annually, beginning in 2015. To assess the curriculum, we used formative evaluation methods, using primarily anonymous, electronic surveys, and collected quantitative and qualitative data. Most surveys assessed resident learning by quantifying residents' self-reported comfort with skills taught in the module pre- and postsession. Results: Of 131 residents who completed an evaluation in 2022/23, 121 (90%) "somewhat" or "strongly" agreed with their readiness to perform a range of skills taught in the module. In all previous years where pre- and postsurveys were used to evaluate modules, we observed a consistent meaningful increase in the proportion of residents reporting high levels of comfort with the material. Residents particularly valued interactive teaching methods, and direct learning from community members and peers. Conclusion: Our interdisciplinary curriculum was feasible, valued by trainees, and increased resident learning. The curriculum provides a template to address equity issues across a spectrum of women's and gender-affirming care conditions that can be used by other institutions in implementing similar curricula.