COVID-19 and exacerbation of screening mammography inequities

ABSTRACT

Background: After state-mandated cessation of screening mammography (SM) in Spring 2020 due to COVID-19, centers were urged to resume screening, particularly of patients at increased risk. As our tertiary-care medical center's screening program provides SM at four sites across our metropolitan area, we examined whether sites that historically served more patients from more disadvantaged areas returned slower to pre-COVID volumes. Methods: Patient records were linked by ZIP code of residence to ZIP Code Tabulation Area (ZCTA)-level area-based social metrics (ABSMs) from the 2014-2018 American Community Survey. We compared baseline pre-COVID (MayOctober, 2015-2019) SM population ABSMs between our four imaging sites for % persons below poverty (≥ vs < 10%), % persons of color (POC) (quintiles top 2 vs bottom 3), index of racialized economic segregation (quintiles bottom 2 [more POC low-income households] vs top 3 [more white non-Hispanic (WNH) highincome households]);and race/ethnicity (% WNH vs POC). We modeled weekly SM volumes per screening day by site using Poisson regression and tested for weekly differences at each site, COVID-era (May-October 2020) vs preCOVID;and tested for monthly differences in SM population composition by logistic regression modeling. Results: There were 89,082 pre-COVID and 16,220 COVID-era SM exams. At pre-COVID baselines the four sites differed in population composition by ABSMs and race/ethnicity (all chi-square P values <.001) (Table). The two sites that served more disadvantaged populations (A, B) returned slower to pre-COVID volumes (site-specific weekly screening volume no longer different [P >.05] vs pre-COVID) (Table). As a result, compositions of the aggregate SM population across all sites showed a smaller proportion of patients from the most disadvantaged ZCTAs by ABSMs (all P values <.001) before returning to pre-COVID compositions three months after SM resumption. Conclusions: SM was slower to return to pre-COVID volumes at imaging sites that historically served lower-income communities of color. As a result, our COVIDera SM population skewed away from patients in disadvantaged ZCTAs. Our findings highlight the need to monitor for emergent disparities in the pandemic era. Future work will focus on understanding causes of inequitable SM engagement across our imaging sites to mitigate care disparities for our most vulnerable patients. (Table Presented).