The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES: This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. METHODS: In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. RESULTS: Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). CONCLUSIONS: Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Communicating results of diagnostic mammography: what do patients think?

RATIONALE AND OBJECTIVES: The purpose of this study was to investigate women's preferences for who (radiologist or referring physician) should communicate the results of diagnostic mammography. MATERIALS AND METHODS: Data from 153 women presenting to two sites for diagnostic mammography between February and June 1995 were collected with a 24-item, self-administered, closed-ended survey. For both normal and abnormal hypothetical results, contingency tables with chi2 tests and multiple logistic regression were used to determine the association, if any, between women's characteristics and their preferences. RESULTS: Women undergoing diagnostic mammography preferred that their radiologists disclose their normal (90%) and abnormal (88%) mammogram results to them immediately after their examination, rather than have their referring physicians disclose results at a later time. In the case of normal findings, women whose regular physicians were specialists were less likely to want to hear first from their radiologists (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.01, 0.77; P = .03), but women who were nervous about learning their results were more likely to want to hear first from their radiologists (OR = 4.5; 95% CI = 1.2, 17.3; P = .03). CONCLUSION: Radiologists may want to consider assessing women's preferences for who communicates their mammogram results, as most women in this study preferred to hear these results from their radiologists rather than waiting to hear from their referring physicians.

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening.

OBJECTIVES: Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine. METHODS: All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited. RESULTS: Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy. CONCLUSIONS: Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.

Informing patients of diagnostic mammography results: mammographer's opinions.

PURPOSE: The authors' purpose was to determine mammographers' practices and attitudes regarding disclosing results of diagnostic mammograms to patients. MATERIALS AND METHODS: In 1995, the authors mailed a questionnaire to 500 members of the Society of Breast Imaging; 399 (80%) responded to the survey. RESULTS: Three-quarters of respondents stated that mammographers should disclose results to their patients, and approximately half were already doing so (52% for normal results, 51% for abnormal results). A sizable minority (25%) said that not telling patients was the best practice and identified several barriers to direct disclosure, including lack of time. Although bivariate analysis showed direct disclosure to be more common among female mammographers, the sex difference did not persist in multivariate analysis. In both bivariate and multivariate analyses, reading more than 100 mammograms per week and having a radiology practice in a university or academic setting were each strongly associated with direct disclosure. CONCLUSION: Implementation of the Mammography Quality Standards Reauthorization Act of 1998 may not require a major change in mammographers' current practice. It remains critical to establish systems that help radiologists disclose results and communicate with referring physicians efficiently and effectively.

Race and mammography use in two North Carolina counties.

OBJECTIVES: This study investigated racial differences in mammography use and their association with physicians' recommendations and other factors. METHODS: The study used 1988 survey data for 948 women 50 years of age and older from the New Hanover Breast Cancer Screening Program. Racial differences in terms of physician recommendation, personal characteristics, health characteristics, and attitudes toward breast cancer and mammography were examined. Factors at least minimally associated with race and use were included in multivariate logistic regression analyses to examine the effect of race while controlling for other factors. RESULTS: In comparison with White women. Black women were half as likely to report ever having had a mammogram (27% vs 52%) and having a mammogram in the past year (17% vs 36%). Black women also significantly less often reported physician recommendation (25% vs 52%). Although Black and White women differed significantly in other characteristics, multivariate logistic regression analyses indicated that physician recommendation accounted for 60% to 75% of the initial racial differences in mammography use. CONCLUSIONS: Understanding physicians' recommendations for breast cancer screening is a critical first step to increasing mammography use in disadvantaged populations.

Physicians' reactions to change in recommendations for mammography screening.

INTRODUCTION: In December 1993 the National Cancer Institute (NCI) decided to replace its mammography screening guidelines with a Statement of Evidence on Breast Cancer Screening. The Statement of Evidence represented a departure from the institute's previous policy of recommending routine mammography screening in women 40-49 and annual screening in women 50 and over. This study assesses knowledge of and attitudes toward the Statement of Evidence among primary care physicians. In addition, we explore the extent to which physicians changed their individual clinical policies on mammography screening in response to the Statement of Evidence. METHODS: Between October 1994 and June 1995, 545 randomly selected North Carolina primary care physicians completed a mailed questionnaire (overall survey response rate = 42%). RESULTS: Awareness of the Statement of Evidence was high (83%), but attitudes toward it were negative, with a majority of physicians stating that the change in policy was confusing to women and physicians. About 8% of physicians who were aware of the Statement of Evidence changed their practice accordingly. Most physicians reported recommending routine mammography screening in women 40-49 and annual screening in women 50 and over. A majority stated they believe scientific evidence supports these practices. CONCLUSIONS: When faced with a new policy in which guidelines are no longer provided and evidence supporting less use of an established technology is conveyed, physicians demonstrated disinclination to change. The impact of changes in recommendations on physician practice is an important consideration for those who develop and promote screening policies.

The North Carolina Breast Cancer Screening Program: foundations and design of a model for reaching older, minority, rural women.

Breast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor. The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSP's theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the "stages of change" transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable "lessons" in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented. NC-BCSP's goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.

Cost-effectiveness of two nurse-led programs to teach breast self-examination.

The cost-effectiveness of breast cancer screening that includes breast self-examination (BSE) has not been investigated, in part because the costs and effects of programs to teach BSE are not well known. I used data from a randomized, controlled trial and national surveys to compare the benefit, cost, and cost-effectiveness of two one-year, nurse-led programs to teach BSE in a medical practice setting. One program (Mammacare, or MAM) used manufactured silicone models to develop tactile skills; the other program (Traditional, or TRAD) stressed knowledge and examination techniques. I defined benefit as the marginal one-year increase in the number of women in an "average" adult primary care office practice who performed competent and frequent BSE. I defined cost as the marginal increase in the resources used to teach BSE and in the resources used as a result of performing BSE. Cost-effectiveness equaled the cost per competent, frequent BSE examiner added. The "average" practice was derived based on estimates from national surveys of physicians and medical practices. The MAM program's benefit was fivefold greater than the TRAD program's; its total cost was more than threefold greater; and its cost per competent, frequent examiner added was 32% lower. Yet, regardless of the program, one year following teaching only 15%-28% of women were competent, frequent performers. Cost-effectiveness was sensitive to the definition of benefit. Cost-effectiveness was also sensitive to some costs, but generally these sensitivities did not alter the relative cost-effectiveness of the two programs. The cost of teaching BSE was substantial. Benefit, cost, and cost-effectiveness varied by program.(ABSTRACT TRUNCATED AT 250 WORDS)

Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial.

STUDY OBJECTIVE: To evaluate the effectiveness of two teaching interventions to increase residents' performance of smoking cessation counseling. DESIGN: Randomized controlled factorial trial. SETTING: Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals. PARTICIPANTS: 261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months. INTERVENTIONS: Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention. MEASUREMENT AND RESULTS: Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5-1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76-79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3-8.2%; biochemically verified: 3.4-5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant. CONCLUSION: A simple and feasible educational intervention can increase residents' smoking cessation counseling.

Prompting physicians for preventive procedures: a five-year study of manual and computer reminders.

Prompting physicians increases performance of preventive procedures, but the long-term effects of prompting, and of different types of prompting (manual versus computer), on various procedures is unclear. Nor has the effect of the optional enrollment of patients by physicians into a prompting system been studied. We examined performance of eight preventive procedures in a university-based general medical practice during three successive periods over five years: no prompting, nurse-initiated prompting, and computerized prompting. Performance of seven prompted procedures for all patients (regardless of whether they had been enrolled) was significantly increased over the five-year period from 38% (no prompting) to 43% (nurse prompting) to 53% (computer prompting). Among the procedures, influenza vaccination (12% to 59%) and mammography (4% to 33%) showed the greatest increases in performance, while fecal occult blood testing and Pap smears showed no increase or slight declines. Enrollment of patients in the optional prompting system was strongly related to performance. Overall performance of procedures for the enrolled group increased to 68%, while that of the unenrolled group remained at 37%. However, after we adjusted for differences in the percentage of patients enrolled, overall performance for the nurse system (49%) differed little from that for the computer system (55%). Manual and computer prompts had similar effects, but the computer system prompted for more patients. Though prompting remained effective five years after initiation, performance did not increase for unenrolled patients or for some procedures. Understanding these patient- and procedure-specific barriers not addressed by prompting is necessary to increase further physician performance of preventive procedures.

How best to teach women breast self-examination. A randomized controlled trial.

OBJECTIVE: To compare three methods for teaching breast self-examination. DESIGN: Randomized controlled trial with factorial design. SETTING: A general medicine group practice in a university hospital. PATIENTS: Continuing-care patients from 40 to 68 years of age. Of 456 eligible women, 156 refused participation, 300 were randomly assigned, 269 completed assigned interventions, and 260 completed the post-test 1 year later. INTERVENTIONS: One third of patients received nurse instruction stressing tactile skills (Mammacare group) (Mammatech Corporation, Gainesville, Florida); one third, traditional nurse instruction emphasizing technique (traditional group); and one third, no nurse instruction (control group). Half of each group received physician encouragement. MEASUREMENTS AND MAIN RESULTS: One year later, women in the Mammacare group found more lumps (mean, 57%; 95% CI, 54% to 60%) in manufactured breast models than did those in the traditional (mean, 47%; CI, 44% to 51%) and control (mean, 45%; CI, 42% to 48%) groups. Lump detection specificity was unaffected. Self-reported examination frequency rose in all groups, to 5.1 times per 6 months in the traditional group, 4.2 in the Mammacare group, and 3.9 in the control group. Physician encouragement did not improve sensitivity, specificity, or overall frequency. Women in the Mammacare group used more of seven examination techniques (4.9) than did those in the traditional (3.9) or control (3.2) groups (P less than 0.001). No group increased health care use or reported more overall worry about breast cancer. CONCLUSIONS: Mammacare instruction resulted in more long-term improved lump detection and examination technique use than did traditional instruction or physician encouragement. Breast self-examination instruction should emphasize lump detection skills.

How do women compare with internal medicine residents in breast lump detection? A study with silicone models.

OBJECTIVE: Manufactured silicone breast models were used to compare the accuracy of breast examination by 300 women and 62 internal medicine residents. DESIGN: The study design was cross-sectional. SETTING: The study took place in two teaching-hospital general medicine clinics. PATIENTS/PARTICIPANTS: Women were continuing care patients, ages 40 to 68, with no current breast complaint; 300 of 467 (66%) randomly selected women participated. Physicians were internal medicine residents with at least one-half day per week of ambulatory care practice; 62 of 64 (97%) participated. MEASUREMENTS AND MAIN RESULTS: Sensitivity equalled the percentage of 18 lumps correctly detected in examination of six silicone breast models. Specificity equalled the percentage of six models examined without a false-positive detection. Women's sensitivity was lower than physicians' (40% vs. 58%), but their specificity was higher (66% vs. 52%). For both women and physicians, sensitivity varied according to lump size, hardness, and depth, with women's sensitivity lower than physicians' for each characteristic. Examination duration was the technique most strongly and consistently related to accuracy. Physicians spent more time examining models than did women (2.5 vs. 2.1 minutes per model). For both groups duration related positively to sensitivity (r = 0.46, women; 0.55, physicians) and negatively to specificity (r = -0.35, women; -0.59, physicians). After adjusting for differences in technique, women's sensitivity remained lower than physicians', whereas specificity generally remained higher. The sensitivity of physicians with prior tactile experience with breast lumps was higher than that of physicians without such experience (60% vs. 51%, p = 0.01). Too few women (2%) had prior tactile experience to permit analysis. CONCLUSIONS: Women's and physicians' breast examination accuracies differ, but for the two groups accuracies vary similarly by lump characteristics and examination technique. Programs to improve breast examination should focus on specificity as well as sensitivity. Training that includes tactile experience may be important.

Is breast self-examination predicted by knowledge, attitudes, beliefs, or sociodemographic characteristics?

The relationship of women's sociodemographic characteristics, knowledge, attitudes, and beliefs to breast self-examination (BSE) practice is not clear. We therefore studied these variables among older women at risk for developing breast cancer to determine which might be associated with the sensitivity, specificity, and frequency of BSE practice. We interviewed 300 women 40 to 68 years of age and measured BSE sensitivity and specificity using manufactured silicone breast models containing lumps. Of 54 variables and 10 scales examined univariately, six were associated with BSE sensitivity, one was negatively associated with specificity, and 10 were associated with frequency. No variable was associated with more than one component of BSE practice, and BSE frequency was not associated with BSE sensitivity or specificity. Using multivariate analysis, BSE sensitivity was best explained by type of employment, health interest, and perceived vulnerability to breast cancer, which accounted for approximately 16% of the variance. BSE frequency was best explained by intention to perform BSE, knowing how to perform BSE, using the correct method of BSE, self-confidence in the ability to perform BSE monthly, and self-confidence in the ability to find small lumps. These variables accounted for 27% of the variance. Sociodemographic characteristics, knowledge, attitudes, and beliefs poorly predicted how accurately women practiced BSE but somewhat better predicted how often women practiced BSE.

US Preventive Services Task Force. Screening for breast cancer with breast self-examination. A critical review.

We reviewed evidence regarding breast self-examination (BSE) and screening for breast cancer. To our knowledge, no controlled prospective trial links BSE to lives saved from breast cancer. Compared with clinical breast examination and mammography, the estimated sensitivity of BSE is low (20% to 30%) and is lower among older women. The potential sensitivity of BSE should be higher because women can detect small lumps (0.3 cm) in silicone models. Instruction increases BSE frequency over the short term. Sensitivity also increases, but specificity decreases. The psychological effects of teaching and performing BSE are not yet clear. The cost of screening by BSE is unknown but depends on the accuracy of the test as well as the training method used. Breast self-examination has potential as a screening test for breast cancer, but many questions require scientific examination before this procedure can be advocated as a screening test for breast cancer.

Physician acceptance of a computerized health maintenance prompting program.

Computer prompting systems remind physicians to perform health promotion/disease prevention (HP/DP) procedures on their patients, but it is unclear how willingly physicians accept these systems. Because acceptance is critical to long-term system success, we assessed attitudes toward a computerized health maintenance program (HMP) prompting system. We surveyed 23 faculty and 52 residents in a general medicine teaching hospital group practice after the HMP had been in use for three years. Sixty-four physicians (85 percent) responded. Almost all (91 percent) agreed that all ongoing-care patients should receive periodic screening--a significant (p less than .001) increase compared to 1979, when prior to the HMP 56 percent agreed. On average, the physicians believed that 87 percent of their ongoing-care patients over 50 years of age should be enrolled in the HMP. About half (55 percent) felt that losing the HMP would limit their ability to care for their patients, and almost all (97 percent) said they would include a prompting system in any future private practice, with most (87 percent) preferring a computer-based system. A majority (65 percent) said that they liked being reminded. Prompting systems improve physician performance of HP/DP procedures. The HMP received a high level of acceptance and was associated with improved attitudes toward HP/PD activities, suggesting that computerized prompting systems should be more widespread.