Barriers to Screening Mammography in an Urban Family Medicine Residency Clinic Bonnie H. Kwok, MPH, MD (c) University of Wisconsin School of Medicine and.

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

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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

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scre

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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