A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

Abstract

Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

“It's something I'll do until I die”: A qualitative examination into why older women in the U.S. continue screening mammography

“…Despite the consideration of age, life expectancy, and health status in guideline recommendations for the discontinuation of screening mammography, older women in this sample perceived that older age and poor health underscored a need for continued screening. While these findings may reflect the low awareness of the potential harms of screening reported by women in this and other studies, 15,[20][21][22] they also point to a possible disconnect between factors that the medical and research communities deem important for screening recommendations in older populations, and the values and concerns that influence screening mammography decisions among ethnically diverse older women.…”

“…We selected this recruitment approach to ensure diverse representation of older women who actively receive screening mammography and included women 70–74 years to provide insight into the experiences of women who were approaching the age for which screening guidelines change. Participants completed an in‐person survey, administered by bilingual (English and Spanish) research staff at the time of mammography appointment, to collect data on sociodemographic, breast cancer risk factor, clinical and screening mammography history 22 . All participants consented to be contacted for follow‐up studies, and were later invited to participate in semi‐structured interviews to collect in‐depth data on women's perspectives on reducing or stopping routine screening mammography.…”

“…Participants completed an in-person survey, administered by bilingual (English and Spanish) research staff at the time of mammography appointment, to collect data on sociodemographic, breast cancer risk factor, clinical and screening mammography history. 22 All participants consented to be contacted for follow-up studies, and were later invited to participate in semi-structured interviews to collect in-depth data on women's perspectives on reducing or stopping routine screening mammography. Two members of the research team (one Bilingual English-Spanishspeaking, one English-speaking) conducted all interviews, lasting between 30 and 45 min, between June and August 2019; these data serve as the focus of the current study.…”

Evaluating ChatGPT as an Adjunct for Radiologic Decision-Making

“…Most notably, ChatGPT achieved impressive accuracy for breast cancer screening prompts (on average, 88.9% correct responses for SATA prompts). Given increased efforts to reduce overutilization of imaging services in this setting 23,24 and the high prevalence of breast cancer in the United States 25 , this result is especially salient. Some important limitations of our study involve the artificial intelligence model itself.…”

Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison

“…Such limits on the use of life expectancy are congruent with the large extent of literature on patient discomfort with discontinuing care in a range of contexts, including deprescribing or discontinuing medications (Brokaar et al, 2022; Burghle et al, 2020; Vordenberg & Zikmund-Fisher, 2020) and stopping cancer screening (Brotzman et al, 2022; Lewis et al, 2010; Torke et al, 2013). Patient discomfort and resistance to discontinuing care may reflect broader societal enthusiasm for screening and beliefs that more care is better care (O’Keeffe et al, 2021; Schwartz et al, 2004), well-documented clinician discomfort and reluctance to recommending against screening (Hoffman et al, 2010; Schonberg, 2018; Zikmund-Fisher et al, 2017), and multi-level challenges and complexities of deimplementing low-value care (Austin et al, 2021; Norton & Chambers, 2020; J. Smith et al, 2021).…”