Delivery of breast cancer screening services: Role of provider and practice characteristics

Breast cancer is the second leading cause of cancer-death for women. Early detection of breast cancer improves survival and has contributed to the recent declines in mortality. However, disparities exist in screening and mortality rates, with the southeastern region experiencing poorer outcomes than other regions. Also disturbing are recent reports showing declines in mammography rates for women overall and among sub-groups. Because a provider's recommendation is a key driver of screening rates, this study examined: 1) patterns in provision of breast cancer screening services among primary care providers in the southeast; 2) facilitators and barriers to screening delivery; and 3) impact of physician and practice characteristics on screening delivery. Methods: In 2007, we conducted a mail survey of family physicians in the four-state central southeastern region (Mississippi, Tennessee, Alabama, Kentucky), with follow-up using computer-assisted telephone interviewing. The American Academy of Family Physicians database provided the sampling frame. The questionnaire was informed by in-depth interviews with 34 providers and a systematic literature review. Results: Of the 489 responding physicians, 65% were males and 10% members of minority groups. Majority of physicians were in group practices (58%) and in urban/suburban areas (56%). Although the vast majority of physicians believed in the importance of regular mammograms, only 2 of 3 regularly referred 80 – 100% of their eligible female patients for a screening mammogram. Two-thirds of respondents indicated that their clinics did not have a patient reminder system for scheduling mammograms, and one-third of clinics did not follow-up with patients who missed their scheduled mammograms. While the majority of physicians believed in the importance of clinical breast exams, only 35% regularly provided the exam to 80 - 100% of their eligible patients. Barriers to screening delivery were lack of annual physical exams, patient refusal/preferences, patient having another primary care provider, patient limited resources, and provider time constraints. Women physicians and physicians in family-practice groups were more likely to provide screening than male physicians and those in multispecialty practices. Analyses are underway to examine the association between urban/rural location and other characteristics on screening delivery. Conclusion: Major gaps exist in providing mammography referrals and clinical breast exams, and many practices lack reminder and follow-up systems. Barriers to screening exist at the patient, provider, and healthcare system levels. Reversing the recent decline in screening rates requires interventions to increase community awareness of early detection, clinic systems that facilitate screening, and health insurance and service coordination.