Rationale and Objectives
The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability.
Materials and Methods
Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties’ facility and radiologist counts, as well as counts normalized to counties’ Medicare fee-for-service beneficiary volume and land area.
Results
Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%–88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22–0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06–0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both.
Conclusion
Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.
Introduction
Screening mammography rates are highly variable among populations . In particular, previous investigations have focused on the impact of a wide variety of patient characteristics on screening rates, such as demographic, behavioral, and psychosocial factors . Screening mammography rates are also influenced by characteristics of patients’ insurance and of the physicians who order mammograms and counsel women regarding undergoing screening . Awareness of factors that may drive changes in screening rates may thus be important for designing targeted interventions and optimizing efforts at improving screening compliance.
For other radiology services, supply-side factors (eg, the availability of scanners and physicians) have been associated with variation in utilization . Although screening mammography rates are clearly heavily influenced by a range of demand-side factors (eg, those related to patients and referring physicians as drivers of utilization), it is also possible that screening rates are also influenced by supply-side factors relating to the resources and infrastructure required to offer screening services . Namely, the local supply of both mammography facilities and radiologists performing mammography may impact the ease of obtaining and thus demand for a mammogram and consequently impact screening rates. However, the relationship of supply-side factors and screening rates is not firmly established. Past studies have commonly explored supply-side factors in limited geographic regions or outside of the United States , and far more heavily focused on facility supply with minimal attention to the supply of radiologists offering mammography screening services . Most importantly, earlier studies have yielded inconsistent results regarding any potential relationships , and the topic has received little attention in recent years despite considerable interval changes in facility availability, radiologist practice patterns, and screening guidelines themselves (eg, the conversion from analog to digital mammography; the introduction of digital breast tomosynthesis; changing guidelines from the United States Preventive Services Task Force , as well as from the American Cancer Society and the American College of Radiology ). Therefore, to better understand the role of supply-side factors in impacting screening mammography, the aim of this study was to assess, at the US county level, the association between Medicare beneficiary screening mammography rates and the local availability of mammography facilities and mammography-interpreting radiologists.
Methods
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Results
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TABLE 1
Summary of County-level Characteristics Among 3035 Included Counties
Measure Mean ± SD Range Mammography screening rate (%) 60.5 ± 8.2 26–88 Total mammography facilities 2.81 ± 7.30 0–203 Mammography facilities per 100,000 Medicare FFS beneficiaries 31.4 ± 45.8 0–719 Mammography facilities per 100,000 square miles 673.1 ± 5,543.0 0–271,588 Total mammography-performing radiologists 4.2 ± 13.4 0–252 Mammography-performing radiologists per 100,000 Medicare FFS beneficiaries 22.1 ± 59.0 0–1,185 Total breast imaging subspecialist radiologists 0.9 ± 4.6 0–108 Breast imaging subspecialist radiologists per 100,000 Medicare FFS beneficiaries 3.4 ± 40.1 0–2,083
FFS, fee-for-service; SD, standard deviation.
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TABLE 2
Correlation of County-level Characteristics with Mammography Screening Rates
Measure r_P_ Total mammography facilities +0.24<.001 Mammography facilities per 100,000 Medicare FFS beneficiaries +0.06<.001 Mammography facilities per 100,000 square miles +0.26<.001 Total mammography-performing radiologists +0.24<.001 Mammography-performing radiologists per 100,000 Medicare FFS beneficiaries +0.22<.001 Total breast imaging subspecialist radiologists +0.16<.001 Breast imaging subspecialist radiologists per 100,000 Medicare FFS beneficiaries +0.16<.001
FFS, fee-for-service.
P -values listed in bold when statistically significant at P < 0.001.
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TABLE 3
Results of Series of Multivariable Regression Models Exploring Associations Between Screening Mammography Rates and Combinations of County-level Measures of Mammography Facilities and Mammography-performing Radiologists
Models Measure β_P_ 1 Total mammography facilities −0.02 .633 Total mammography-performing radiologists +0.08<.001 2 Total mammography facilities +0.18<.001 Total breast imaging subspecialist radiologists −0.13 .015 3 Mammography facilities per 100,000 Medicare FFS beneficiaries −0.007 .045 Mammography-performing radiologists per 100,000 Medicare FFS beneficiaries +0.01<.001 4 Mammography facilities per 100,000 Medicare FFS beneficiaries −0.0008 .791 Breast imaging subspecialist radiologists per 100,000 Medicare FFS beneficiaries +0.007 .047 5 Mammography facilities per 100,000 square miles 0.00003 .309 Mammography-performing radiologists per 100,000 Medicare FFS beneficiaries +0.01<.001 6 Mammography facilities per 100,000 square miles 0.00003 .194 Breast imaging subspecialist radiologists per 100,000 Medicare FFS beneficiaries 0.007 .054
FFS, fee-for-service.
P -values listed in bold when statistically significant at P < 0.001.
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Discussion
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