Rationale and Objectives
The objective of this study was to evaluate the association of communication practices with timely follow-up of screening mammograms read as Breast Imaging Reporting and Data Systems (BI-RADS) 0 in the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.
Materials and Methods
A radiology facility survey was conducted in 2015 with responses linked to screening mammograms obtained in 2011–2014. We considered timely follow-up to be within 15 days of the screening mammogram. Generalized estimating equation models were used to evaluate the association between modes of communication with patients and providers and timely follow-up, adjusting for PROSPR site, patient age, and race and ethnicity.
Results
The analysis included 34,680 mammography examinations with a BI-RADS 0 assessment among 28 facilities. Across facilities, 85.6% of examinations had a follow-up within 15 days. Patients in a facility where routine practice was to contact the patient by phone if follow-up imaging was recommended were more likely to have timely follow-up (odds ratio [OR] 4.63, 95% confidence interval [CI] 2.76–7.76), whereas standard use of mail was associated with reduced timely follow-up (OR 0.47, 95% CI 0.30–0.75). Facilities that had standard use of electronic medical records to report the need for follow-up imaging to a provider had less timely follow-up (OR 0.56, 95% CI 0.35–0.90). Facilities that routinely contacted patients by mail if they missed a follow-up imaging visit were more likely to have timely follow-up (OR 1.65, 95% CI 1.02–2.69).
Conclusions
Our findings support the value of telephone communication to patients in relation to timely follow-up. Future research is needed to evaluate the role of communication in completing the breast cancer screening episode.
Introduction
Mammography screening reduces breast cancer mortality among women aged 40–74 years . Progression through the screening process, from initial screening, through follow-up of abnormal results, to treatment, can fail at multiple points in the screening episode . Lack of effective communication between facilities, providers, and patients may delay follow-up and lead to adverse health outcomes, including anxiety, delay in diagnosis, and widening of cancer outcome disparities .
Mode of communication can impact timely follow-up of abnormal mammograms. Commonly used modes of communicating mammography results to patients include verbal communication (including in-person communication, by telephone, and leaving a voice message) and written communication by conventional mail or through a patient portal to the electronic medical record (EMR). In a study among women of diverse ethnicity who had a screening mammogram and a Breast Imaging Reporting and Data Systems (BI-RADS) 0 result, discussion of results with a provider was associated with more timely follow-up, although this finding did not persist on multivariate analysis controlling for insurance status . Communication factors such as patients asking questions, receiving next-step information, and being told that follow-up is needed have also been associated with timely follow-up of an abnormal mammogram .
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Materials and Methods
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Survey Content and Coding of Responses
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Survey Protocol
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Statistical Analysis
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Results
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Table 1
Facilities, Screening Examinations (2011–2014), BI-RADS 0, and Timely Follow-up
Health-care Setting (PROSPR Center) Number of Facilities Screening Examinations Number of Months of Examinations Included BI-RADS 0
n (%) Follow-up, ≤15 d
n (%) \* Follow-up, Same Day
n (%) Follow-up, Days 1–15
n (%) A 7 69,038 24 7,125 (10.3) 5,983 (84.0) 2,402 (40.1) 3,581 (59.9) B 5 15,362 45 1,013 (6.7) 768 (75.8) 185 (24.1) 583 (75.9) C 3 43,074 48 4,069 (9.5) 3,358 (82.5) 196 (5.8) 3,162 (94.2) D 13 198,011 45 22,473 (11.4) 19,589 (87.2) 3,519 (18.0) 16,070 (82.0) Total 28 325,485 34,680 (10.7) 29,698 (85.6) 6,302 (21.2) 23,396 (78.8)
BI-RADS, Breast Imaging Reporting and Data Systems; PROSPR, Population-based Research Optimizing Screening through Personalized Regimens.
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Table 2
Demographic Characteristics of Screening Mammograms
Patient Characteristics Screening Mammograms
n Abnormal Screening Results BI-RADS 0
n (%) Follow-up, ≤15 d
n (%) Age (y) 40–49 87,472 12,829 (14.7) 10,969 (85.5) 50–64 168,714 16,083 (9.9) 13,696 (85.2) 65–74 69,299 5,768 (8.3) 5,033 (87.3) Race and ethnicity White non-Hispanic 279,252 29,466 (10.5) 25,605 (86.9) Black non-Hispanic 23,345 2,531 (10.8) 1,895 (74.9) Hispanic 6,037 665 (11.0) 538 (80.9) Asian non-Hispanic 4,726 478 (10.1) 374 (78.2) Other non-Hispanic 6,561 808 (12.3) 668 (82.7) Missing 5,564 732 (13.2) 618 (84.4) Total 325,485 34,680 (10.7) 29,698 (85.6)
BI-RADS, Breast Imaging Reporting and Data Systems.
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Communication of Mammography Results
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Table 3
Association of Timely Follow-up and Facility-level Communication Modality
Communication Type Patient Misses Scheduled Appointment for Additional Imaging Facilities Endorsing in Survey (%) Follow-up in 1–15 d When Endorsed (%) vs Not Endorsed (%) Impact on Timely Follow-up After Adjustment \* ( P Value) OR (95% CI) To patient Phone 71.4 85.5 vs 72.8 .08 1.81 (0.93–3.53) Mail 32.1 85.1 vs 80.3 .0429 1.65 (1.02–2.69) Patient portal 3.6 81.8 vs 82.4 <.0001 2.05 (1.73–2.41) In person 0.0 — — — To provider Phone 28.6 89.3 vs 77.3 .0012 2.61 (1.46–4.66) Mail 17.9 76.9 vs 83.1 .63 1.30 (0.45–3.79) Electronic medical record 21.4 78.0 vs 83.3 .95 0.98 (0.49–1.93) Fax 7.1 82.2 vs 82.5 .57 0.79 (0.35–1.79)
CI, confidence interval; OR, odds ratio; PROSPR, Population-based Research Optimizing Screening through Personalized Regimens.
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Bivariate Analysis
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Table 4
Association of Timely Follow-up and Facility-level Communication Modality
Communication Type Additional Imaging Recommended Facilities Endorsing in Survey
(%) Follow-up in 1–15 d When Endorsed (%) vs Not Endorsed (%) Impact on Timely Follow-up After Adjustment \* ( P Value) OR (95% CI) To patient Phone 89.3 83.5 vs 53.1 <.0001 4.63 (2.76–7.76) Mail 57.1 77.3 vs 87.8 .0012 0.47 (0.30–0.75) Patient portal 39.3 77.7 vs 85.4 .13 0.66 (0.39–1.12) In person 10.7 65.2 vs 82.7 .17 0.56 (0.25–1.27) To provider Phone 3.6 70.3 vs 82.5 .0051 1.24 (1.07–1.44) Mail 14.3 77.9 vs 83.5 .58 0.80 (0.36–1.76) Electronic medical record 82.1 81.9 vs 89.2 .0163 0.56 (0.35–0.90) Fax 42.9 81.3 vs 82.9 .65 0.85 (0.42–1.71)
CI, confidence interval; OR, odds ratio; PROSPR, Population-based Research Optimizing Screening through Personalized Regimens.
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Multivariate Analysis
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Table 5
Association of Patient and Provider Communication Strategies with Timely Follow-up in Multivariate Analyses
Variable OR 95% CI_P_ Value Model A: Additional imaging recommended—patient communication \* Patient phone communication 3.63 2.29–5.76 <.0001 Patient mail communication 0.53 0.34–0.81 .003 Model B: Additional imaging recommended—provider communication \* Provider electronic medical recordcommunication 0.52 0.29–0.92 .02 Provider phone communication 0.64 0.36–1.16 .14 Model C: Patient misses scheduled appointment for additional imaging—patient communication \* Patient mail communication 1.65 1.01–2.69 .04 Patient portal communication 1.28 0.79–2.07 .32
CI, confidence interval; OR, odds ratio; PROSPR, Population-based Research Optimizing Screening through Personalized Regimens.
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Sensitivity Analysis
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Discussion
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Conclusions
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Appendix
Supplementary Data
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Appendix S1
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