Rationale and Objectives
To assess associations between screening mammography utilization and Medicare beneficiaries’ relationships with, and impressions of, their primary care physicians.
Materials and Methods
Using the Medicare Current Beneficiary Survey Access to Care Public Use File, we retrospectively studied responses from a national random cross section of Medicare beneficiaries surveyed in 2013 regarding perceptions of their primary care physicians and their screening mammography utilization. Statistical analysis accounted for subject weighting factors to estimate national screening utilization.
Results
Among 7492 female Medicare beneficiaries, 62.0% (95% confidence interval 59.8%–64.2%) underwent screening mammography. Utilization was higher for beneficiaries having (vs. not) a regular medical practice or clinic (63.2% vs. 34.6%) and a usual physician (63.8% vs. 50.3%). Utilization was higher for beneficiaries very satisfied (vs. very dissatisfied) with the overall quality of care they received (66.0% vs. 35.8%), their ease of getting to a doctor (67.7% vs. 43.2%), and their physician’s concerns for their health (65.7% vs. 53.4%), as well as for beneficiaries strongly agreeing (vs. strongly disagreeing) that their physician is competent (66.0% vs. 54.1%), understands what is wrong (66.3% vs. 47.1%), answers all questions (67.0% vs. 46.7%), and fosters confidence (66.0% vs. 50.6%). Independent predictors of screening mammography utilization ( P < .05) were satisfaction with quality of care, having a regular practice or clinic, and satisfaction with ease of getting to their physician.
Conclusions
Screening mammography utilization is higher among Medicare beneficiaries with established primary physician relationships, particularly when those relationships are favorable. To optimize screening mammography utilization, breast imagers are encouraged to support initiatives to enhance high-quality primary care relationships.
Introduction
Although screening mammography has been shown to be important for early detection of breast cancer and reduction of mortality , women’s utilization of mammography is highly variable . Past studies have demonstrated such utilization to be associated, for example, with women’s age, race, ethnicity, English language proficiency, insurance coverage, and geographic proximity to screening facilities . Breast imagers have thus been enc ouraged to pursue initiatives to promote improved screening adherence, including automated reminders, patient navigators, and educational community outreach sessions . To be maximally effective, however, such programs must be designed with an understanding of a radiology practice’s patient population, including particular patient risk factors for reduced screening compliance . Attention to such issues will be increasingly important for radiology practices as screening rates are being applied as a quality metric in existing and new federal programs for assessing the performance of physicians and their health system clinical partners .
In considering factors impacting screening adherence, prior studies have explored women’s perceptions of the screening mammography experience, including not only the process of actually undergoing the mammogram, but also aspects of the facility, its staff, as well as the breast imager . Insights from such studies have been useful for breast imagers in better understanding how to optimize the patient experience in mammography so as to improve screening rates . However, with increasing health system merger and integration, most radiologists (including breast imagers) now increasingly find themselves parts of larger health networks and thus in positions to consider a broader array of practice- and provider-related factors . In particular, women’s likelihood of undergoing screening may be influenced not only by their interactions with, and perceptions of, the physicians interpreting those screening tests, but also interactions and perceptions relating to the physicians ordering such tests in the first place. Indeed, earlier preliminary studies suggest associations between women’s satisfaction with their primary care providers and screening rates . Nonetheless, larger population-based studies are necessary to validate and further understand such observations. In this study, we assess associations between women’s utilization of screening mammography and relationships with, and impressions of, their primary care physicians within the Medicare population.
Methods
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Survey
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Analysis
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Results
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TABLE 1
Screening Mammography Utilization, Stratified by Survey Responses \*
Cohort Unweighted Data Weighted Data Screening Utilization_n__P_ (nominal)P (ordinal) Screening Utilization 95% CI_P_ (nominal)P (ordinal) Overall cohort 61.0% 4570/7492 62.0% 59.8%–64.2% Have you had any trouble getting the health care that you wanted or needed over the past year?<.001 —.008 — Yes 49.7% 213/429 50.1% 40.8%–59.4% No 61.7% 4353/7055 62.8% 60.5%–65.0% How satisfied are you with the overall quality of health care that you have received over the past year?<.001<.001<.001.002 Very satisfied 65.1% 2465/3788 66.0% 62.9%–68.9% Satisfied 58.7% 1946/3316 59.8% 56.4%–63.1% Dissatisfied 55.9% 119/213 58.0% 44.4%–70.4% Very dissatisfied 34.1% 15/44 35.8% 13.1%–67.4% No experience 15.7% 18/115 16.0% 6.9%–32.9% How satisfied are you with the ease and convenience of getting to a doctor from where you live?<.001<.001<.001<.001 Very satisfied 66.6% 1879/2821 67.7% 64.1%–71.0% Satisfied 59.2% 2476/4179 60.2% 57.2%–63.2% Dissatisfied 51.9% 160/308 51.9% 40.7%–62.9% Very dissatisfied 41.8% 28/67 43.2% 22.0%–67.3% No experience 21.9% 21/96 21.3% 9.3%–41.8% How satisfied are you with the concern of your doctors for your overall health rather than just for an isolated symptom or disease?<.001<.001<.001.013 Very satisfied 64.4% 1740/2700 65.7% 62.0%–69.2% Satisfied 61.3% 2558/4176 62.3% 59.3%–65.2% Dissatisfied 50.5% 158/313 50.9% 39.8%–61.9% Very dissatisfied 53.6% 30/56 53.4% 28.2%–76.9% No experience 30.6% 56/183 30.5% 19.2%–44.8% How satisfied are you with the availability of care by specialists when you feel you need it?<.001<.001<.001.003 Very satisfied 66.9% 1610/2408 68.0% 64.1%–71.6% Satisfied 60.8% 2397/3943 61.8% 58.7%–64.8% Dissatisfied 53.1% 172/324 55.3% 44.4%–65.6% Very dissatisfied 56.7% 38/67 56.6% 32.9%–77.6% No experience 47.1% 338/718 47.5% 40.3%–54.7% Is there a particular medical practice or a clinic that you usually go to when you are sick or for advice about your health?<.001 —<.001 — Yes 62.1% 4461/7178 63.2% 60.9%–65.4% No 34.9% 105/301 34.6% 24.7%–45.9% Is there a particular doctor you usually see at this place?<.001 —.049 — Yes 62.4% 844/1352 63.8% 58.5%–68.8% No 49.1% 115/234 50.3% 37.8%–62.8% Your doctor is competent and well trained..001<.001 .298.036 Strongly agree 64.8% 2284/3527 66.0% 62.8%–69.0% Agree 60.5% 2030/3356 61.4% 58.0%–64.7% Disagree 54.5% 36/66 54.9% 31.3%–76.5% Strongly disagree 53.8% 7/13 54.1% 12.0%–91.0% No experience 47.6% 10/21 49.9% 15.8%–84.1% Your doctor has a good understanding of your medical history.<.001<.001 .164.017 Strongly agree 65.0% 2194/3376 66.1% 62.9%–69.2% Agree 60.7% 2043/3366 61.7% 58.4%–65.0% Disagree 53.0% 96/181 52.3% 38.0%–66.2% Strongly disagree 56.3% 18/32 58.1% 25.2%–85.1% No experience 53.8% 21/39 55.8% 26.4%–81.5% Your doctor has a complete understanding of things that are wrong with you.<.001<.001 .069.008 Strongly agree 65.3% 1983/3038 66.3% 62.9%–69.5% Agree 61.3% 2196/3581 62.4% 59.1%–65.5% Disagree 50.3% 145/288 51.6% 40.1%–62.9% Strongly disagree 44.8% 13/29 47.1% 16.9%–79.5% No experience 53.2% 25/47 54.0% 27.1%–78.8% Your doctor often seems to be in a hurry..024.006 .463 .124 Strongly agree 57.4% 108/188 58.0% 43.5%–71.2% Agree 58.1% 467/804 58.6% 51.6%–65.2% Disagree 63.0% 2674/4243 64.2% 61.3%–67.1% Strongly disagree 63.7% 1123/1762 64.9% 60.3%–69.2% No experience 54.2% 13/24 53.1% 18.2%–85.2% Your doctor often does not explain your medical problems to you..003.001 .385 .095 Strongly agree 55.2% 69/125 57.1% 39.4%–73.2% Agree 58.7% 320/545 59.3% 50.7%–67.3% Disagree 62.3% 2726/4378 63.5% 60.5%–66.3% Strongly disagree 65.2% 1230/1887 66.0% 61.7%–70.1% No experience 51.4% 38/74 51.2% 30.0%–72.0% You often have health problems that should be discussed but are not.<.001<.001 .066.035 Strongly agree 54.7% 35/64 56.1% 31.9%–77.8% Agree 57.7% 320/555 58.9% 50.5%–66.8% Disagree 62.3% 2850/4578 63.2% 60.4%–66.0% Strongly disagree 66.1% 1146/1733 67.4% 62.9%–71.6% No experience 40.8% 29/71 40.2% 20.9%–63.1% Your doctor often acts as though he or she is doing you a favor by talking to you.<.001<.001 .087.011 Strongly agree 50.0% 34/68 50.3% 28.1%–72.3% Agree 52.7% 174/330 53.2% 42.3%–63.8% Disagree 61.9% 2505/4049 62.9% 59.9%–65.9% Strongly disagree 65.3% 1652/2530 66.4% 62.7%–70.0% No experience 48.6% 17/35 49.9% 20.7%–79.1% Your doctor tells you all you want to know about your condition and treatment.<.001<.001 .117.017 Strongly agree 66.0% 1713/2597 67.0% 63.3%–70.5% Agree 60.9% 2409/3953 61.9% 58.8%–64.9% Disagree 58.9% 218/370 60.4% 50.1%–69.9% Strongly disagree 46.7% 21/45 46.7% 21.0%–74.2% No experience 48.1% 26/54 49.4% 25.1%–74.0% Your doctor answers all of your questions.<.001<.001 .116.032 Strongly agree 65.8% 1825/2775 66.8% 63.2%–70.1% Agree 60.4% 2391/3956 61.4% 58.3%–64.5% Disagree 63.6% 136/214 65.8% 52.3%–77.1% Strongly disagree 41.7% 15/36 42.6% 16.4%–73.8% No experience 51.1% 24/47 51.8% 25.0%–77.7% You have great confidence in your doctor.<.001<.001 .187.018 Strongly agree 65.0% 2073/3191 66.0% 62.7%–69.2% Agree 61.3% 2101/3426 62.4% 59.0%–65.6% Disagree 53.1% 146/275 54.5% 42.6%–65.8% Strongly disagree 49.1% 27/55 50.6% 26.0%–74.9% No experience 55.6% 25/45 57.7% 29.4%–81.7% You depend on your doctor to feel better both physically and emotionally..011.002 .557 .128 Strongly agree 65.3% 1524/2334 66.3% 62.3%–70.0% Agree 61.3% 2194/3579 62.4% 59.2%–65.6% Disagree 61.3% 521/850 62.3% 55.7%–68.5% Strongly disagree 56.3% 54/96 57.3% 37.2%–75.2% No experience 59.2% 74/125 60.4% 42.7%–75.8%
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TABLE 2
Predicted Probability of Undergoing a Screening Mammogram as a Function of the Three Survey Questions Identified to Be Significant Independent Predictors of Screening Mammography Utilization at Multivariable Analysis
Satisfaction with Quality of Care Satisfaction with Ease of Getting to Doctor No Regular Practice Regular Practice Very satisfied Very satisfied 51.6% 68.9% Very satisfied Satisfied 45.6% 63.6% Very satisfied Dissatisfied 38.0% 56.1% Very satisfied Very dissatisfied 34.7% 49.4% Very satisfied No experience 27.4% 44.0% Satisfied Very satisfied 48.2% 66.0% Satisfied Satisfied 42.3% 60.4% Satisfied Dissatisfied 34.9% 52.7% Satisfied Very dissatisfied 29.1% 46.1% Satisfied No experience 24.8% 40.7% Dissatisfied Very satisfied 48.3% 66.0% Dissatisfied Satisfied 42.4% 60.5% Dissatisfied Dissatisfied 35.0% 52.8% Dissatisfied Very dissatisfied 29.2% 46.2% Dissatisfied No experience 24.8% 40.8% Very dissatisfied Very satisfied 30.2% 45.9% Very dissatisfied Satisfied 24.3% 40.1% Very dissatisfied Dissatisfied 19.0% 32.8% Very dissatisfied Very dissatisfied 15.2% 27.3% Very dissatisfied No experience 12.6% 22.0% No experience Very satisfied 16.8% 29.7% No experience Satisfied 13.7% 24.9% No experience Dissatisfied 10.4% 19.5% No experience Very dissatisfied 8.2% 17.8% No experience No experience 6.7% 13.0%
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Discussion
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