Austin Jessica D, Tehranifar Parisa, Rodriguez Carmen B, Brotzman Laura, Agovino Mariangela, Ziazadeh Danya, Moise Nathalie, Shelton Rachel C
Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA.
Implement Sci Commun. 2021 Sep 26;2(1):110. doi: 10.1186/s43058-021-00217-7.
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.
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.
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.
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.
人们越来越担心老年女性中常规乳腺钼靶筛查存在过度使用的情况。要成功且公平地减少乳腺钼靶筛查的使用，需要对导致其过度使用的因素有多层次的理解。
这项解释性、序列性、混合方法研究收集了在进行乳腺钼靶筛查时年龄≥70岁女性的调查数据（n = 52，73.1%为西班牙裔，73.1%说西班牙语），随后对完成调查的一部分老年女性（n = 19，63.2%为西班牙裔，63.2%说西班牙语）和医疗服务提供者（n = 5，4名初级保健医生，1名妇产科医生）进行半结构化访谈，以更好地理解影响乳腺钼靶过度使用的多层次因素，并为潜在的减少使用策略提供信息。我们对调查数据进行了描述性分析，对定性访谈数据进行了内容分析。调查和访谈数据分别进行检查、比较、整合，并根据诺顿和钱伯斯影响减少实施过程的因素连续体进行组织。
调查结果显示，87.2%的老年女性认为计划每年进行一次乳腺钼靶检查很重要，80.8%的人收到了医疗服务提供者的建议，78.9%的人在过去12个月里收到了预约乳腺钼靶检查的提醒。根据对老年女性的访谈，大多数人不知道或不认为自己经历了过度使用，并打算继续进行乳腺钼靶筛查。对老年女性和医疗服务提供者的访谈结果表明，老年女性有多个机会进行乳腺钼靶检查。根据对医疗服务提供者的访谈，几乎所有人都报告说，系统或其他医疗服务提供者不认为减少过度使用是一个优先事项。医疗服务提供者还讨论了不同医疗服务提供者之间乳腺钼靶筛查做法的差异、对医疗事故的担忧以及金钱激励可能导致过度筛查。医疗服务提供者确定了减少过度筛查的潜在策略，包括围绕筛查危害对患者和医疗服务提供者进行教育、利用电子健康记录识别可能从筛查中获得较少健康益处的女性、定制系统生成的提醒信，以及组织工作组制定围绕乳腺钼靶筛查的标准护理流程。
导致乳腺钼靶过度使用的多层次因素是动态的、相互关联的且相互强化的。为确保公平地减少使用，需要对减少实施的理论、模型和框架进行更精细的实证测试，这些理论、模型和框架要有强大的患者层面组成部分，考虑到多层次因素与更大的护理提供过程之间的相互作用。
