Abstract

BackgroundThere 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.MethodsThis 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.ResultsSurvey 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.ConclusionsMulti-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.

Highlights

  • In recent years, there has been a growing emphasis on de-implementing the delivery of unnecessary or lowvalue healthcare [1,2,3,4,5]

  • Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced

  • De-implementation of routine mammography screening in older women offers an opportunity for advancing the science of de-implementation

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Summary

Introduction

There has been a growing emphasis on de-implementing the delivery of unnecessary or lowvalue healthcare [1,2,3,4,5]. De-implementation refers to reducing, discontinuing, or replacing healthcare that is ineffective, inappropriate, and/or unproven This area has received growing attention among funders and healthcare systems given that it is a vital part of improving overall population health, increasing the quality of care, decreasing unnecessary costs, and minimizing patient harm [1]. Mammography screening is associated with a 15 to 25% reduction in breast cancer mortality after 10–15 years [13], but evidence suggests that it does not lead to a significant reduction in breast cancer mortality among women with limited life expectancies and greater competing health risks [14,15,16,17] Rather, it may pose substantial and immediate harms, such as anxiety, financial, and time burden, as well as diagnosis and treatment of tumors that would not have resulted in death [15, 18,19,20]. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse

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