title: Mammography Screening in a Large Health System Following the U.S. Preventive Services Task Force Recommendations and the Affordable Care Act.
abstract: BACKGROUND
  Practice recommendations for mammography screening were issued by the U.S. Preventive Services Task Force in 2009 and expansion of insurance coverage was provided under the Patient Protection and Affordable Care Act soon thereafter, yet the influence of these changes on screening practices in the United States is not known.
  
  
  METHODS
  To determine changes in mammography screening and their associations with new practice recommendations and the Affordable Care Act, we examined patient-level data from 249,803 screening mammograms from January 1, 2008 through December 31, 2012 in a large community-based health system in the northwestern United States. Associations were determined by an intervention analysis of time-series data method.
  
  
  RESULTS
  Among women screened, 64% were age 50-74 years; 84% self-identified as white race; 62% had commercial insurance; and 70% were seen in facilities located in metropolitan areas. Practice recommendations were associated with decreased screening volumes among women age <40 (-37.4 mammograms/month; -39.4% change; P<0.001), 40-49 (-106.0 mammograms/month; -11.2% change; P<0.001), and ≥75 (-54.7 mammograms/month; -10.0% change; P<0.001), but not women age 50-74. Implementation of the Affordable Care Act was associated with increased screening among women age 50-74 (+184.3 mammograms/month; +7.2% change; P=0.001), but not women <40 or ≥75; increases for age 40-49 were of borderline statistical significance (+56.9 mammograms/month; +6% change; P=0.06). Practice recommendations were also associated with decreased screening for women with commercial insurance, while the Affordable Care Act was associated with increased screening for women with Medicare, Medicaid, or other noncommercial sources of payment.
  
  
  CONCLUSIONS
  Mammography screening volumes in a large community health system decreased among women age <50 and ≥75 in association with new U.S. Preventive Services Task Force practice recommendations, while insurance coverage changes under the Affordable Care Act were associated with increased screening volumes among women age 50-74.
authors.affiliation: Providence Cancer Center, Providence Health and Services, Portland, Oregon, United States of America; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States of America; Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States of America.
authors.forename: Heidi D
authors.initials: HD
authors.lastname: Nelson
authors.affiliation: Providence Cancer Center, Providence Health and Services, Portland, Oregon, United States of America.
authors.forename: Roshanthi
authors.initials: R
authors.lastname: Weerasinghe
authors.affiliation: Medical Data Research Center, Providence Health & Services, Portland, Oregon, United States of America.
authors.forename: Lian
authors.initials: L
authors.lastname: Wang
authors.affiliation: Medical Data Research Center, Providence Health & Services, Portland, Oregon, United States of America.
authors.forename: Gary
authors.initials: G
authors.lastname: Grunkemeier
mesh_terms: D017677:Age Distribution; D000368:Aged; D005260:Female; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008327:Mammography / Q000706:statistics & numerical data*; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D058991:Patient Protection and Affordable Care Act; D014481:United States