Factors Associated with Routine Recommendation of Mammography for Women Aged 40-49: Provider Characteristics and Screening Influences.
Despite the US Preventive Services Task Force recommendation against screening mammography in women younger than 50 years, rates remain high, suggesting that screening recommendations may be motivated by other factors. The objective of this study was to understand provider-reported influences on screening recommendations for women 40 to 49 years old at average risk for breast cancer.



An online survey of primary care providers was conducted at four health centers in Cleveland, Ohio in 2015. Provider-reported routine recommendation of mammography for women aged 40 to 49 at average risk for breast cancer was the primary outcome. The independent measures included influence of electronic health records, national guidelines, institutional policy, patient preferences, concerns about overtreatment, concerns about false-positives, and interest in early detection on screening recommendations. We used multivariable logistic regression to estimate the odds of recommending screening by potential influences, controlling for provider characteristics and provider-assessed balance of harms and benefits of screening in this age group.



Of 612 providers invited, 220 completed the survey (response rate 36%); 69% routinely recommended screening and 24% believed that the harms of screening in younger women outweighed the benefits. Being influenced by institutional policy was associated with higher odds of recommending screening (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.35-12.9), as was interest in early detection (OR 4.19, 95% CI 1.31-12.9). Conversely, strong influence of national guidelines was associated with a lower odds of recommending screening (OR 0.25, 95% CI 0.09-0.71). The influence of patient preferences was not associated with screening recommendation.



Providers face competing influences on screening recommendations for younger patients, some of which may be at odds with their beliefs. Institutional policy change allowing individually tailored screening discussions may improve patient-centered care.
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Kathryn A
KA
Martinez
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Abhishek
A
Deshpande
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Allison L
AL
Ruff
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Shari D
SD
Bolen
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Kathryn
K
Teng
From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.
Michael B
MB
Rothberg
D000328:Adult; D000367:Age Factors; D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000175:diagnosis / Q000453:epidemiology; D055088:Early Detection of Cancer / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008327:Mammography / Q000379:methods / Q000706:statistics & numerical data; D008403:Mass Screening / Q000009:adverse effects / Q000379:methods; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D057240:Patient Preference / Q000706:statistics & numerical data; D011314:Preventive Health Services / Q000379:methods / Q000458:organization & administration; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data; D058996:Quality Improvement; D018570:Risk Assessment