Reducing Barriers to the Use of Breast Cancer Screening

For nearly 20 years research and practice fields have acknowledged the relationship between increased mammography screening among older women and decreased breast cancer mortality. Despite this information, adherence to breast cancer screening guidelines has not been achieved. This barrier, coupled with the knowledge that physician recommendations for women to receive mammograms appears to increase utilization, underscores the importance of developing and testing strategies to improve physician performance of breast cancer screening.

The program reported here represents the physician intervention component of a larger NCI-supported "Early Detection Guidelines Education" project. The project's focus was to test the effect on older women's use of breast cancer screening, of barrier-specific telephone counseling for women, and continuing medical education (CME) directed at breast cancer screening practices among physicians.

The physician intervention aims to increase the breast cancer screening practices of community-based physicians by employing a 1 to 2 hour long continuing medical education intervention delivered in the physician's office by a nurse educator. This is followed by a visit by a standardized patient trained to provide feedback to the physician to enhance his/her communication and clinical breast examination skills. The project hypothesized that physicians in need of educational intervention to improve breast cancer screening who received CME would have increased knowledge and breast cancer screening practices and skills.

The physician intervention, conducted by a master's level nurse educator, takes 1 to 2 hours to deliver, followed by the standardized patient visit.

Participants were primary care physicians practicing in four towns on Long Island, New York. These suburban communities were selected based on their demographics. Each had over 100,000 women aged 50 - 80 years, at least one community hospital, over 100 primary care physicians, and were not geographically contiguous.

The intervention is suitable for implementation in a physician's office.

The Continuing Medical Education workbook, Building Skills in Office Preventive Services Delivery is required. Costs associated with the program's implementation are not provided.

Four towns on Long Island in New York were selected to participate in this study. Two of the four towns were designated as CME intervention areas and two as control areas. Prior to intervention, physicians were surveyed and classified as being in "high" or "low" need of an improvement on adherence to breast cancer screening guidelines. Physicians in the CME areas who were categorized as having "high need" qualified for the intensive in-office CME intervention. These physicians received a 1 to 2 hour in-office visit by a master's level nurse educator followed by a visit by a standardized patient. Physicians in the CME area who were classified as "low need" received a self-study intervention (CME workbook).

Results indicated:

• Among physicians with high pre-intervention need, improvement in breast screening need scores increased more for physicians receiving CME (40%) than for controls (29%); for those CME physicians receiving the in-office CME, score increases were statistically significant compared to the controls (49% vs. 29%).
• The use of provider reminder systems increased, preparedness to counsel about clinical breast exams increased, and recognition that age is an important risk factor for breast cancer improved more in the CME intervention group than the control group.
• The CME intervention group had greater post-intervention improvement than controls in the areas of mammography referrals, performance of annual clinical breast exams, and the use of aids to teach self breast exams although a small sample size prevented the finding of a statistically significant difference.