Eric E Howell, MD

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.