Adherence to screening mammography guidelines by recently-licensed family physicians

Background. Practice guidelines for screening mammography diverge on the recommended age at which systematic screening should begin for women aged 40 to 69 years. 'Routine' guidelines recommend screening starting at 40 years; 'age-selective', at 50 years and only for younger women who have a first-degree family history of breast cancer. Objectives. (1) To estimate and compare recently-licensed family physicians' adherence to 'routine' and 'age-selective' guidelines in women aged 40 to 69 years, (2) To identify intrinsic physician and practice environment factors which predict referral rates for women aged 50 to 69 years as well as age-selective referral. Study Design. A census sample of 743 recently-licensed family physicians was followed for 18-months of incipient medical practice. Mammograms were identified from physician claims to the Regie de l'assurance-maladie du Quebec for every clinically eligible woman aged 40 to 69 years who had a complete physical examination by a study physician in a community setting (primary care practice). Adherence to 'routine' guidelines was measured as the percent of women with a screening mammogram referred by the study physician in the study period. Adherence to 'age-selective' guidelines was referral rates in older (50-to-69 years) minus younger (40-to-49 years) women. Multiple linear regression was used to identify predictors of mammography referral. Results: Study physicians referred 6% (SD: 10) of younger women and 12% (SD: 15) of older women in their primary care practice. The correlation or ranks of adherence to 'routine' and 'selective' guidelines corresponded poorly (Spearman r = 0.51). Factors positively associated with higher referral rates in women aged 50 to 69 years were female gender, prevention competence, later medical school graduation, the combination of comprehensive inquiry and continuity care, and the extent of community-based care. Negatively associated factors were higher patient volume and shared primary care (model R2 = 0.48). Age-selective referral was associated with prevention competence; routine referral with women physicians in urban areas (model R2 = 0.10). Conclusions: Mammography referral fell short of recommended practice by any standard. The overall rate of women referred (routine adherence) masked underlying differences in age-selective referral. Physician characteristics and delivery of community-based, comprehensive, and continuity care predict mammography referral rates in older women.