New Research Examines Socioeconomic Factors with Mammography No-Shows

Language differences, racial disparities and economic issues continue to be significant factors with reduced adherence to regular mammography screening.

In a new study, recently published in the Journal of the American College of Radiology (JACR), researchers examined the impact of socioeconomic factors upon screening mammography appointments at a community health center in 2021.1 They noted that 743 out of 6,159 (12.1 percent) women with scheduled mammograms did not come to their appointments and 302 of those women (40.7 percent) did not complete a screening mammography at one year.

The JACR study authors found that poverty, primary non-English language and race and ethnicity other than non-Hispanic White were more common among women with missed mammography appointments.

“Our data indicate screening mammography appointment no-shows is a health equity issue where socioeconomically disadvantaged and racial and ethnic minority patients are disproportionately more likely to experience missed appointments and potential care delays,” noted Gary X. Wang, M.D., who is affiliated with the Department of Radiology at Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues. (Image courtesy of Adobe Stock.)

In a separate August 9 report from the Centers for Disease Control’s (CDC) Morbidity and Mortality Weekly Report (MMWR), researchers found that nearly 35 percent of women (50 to 74 years of age) who had three or more adverse social determinants of health (SDOHs) and health-related social needs (HRSNs) did not have mammography exams in 2020 or 2021.2

Specifically, according to the JACR study, 32 percent of women with a primary language other than English missed mammography appointments in comparison to 26 percent of those with English as their primary language.1

Women with race and ethnicity other than non-Hispanic White missed mammography appointments at a nearly 9 percent higher rate (42.3 percent) than White non-Hispanic women (33.6 percent), according to the JACR researchers.1

The JACR study authors also pointed out that those living in higher poverty areas were 5.4 percent more likely (19.5 percent vs. 14.1 percent) and patients with Medicaid or means-tested insurance were over 27 percent more likely (62 percent vs. 34.4 percent) to miss mammography appointments.1

“Our data indicate screening mammography appointment no-shows is a health equity issue where socioeconomically disadvantaged and racial and ethnic minority patients are disproportionately more likely to experience missed appointments and potential care delays,” wrote lead study author Gary X. Wang, M.D., who is affiliated with the Department of Radiology at Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues.

Based on data from the 2022 Behavioral Risk Factor Surveillance System, for women between 50 to 74 years of age, the MMWR study authors found that a nearly 18 percent higher adherence rate with mammography screening for those with no adverse SDOHs and HRSNs (83.2 percent) in comparison to women with three or more adverse SDOHs and HRSNs (65.7 percent).2

Cost barriers with health care access were associated with a 96 percent higher likelihood of no mammography exams in 2020/2021 among women 40 to 49 years of age and a 2.11 odds ratio (OR) among women 50 to 74 years of age, according to the MMWR researchers. For women 40 to 49 years of age, those with lost or reduced hours of employment were 35 more likely to miss mammography exams during the aforementioned two-year period.2

“Cost as a barrier to accessing health care was most strongly associated (with lack of mammography exams), which might represent a wide range of factors beyond the cost of health care, including costs for transportation, child care, and taking time off work,” wrote lead MMWR study author Jacqueline Miller, M.D., FACS, the medical director for CDC’s National Breast and Cervical Cancer Early Detection Program in the Division of Cancer Prevention and Control, and colleagues.

“Further, mammography use decreased as women experienced an increasing number of adverse SDOH and HRSNs. The impact of these SDOH and HRSNs might have been exacerbated during the COVID-19 pandemic when persons often remained at home, which potentially increased social isolation and job loss.”

In their assessment of adjusted odd ratios (aORs) for independent predictive factors associated with mammography shows, the JACR study authors found that having Medicaid or means-tested insurance was associated with more than double the risk of missed mammography appointments (2.75 aOR). The researchers also noted that women in higher poverty residential zip code tabulation areas (ZCTAs) were 76 percent more likely to miss mammography exams.1

“Socioeconomic disadvantage may exacerbate barriers to screening mammography access and completion within our healthcare systems, barriers that may lead to delays in care and worse outcomes unless recognized and addressed by systems-level solutions,” added Wang and colleagues. “Reported barriers to screening mammography completion include competing priorities, financial concerns, transportation challenges, and poor health literacy.”

The JACR study authors also noted lower levels of engagement with regular mammography screening. For women with missed appointments, 74.6 percent had a previous mammogram in comparison to 87.5 percent for women with completed mammography exams in this study. The study findings also revealed a significantly longer gap between appointments and prior mammography exams (median of 792.5 days for the no-show group vs. 527 days for women with completed mammograms).1

“Only 60% of patients who experience no-shows go on to complete their missed exams within the following 365 days. … Our findings point to a clear need to better understand the patient population who do not complete screening mammography following appointment no-shows,” maintained Wang and colleagues. “Specifically, we are currently undertaking efforts to characterize this population and to understand their barriers and facilitators to scheduling and completing screening mammography at our institution.”

The JACR study authors suggested that a system that provides and tracks targeted outreach after no-shows, improved engagement with referring primary care physicians and re-examination of the use of pre-appointment reminders may facilitate improved adherence with mammography screening.1

The MMWR authors emphasized the need for multicomponent approaches to help alleviate the impact of adverse SDOH and HRSNs on mammography screening adherence. They added that a new CMS billing code facilitates reimbursement for assessing SDOH and HRSN for patients.2

In regard to study limitations, while the JACR researchers noted the exclusion of patients who had diagnostic mammography within a 60-day period prior to a missed appointment, they noted the possibility that some patients may have completed screening mammography at another facility and other patients may have proceeded to diagnostic mammography due to symptoms.

References

1. Wang GX, Mercaldo SF, Cahill JE, Flanagan JM, Lehman CD, Park ER. Missed screening mammography appointments: patient sociodemographic characteristics and mammography completion after one year. J Am Coll Radiol. 2024. doi: https://doi.org/10.1016/j.jacr.2024.03.017 . Online ahead of print.

2. Miller JW, King JA, Trivers KF, et al. Mammography use and association with social determinants of health and health-related social needs among women — United States, 2022. MMWR Morb Mortal Wkly Rep. doi: https://dx.doi.org/10.15585/mmwr.mm7315e1 . Published April 9, 2024.