Self-Report and Primary Care Medical Record Documentation of Mammography: DISCUSSION
This study identified high rates of self-reported breast and cervical cancer screening among poor, African-American, Puerto Rican women and non-Hispanic white women living in the inner-city with access to primary care. This shows that primary care truly can have a positive impact on the receipt of preventive health services among minority, low-income women. The screening rates found in this study were compared to national averages. Receipt of a Pap smear in the past three years according to self-report (96%) and chart review (92%) exceeds the Healthy People 2010 goal of 90%. Self report of mammography in this study (91%) exceeds the Health People 2010 goal of 70% of women over 40 receiving a mammogram within the preceding two years. However, chart documentation of mammography (57%) is below the 2010 goal. This study used 1997 American Cancer Society Guidelines to assess appropriateness of screening. We did not assess the guidelines that the patients’ physicians inherently followed if any. Self-report of receipt of mammography and Pap smear was consistently higher than medical record documentation of screening. Self-report misrepresented actual screening practices as identified by high sensitivity rates and low specificity rates. However, high negative predictive values suggested that asking women about their recent mammography use may be an inexpensive, easy intervention to increase screening among women currently not being screened by encouraging dialog between patient and provider about reasons for not being screened and/or other means of obtaining screens.
Specificity was moderate-to-low, suggesting that women who are not up-to-date, according to medical record documentation, will report that they are up-to-date. The negative predictive values were low for Pap smear utilization, perhaps due to the extremely high number of women reporting that they were screened. Given the fact that a woman may receive a pelvic exam for multiple indications without receiving a Pap smear, it is not surprising that more women reported getting a Pap smear than documented in the charts. From the perspective of a patient, she may not be able to tell if a Pap smear is taken or not when receiving a pelvic exam. Negative predictive values were high for mammography, indicating that women who report they are not up-to-date on screening, most likely are not, as supported by medical record documentation. Although this percentage of women was small, it is a group that is easily and inexpensively targeted for intervention. It is simple to ask, and follow-up would be manageable. Given physical and emotional reactions often associated with mammograms, such as fear discomfort, pain and embarrassment, it is not surprising that it can be recalled more accurately. buy kamagra oral jelly
Similar to other studies, this study found higher levels of agreement and higher positive predictive values among more recent tests. As previously documented in the literature, self-report of recommended screening was consistently higher than medical record documentation. This may reflect overestimates of self-report or poor record keeping within the healthcare system. In this study, medical record documentation referred to documentation of results in the primary care medical record. Laboratory reports from outside gynecologists or from outside labs may not have been incorporated into the primary care chart. Some studies have begun to use billing data, laboratory results or have reviewed records of the provider that performed the tests for additional accuracy. Women were not asked about other avenues by which screening tests could be obtained, such as outreach clinics or health fairs. More accurate record keeping would result if a provider simply asks about screening, since it would confirm other sources of screening.
The primary care offices participating in this study provided gynecologic care for 86% of women in this sample. Pap smears were received in-office and mammography required the use of outside health services. This study found more accuracy in self-report for Pap smears than mammography. Other studies found that recall accuracy of Pap smears was less than recall accu racy of mammography. Since many other studies were conducted outside of the primary care office, this discrepancy may be a product of sample being engaged in a primary care setting where women receive most of their gynecologic care. There was no way to differentiate between women that did not receive care and women that received care outside of the primary care office. Therefore, we were unable to determine if there was a racial/ethnic differential in communicating lab results to the primary care practice. Since this information is unavailable and it is assumed that if the results were not in the chart that the woman was not screened, the results documented here may underestimate the accuracy of a woman’s recall. Viagra Online Canadian Pharmacy
Charting the referral, delivery and follow-up of preventive services may vary among different office systems. For example, some offices incorporate reminder systems or have staff to assist with preventive medicine. Some offices have access to an electronic medical record. This study did not assess site characteristics that may impact a woman’s recall of screening. Provider biases towards screening were not assessed. For example, the specific guideline a provider adheres to was unknown.
This practice-based study used self-reported data from poor women residing in inner-city communities who used primary healthcare services. Although this makes the study unique, it limits the generalizability of the findings. This sample also allows for large samples of minority patients. These health centers were located in similar areas within the city of Buffalo. However, Puerto Rican women were more likely than African-American women to have a total household income <$ 10,000 and to have less than an eighth-grade education. Puerto Rican women were also more likely to be married or living with a partner. Despite these socioeconomic and social differences, there were no consistent patterns apparent in racial/ethnic differences in accuracy of self-report of Pap smear use compared to medical record documentation.
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Non-Latina white women were more likely to be uninsured compared to African-American and Puerto Rican women. Puerto Rican women had lower incomes than African-American and non-Latina white women. Medicaid is accessible in New York State for low-income women, particularly with children. This may explain the racial/ethnic difference in insurance status found in this sample.
A lack of racial/ethnic effect among low-income women was consistent with other findings reported in the literature. However, sensitivity, specificity, positive predictive value and negative predictive value for history of mammography use was lower among Puerto Rican women than non-Latinas and African-American women. In this study, findings for Puerto Rican women may be attributed to cultural or linguistic barriers to screening. For example, some women may not fully understand the screening tests because of language barriers and may have difficulty dealing with a system that is exclusively English-based if they are monolingual. Even women that speak English may have difficulty understanding the complexity of screening tests.
Although this study represented Puerto Rican, non-Latina white and African-American women, the numbers were not large enough to assess confounding and interaction effects that may be present. For example, racial/ethnic differences may be attributed to education level or income level differences rather than race. order levitra
This study represented screening practices of women, particularly African Americans and Puerto Rican women, within the primary healthcare system limiting the generalizability of findings to all low-income women. However, findings provide insight for providers serving low-income minority women in similar clinical settings. We did not have access to screen ing that may have been obtained at other sites and did not follow-up with labs or referrals on completed tests that were not documented in the primary care record. Since women in this study had access to primary care, the results may not be generalizable to other minority, low-income communities with more access barriers to primary care. Self-reported data infers the potential for overreporting positive behavior. However, there is no reason to assume that variation of overreporting would exist among racial/ethnic groups.
In summary, self-report of most recent mammogram may be useful in the primary care setting to identify women who have not received mammography within recommended guidelines, especially among minority women. Although we assume screening is regularly discussed in current practice, preventive services may be overridden by acute care needs. Simply asking a woman when she was last screened is a cost- and time-efficient way to identify a small target group that may be amenable to provider recommendation for screening. Asking women about their screening rather than relying on medical record information will stimulate a conversation that will improve the delivery of preventive services in the primary care setting. This conversation provides an opportunity to learn if women are receiving their cancer screening from sources outside of the office or to openly discuss fears or concerns that may be hindering a woman from receiving mammography or Pap smears. suhagra 100
The ultimate goal of regular breast and cervical cancer screening for eligible women will contribute to a reduction of early deaths from these two important causes of death. Future studies warrant the evaluation of an intervention, such as the incorporation of asking about screening into the collection of vital statistics on screening outcomes. Larger studies conducted in practice based research networks would allow for the comparison of site and provider information as well as assessing the effects of income, education and race/ethnicity. A complement of qualitative studies will increase the understanding of women’s understanding of screening and their related needs.
