Table 3 Multi-level factors perceived to contribute to mammography overuse and potential associated de-implementation strategies
Level | Patient- and provider-identified factors | Provider-identified strategies from interviews |
|---|---|---|
Patient | - Lack of awareness or confusion about overuse - Perception that all healthcare recommended by a provider is necessary - Perceive mammography screening to be important for early detection despite age/health - Perceived need for an annual mammogram | - Develop educational resources for patients, family members, and others involved in mammography screening decisions about the harms of mammography overuse. - Implement or adapt/refine existing decision-aids around mammography screening to older women to facilitate informed discussions around screening. |
Provider | - Providers continue to recommend routine mammography screening - Mammography screening practices and guidelines vary across providers within the same clinic and across specialties (e.g. primary care, OB/GYN, radiology) - Challenges identifying older women who are less likely to benefit from mammography screening - Challenges discussing reducing or stopping mammography screening based on age and life expectancy | - Develop educational resources and trainings for providers about the potential harms of mammography overuse. - Leverage the electronic health record to include a decision support system to aid providers and patients in the decision. - Support provider training and feedback regarding communication about mammography overuse and life expectancy. |
System/setting | - System-generated reminder letters are in conflict with published guidelines for primary care provider and reinforce mammography screening for older women - System is reimbursed and incentivized for completing mammograms - Mammography overuse is not prioritized or perceived as a problem at the system level - Patients can bypass their providers to get a mammogram and there is no standard referral process | - Patient reminder letters are customized based on individual risk (i.e., family history, personal history). - Modify the electronic health record to include a risk-stratified process for mammography screening. - Convene a system task force to enact consistent mammography screening guidelines across the system - Designate a champion that oversees de-implementation of mammography in older women. |