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Timeliness of Abnormal Screening and Diagnostic Mammography Follow-up at Facilities Serving Vulnerable Women

Goldman, L. Elizabeth MD, MCR*; Walker, Rod MS; Hubbard, Rebecca PhD; Kerlikowske, Karla MD*for the Breast Cancer Surveillance Consortium

doi: 10.1097/MLR.0b013e318280f04c
Original Articles

Background: Whether timeliness of follow-up after abnormal mammography differs at facilities serving vulnerable populations, such as women with limited education or income, in rural areas, and racial/ethnic minorities is unknown.

Methods: We examined receipt of diagnostic evaluation after abnormal mammography using 1998–2006 Breast Cancer Surveillance Consortium-linked Medicare claims. We compared whether time to recommended breast imaging or biopsy depended on whether women attended facilities serving vulnerable populations. We characterized a facility by the proportion of mammograms performed on women with limited education or income, in rural areas, or racial/ethnic minorities.

Results: We analyzed 30,874 abnormal screening examinations recommended for follow-up imaging across 142 facilities and 10,049 abnormal diagnostic examinations recommended for biopsy across 114 facilities. Women at facilities serving populations with less education or more racial/ethnic minorities had lower rates of follow-up imaging (4%–5% difference, P<0.05), and women at facilities serving more rural and low-income populations had lower rates of biopsy (4%–5% difference, P<0.05). Women undergoing biopsy at facilities serving vulnerable populations had longer times until biopsy than those at facilities serving nonvulnerable populations (21.6 vs. 15.6 d; 95% confidence interval for mean difference 4.1–7.7). The proportion of women receiving recommended imaging within 11 months and biopsy within 3 months varied across facilities (interquartile range, 85.5%–96.5% for imaging and 79.4%–87.3% for biopsy).

Conclusions: Among Medicare recipients, follow-up rates were slightly lower at facilities serving vulnerable populations, and among those women who returned for diagnostic evaluation, time to follow-up was slightly longer at facilities that served vulnerable population. Interventions should target variability in follow-up rates across facilities, and evaluate effectiveness particularly at facilities serving vulnerable populations.

Supplemental Digital Content is available in the text.

*Department of Medicine, University of California San Francisco, San Francisco, CA

Biostatistics Unit, Group Health Research Institute, Seattle, WA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Agency for Health Care Research and Quality, Grant #1 K08 HS018090-01, NIH/NCRR/OD UCSF-CTSI Grant Number KL2 RR024130, California Breast Cancer Research Project, Grant #14IB-0062, and the National Cancer Institute-funded Breast Cancer Surveillance Consortium (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040, HHSN261201100031C). The collection of cancer and vital status data used in this study was supported in part by several state public health departments and cancer registries throughout the US. For a full description of these sources, please see: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

The authors declare no conflict of interest.

Reprints: L. Elizabeth Goldman, MD, MCR, Department of Medicine, University of California San Francisco, 1001 Potrero Ave., P.O. Box 1364, San Francisco, CA 94110. E-mail:

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