Siedlikowski, Sophia (2018).  An exploration of primary care provider perspectives on mammography screening research and decision-making with average-risk women. McGill Family Medicine Studies Online, 13: e17

Download Thesis here

Abstract 

Context: Growing evidence nuancing the benefits and harms of mammography screening has put systematic screening into question. Given the responsibility of primary care providers in counseling women in mammography decision-making, it is important to understand their thoughts on this process. Understanding primary care providers' perspectives on clinical research on mammography will also help inform future best practices as guidelines evolve.

Objective: 1) To explore the perspectives and approaches of primary care providers with respect to mammography decision-making with average-risk women, and 2) To explore physician perspectives on evidence-based research synopses on mammography for average-risk women and how they may apply this information in practice. Design: Critical interpretive review and dynamic cohort study.

Methods: First, a critical interpretive review was conducted, using an interpretive descriptive analytical framework that drew on primary care providers' codes of ethics. Ovid MEDLINE®, Scopus, and PsycInfo databases were searched from 2002 to 2018. Following an inductive analysis of the data extracted from the included articles, resulting themes were subjected to an interpretative descriptive analysis. Second, the Essential Evidence Plus database was searched to identify POEMs (Patient Oriented Evidence that MattersTM), clinical research summaries on mammography evidence. Using the Information Assessment Method (IAM), physician ratings and comments about mammography evidence were extracted from reflections on the POEMs. Quantitative data were assessed with descriptive statistics; qualitative data were summarized and assessed iteratively and thematically. Connections were sought between both sources of data.

Results: This thesis revealed that physicians hold a wide range of perspectives and practice patterns and perspectives regarding mammography screening for average-risk women. Primary care providers greatly differed in terms of their beliefs in screening effectiveness, their level of trust in screening guidelines, and their thoughts about the recommended age at which average-risk women should begin mammography screening. The critical interpretive review included nine articles that highlighted numerous factors influencing a primary care provider's decision to order mammography screening in addition to professional guidelines. These factors include: providers' beliefs on screening effectiveness, patients' anxiety and requests to be screened, physicians' colleagues' practice patterns, clinical time, and providers' feelings of potential regret about missing diagnoses. The POEMs analysis yielded four POEMs on mammography screening and the number of quantitative POEM ratings ranged from 1243 to 1351. Across all four POEMs, among the physician ratings about using the information for a patient, over 50% were about using it in a discussion with a patient or other healthcare provider. This study showed divergences in the ways in which physicians value and use clinical evidence on mammography screening. Overall, physicians' opinions on the quality of the research used to inform the POEM information and the worth of mammography screening greatly differed. Physicians were divided on the usefulness of POEMs in screening discussions with patients, due to patient, provider, and system-related factors. Physicians also pointed out that a strong screening culture affects both providers' and women's screening decision-making.

Conclusions: Primary care providers hold a diversity of perspectives and approaches with respect to mammography screening for average-risk women. The complexity of current evidence on the harms and benefits of screening, coupled with the uniqueness of each patient's values and preferences, warrant increasingly patient-centered approaches to mammography decision-making. Further research should continue to examine ways of optimizing screening decision-making for primary care providers and their patients.