Increasing Mammography Screening Among African Americans

By Sonya Ridout, RNP; Dawn Fitzgerald, MS; and Marlo Heft, MS

The Problem
American healthcare quality has improved significantly over the past 50 years. Yet, despite this progress, healthcare quality and outcomes remain unequal for minorities, particularly African Americans, who continue to have higher rates of morbidity and mortality from many diseases such as breast cancer.¹ Elderly African American women are less likely to have had mammograms than white women in the same age group. Among Medicare-eligible women in 1998-1999, the difference in the percentage receiving breast cancer screening between whites and African Americans was greater than 10%.²

In Arkansas, the difference in mammography screening among whites (55.4%) and African Americans (41.4%) is 14%, which exceeds the national disparity rates. The disparity is further illustrated by examining the correlation between Arkansas counties’ Medicare mammography screening rates and the counties’ percentage of female Medicare recipients who are African American. 

For counties where 0 to 15% of the women on Medicare are African American, the Medicare Biennial Mammography rate was 54.7%. For counties where more than 45% of the women on Medicare are African American, the mammography screening rate was 44.1%.

Efforts to reduce disparities in healthcare are hindered by many factors, including the inability to define the root cause of these disparities. For example, race/ethnicity and socioeconomic status are so strongly associated with one another, it is difficult, if not impossible, to determine which is the more powerful predictor of healthcare quality. 

Yet, according to an article by Gornick, et al., in the New England Journal of Medicine, “In studies that used Medicare data, older black women less often used mammography, even after adjustment for age, income, and number of primary care visits.”³ 

Other potential barriers to healthcare include access, culture, health behavior and beliefs, discrimination and genetics. The Arkansas Foundation for Medical Care (AFMC) seeks to target these barriers through the development of a culturally effective campaign to increase mammography screenings among African American women.

Evidenced Based Solutions
Through collaboration with community-based organizations such as the Witness Project, much progress can be made toward improving mammography use among African American women. The Witness Project is a nationally recognized faith-based organization dedicated to improving breast cancer awareness and knowledge among underserved populations. 

The success of the Witness Project is largely due to community support and involvement. Breast cancer survivors within each community participate in the education programs demonstrating effective breast self-exams and breast-care strategies. The meetings are held in churches and other community centers. Participants “witness” and share from a personal perspective how breast cancer affected their lives and the importance of early detection and treatment.

The Witness Project has provided valuable access into the community. AFMC has utilized this avenue to establish more complete local community relationships to target an audience that might otherwise be out of reach. AFMC is also addressing access to and availability of mammography centers within African American communities.

Another barrier, lack of knowledge and awareness about breast cancer, is being addressed carefully through publications, health fairs and other communication efforts that are targeted specifically to the African American community.

Community Partners
Through discussions with various stakeholders in the target communities, public health forums, focus groups, and evaluation of interventions, AFMC developed a project plan that will provide effective outreach strategies for minorities. 

Arkansas, Crittenden, Cross, Desha, Lee, Mississippi, Monroe, Phillips and St. Francis counties were selected because of low mammography screening rates among African American women on Medicare. In 1999, African Americans comprised 33% of the Medicare population for these nine counties, compared with a statewide percentage of 11.7%. The African American Medicare Biennial Mammography rate for 1998-1999 in those counties was 34.6%, compared to the Caucasian rate of 48.3%.

Over the next 18 months, AFMC will conduct a series of culturally specific health events titled “Healthy Family Jubilees” in each of the targeted nine counties. Involving community leaders in the planning process to encourage healthy lifestyles and preventive health screening is a critical component to this program to improve health disparities within the state. AFMC will partner with local mobile mammography units to provide on-site screenings during the Jubilees. 

Other health screenings and information booths will be available as well as entertainment from community residents. These health outreach events will address many barriers to mammography screening, such as a lack of access to mammography centers and a lack of knowledge and awareness about breast cancer.

The recognition of disparities in health care as a quality issue has far-reaching implications. Healthcare alone cannot be expected to eradicate racial disparities in health outcomes.⁶ 

AFMC will continue to create culturally specific interventions to reduce racial disparities and to improve clinical outcomes for the state. Through community collaboration and partnerships with key stakeholders, AFMC endeavors to increase mammography screening rates among African Americans and to remove existing barriers.

AFMC is available to assist you.  If you have further questions please call 501-375-5700, ext. 673.

References
(1) HCFA (CMS) National Medicare Claims Part B data.
(2)  Williams D, Rucker T.  Understanding and Addressing Racial Disparities in Health Care. Health Care Financing Review, 200:21(4), 75-89.
(3)  Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries.  N Engl J Med. 1996;335: 791-799.
(4)  American Cancer Society, Inc. Cancer Facts and Figures.  Atlanta: American Cancer  Society, 2001.
(5)  Arkansas Department of Health, Centers for Health Statistics and Division of Vital Records. Mortality in Arkansas, 1998. Jan 2000;7-14.

(6)  Fiscella K, Franks P, et al. Inequality in Quality: Addressing Socioeconomic, Racial and Ethnic Disparities in Health Care. JAMA 2000; 2583.

Reprinted with permission from the Journal of the Arkansas Medical Society

Be Wary of Medicare Consultants
During the Arkansas Hospital Association/Medicare Fiscal Intermediary’s annual August Medicare Update workshop, AHA legal counsel Diane Mackey warned participants about Medicare consultants.  Both the General Accounting Office and HHS’ Office of Inspector General (OIG) have issued reports relating to the use of consultants for both hospitals and physicians.

If the consultation is to learn how to get Medicare to pay more without triggering Medicare audits, extreme caution is advised because of undercover government activities and hearing the term “revenue enhancement,” which is a red flag.

The OIG’s list of questionable practices by consultants mentions:

• Illegal or misleading representation about their relationship to Medicare, Centers for Medicare and Medicaid Services (formerly HCFA), Medicaid or the OIG, such as claiming approval, certification, or recommendation by the government
• Promises or guarantees of results
• Encouraging abusive practices and aggressive billing
• Discouraging compliance efforts