A Systems Model of Clinical Preventive Care: The Case of Breast Cancer Screening among Older Women,

Background. In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. Methods. A population-based survey of women age 65 years and older was conducted in five National Cancer Instituteʹs Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). Results. Physician recommendation and mammography use declined with womenʹs increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening—lower income, education, and insurance—and seeing only one physician. Conclusions. Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.