Rural Primary Care and the Diagnostic Resolution of Abnormal Screening Mammograms: A Mixed Methods Study in Rural Missouri

63 Rural Primary Care and the Diagnostic Resolution of Abnormal Screening Mammograms: A Mixed Methods Study in Rural Missouri Hunleth et al. Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019, pp. 63-79 © 2011 Center for Health Disparities Research School of Community Health Sciences University of Nevada, Las Vegas Rural Primary Care and the Diagnostic Resolution of Abnormal Screening Mammograms: A Mixed Methods Study in Rural Missouri Jean Hunleth, Washington University School of Medicine in St. Louis Julia Maki, Washington University School of Medicine in St. Louis Amanda Lee, University of Arizona Aimee James, Washington University School of Medicine in St. Louis Rebecca Lobb, Family Reach Foundation Corresponding Author: Jean Hunleth, ABSTRACT Rural health clinics (RHCs) and federally qualified health centers (FQHCs) play a vital role in initiating cancer screening in underserved, rural settings. Yet there is limited information about their involvement in diagnostic tests when a mammogram result is abnormal. Diagnostic resolution of abnormal mammograms varies widely by geographic location and resources, and timely resolution is important for addressing rural-urban cancer disparities. This mixed methods study in a rural region of Missouri with high rates of cancer mortality examined the roles of primary care providers during follow-up after an abnormal mammogram, the processes they used, and the clinic specific variations among these roles and processes. Our data show substantial involvement of primary care during follow-up, with differences in resources and formalized and informal strategies between FQHCs and RHCs. Elucidating roles and processes is a necessary step before evidence based strategies, often developed in urban settings, can be adapted for rural settings. Keywords: Rural Healthcare Disparities, Mammography, Primary Health Care, Prevention and Control, Early Detection of Cancer, United States INTRODUCTION Rural areas often have higher cancer incidence and mortality compared to urban and suburban areas (James et al., 2017; Pruitt et al., 2015; Singh & Siahpush, 2014a, 2014b; Zahnd et al., 2018). In addition to greater travel distances to specialists and diagnostic and treatment Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 64 Rural Primary Care and the Diagnostic Resolution of Abnormal Screening Mammograms: A Mixed Methods Study in Rural Missouri Hunleth et al. facilities, rural residents tend to have higher rates of poverty and unemployment than residents in urban areas. In Missouri, where we carried out our research, rural residents are also more likely to be uninsured than urban residents (Robert Wood Johnson Foundation, 2018). Primary care providers play a critical role in health care, especially in underserved rural areas, where federally qualified health centers (FQHCs) and rural health clinics (RHCs) provide care to people who might not be able to otherwise access or afford care. With rural cancer disparities recently gaining national attention, it is critical to understand the roles that FQHCs and RHCs are already taking to prevent and control the impact of cancer in their patient populations. In this article, we focus on one aspect of the cancer prevention and control continuum that can lead to disparities: diagnostic resolution of abnormal screening results. Screening efforts are only effective in preventing mortality when abnormal results are followed up adequately and treatment is available, and the National Academy of Medicine has identified incomplete diagnostic resolution of abnormal test results as a critical healthcare quality issue (Crossing the Quality Chasm: A New Health System for the 21st Century, 2001). Researchers have estimated that anywhere from 9% to 50% of US women do not complete follow-up after an abnormal mammogram (Taplin, Yabroff, & Zapka, 2012). For breast cancer, incomplete diagnostic resolution contributes to later stage at diagnosis (Taplin et al., 2004), and a systematic review and meta-analysis found significant rural-urban disparities in screening and diagnostic completion (Leung, McKenzie, Martin, & McLaughlin, 2014). Such findings offer compelling evidence for the promotion of mammographic screening and also necessitate attention to improving follow-up processes and reducing barriers, where needed (Lee et al., 2018). There are known effective strategies for improving rates of resolution of abnormal screening results. These include the reduction of out of pocket costs, removal of structural barriers, and the implementation of tracking systems (Baron et al., 2010; Wei, Ryan, Dietrich, & Colditz, 2005; J. M. Zapka, Edwards, Chollette, & Taplin, 2014). Further, patient navigator programs that help patients navigate the health system and psychosocial and structural barriers are shown to reduce time to diagnostic resolution for women who experience the greatest delays in care (Freund et al., 2014). However, such strategies must be adapted to specific settings and contexts in order to be feasible and effective (Bauman, Cabassa, & Stirman, 2018; Damschroder et al., 2009), and they must take into account the specificities of rural health care. We carried out a mixed-method study to identify the role of rural primary care clinics in diagnostic resolution, and the organizational and setting contexts that shaped these processes and roles. Our research was set in the Missouri Bootheel, an area of the US Midwest that has a greater burden of mortality from breast cancer than other rural and urban areas in the region (Moore et al., 2018; U.S. Cancer Statistics Working Group, 2018). We focused on FQHCs and RHCs because these clinics serve the most underserved rural areas and populations and were the main providers of primary care in the Bootheel region (RHCs made up 87% of primary care in the region). FQHCs and RHCs also have different requirements, funding streams, and governance ("U.S. Department of Health and Human Services, Office of Rural Health Policy. Comparison of the Rural Health Clinic and Federally Qualified Health Center Programs," 2006), enabling a preliminary exploration of similarities and differences in their roles related to cancer prevention and control. Because rural areas are heterogenous, this study contributes to an emerging focus on rural cancer prevention in the Midwest (Charlton et al., 2014; Levy, Xu, Daly, & Ely, 2013; Muthukrishnan et Journal of Health Disparities Research and Practice Volume 12, Issue 6, Winter 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 65 Rural Primary Care and the Diagnostic Resolution of Abnormal Screening Mammograms: A Mixed Methods Study in Rural Missouri Hunleth et al. al., 2018; Overholser et al., 2009; Rim et (...truncated)