Follow-up among women with an abnormal mammogram in an HMO: Is it complete, timely, and efficient?

Objective: To describe the extent to which women with seriously abnormal ma mmograms complete indicated follow-up, the timeliness of this follow-up, an d variations in the pattern of use of diagnostic procedures. Study Design: Retrospective chart review. Patients and Methods: Ninety-two women enrolled in a single urban health ma intenance organization (HMO) with an abnormal index mammogram (mass or susp icious calcifications) during 1995 or 1996 were identified by review of all HMO mammography reports. Data were abstracted from medical records concern ing all clinical services received over the 11 months after the date of the abnormal mammogram. Procedure costs were estimated based on 1997 Medicare relative-value units. Logistic regression and a multivariate accelerated fa ilure-time model were used to evaluate the association between predictor va riables and the occurrence and timing of completion of follow-up. Results: Follow-up was not completed by 31 (34%) of the 92 study women and was delayed beyond 60 days for another 32 (35%). In adjusted analysis, fact ors associated with completion within 60 days included age less than 50 yea rs and inclusion of a specific follow-up recommendation in the mammogram re port. Completion by the end of the study (a minimum of 11 months after the index mammogram) was associated only with the presence of a specific follow -up recommendation. The follow-up process (ie, the diagnostic procedures us ed) was highly variable but almost always included surgical evaluation. The average cost among those completing follow-up was about $1900 (in 1997 dol lars). Conclusions: Incomplete follow-up after a potentially seriously abnormal ma mmogram constitutes an important barrier to breast cancer control efforts i n the study HMO, but its explanation remains incompletely understood. The f ollow-up process itself is highly variable, and improvement in its efficien cy and timely completion will require a better understanding of its determi nants.