Faculty Bibliography

BACKGROUND:To date, 38 states have enacted dense breast notification (DBN) laws mandating that mammogram reports include language informing women of risks related to dense breast tissue. OBJECTIVE:Nationally representative survey to assess the association between residing in a state with a DBN law and women's awareness and knowledge about breast density, and breast cancer anxiety. DESIGN/METHODS:Internet survey conducted in 2018 with participants in KnowledgePanel®, an online research panel. PARTICIPANTS/METHODS:English-speaking US women ages 40-59 years without a personal history of breast cancer who had received at least one screening mammogram (N = 1928; survey completion rate 68.2%). MAIN MEASURES/METHODS:(1) Reported history of increased breast density, (2) knowledge of the increased risk of breast cancer with dense breasts, (3) knowledge of the masking effect of dense breasts on mammography, and (4) breast cancer anxiety. KEY RESULTS/RESULTS:Women residing in DBN states were more likely to report increased breast density (43.6%) compared with women residing in non-DBN states (32.7%, p < 0.01, adjusted odds ratio, 1.70, 95% CI,1.34-2.17). Interaction effect between DBN states and education status showed that the impact of DBN on women's reporting of dense breasts was significant for women with greater than high school education, but not among women with a high school education or less (p value = 0.01 for interaction). Only 23.0% of women overall knew that increased breast density was associated with a higher risk of breast cancer, and 68.0% of women understood that dense breasts decreased the sensitivity of mammography. There were no significant differences between women in DBN states and non-DBN states for these outcomes, or for breast cancer-related anxiety. CONCLUSIONS:State DBN laws were not associated with increased understanding of the clinical implications of breast density. DBN laws were associated with a higher likelihood of women reporting increased breast density, though not among women with lower education.

Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insurance. Provider directories help patients identify in-network providers, although directory information is often not accurate. We conducted a national survey of privately insured patients who received specialty mental health treatment. We found that 44 percent had used a mental health provider directory and that 53 percent of these patients had encountered directory inaccuracies. Those who encountered inaccuracies were more likely (40 percent versus 20 percent) to be treated by an out-of-network provider and four times more likely (16 percent versus 4 percent) to receive a surprise outpatient out-of-network bill (that is, they did not initially know that a provider was out of network). A federal standard for directory accuracy, stronger enforcement of existing laws with insurers liable for directory errors, and additional monitoring by regulators may be needed.

Background: In the United States, clinical practice guidelines (CPG) provide conflicting recommendations on whether screening mam-mography (SM) should be annual versus biennial. We assessed whether women who receive annual SM are aware that some CPG recommend biennial SM and whether they would be willing to change from annual to biennial SM.
Method(s): This is a cross-sectional study of women aged 40-59 years with no history of breast cancer and 1 SM. Women recruited by GfK KnowledgePanel (a survey research firm that uses probability-based sampling) participated in an online survey in 2018. Survey items assessed whether women who reported annual SM use were aware that some CPG also recommend biennial SM and if they would be willing to change to biennial SM if their doctor recommended it. Women who were unwilling to switch to biennial screening were asked why. We used multivariable logistic regression to estimate sociodemographic factors associated with 1) awareness that some CPG recommend biennial screening, and 2) willingness to change from annual to biennial SM. The model adjusted for age, race, education, income, health insurance, history of dense breasts and geographic region. We conducted all analyses in Stata using poststratification weights to generate nationally representative estimates.
Result(s): Of the women invited to participate, 68.2% completed the survey, of whom 60.7% reported receiving SM annually. Of these women, 50.9% were aware that some CPG also recommend biennial SM, and 42.8% were unwilling to switch to biennial SM. In adjusted analysis, women who were younger (age 40-49 versus 50-59 years, OR 0.66 [95% CI 0.49, 0.88]) and those with lower levels of education versus those with graduate degrees (did not graduate high school, OR 0.36 [95% CI 0.14, 0.93]; graduated high school, OR 0.31 [95% CI 0.19, 0.50]; completed some college, OR 0.41 [95%CI 0.26, 0.66]) were significantly less likely to be aware that some CPG recommended biennial SM. However, we found no significant association between any sociodemographic factors with willingness to change from annual to biennial SM, including awareness that some CPG recommend biennial SM. The most common reasons cited by women who were unwilling to transition to biennial SM were that annual SM: is superior at detecting breast cancer (46.1%), eases their mind (22.9%), or is part of a regular health routine that they wouldn't want to change (17.8%).
Conclusion(s): In this nationally representative survey, the majority of women received SM annually, approximately half of whom were unaware that some CPG recommended biennial SM, and half were unwilling to adopt biennial SM even if it was recommended by their physician. Future attempts to modify the frequency of SM use may depend on an improved understanding of the beliefs that hinder willingness to change from the existing annual approach to screening

Background: Digital mammography has imperfect sensitivity and specificity for detecting breast cancer. Digital breast tomosynthesis (

Background: Provider networks are an important tool for private health insurers to control costs and ensure quality care for their enrollees. However, provider networks have been criticized for inaccurate directories, limited or narrow choice of providers that omit highly rated " star" hospitals and may lead to undesired or surprise out-of-network care, and disruption of continuity of care if a provider leaves the network or a patient changes plans. We conducted a nationally representative survey to examine consumer experiences and preferences with provider networks in private health insurance plans.
Method(s): Internet survey conducted in 2018 with participants in the GfK KnowledgePanel, a probability-based online research panel designed to be representative of the U.S. population. The sample included 2,059 English-speaking US adults aged 18 to 64 years enrolled in private health insurance with a provider network and used an outpatient health care provider in the last year.
Result(s): 74% agreed that their insurer had made enough in-network providers available. A significantly greater proportion of respondents rated protection from inpatient surprise bills as extremely important or very important from their plan as compared to inclusion of top rated " star" hospitals in the plan network (77% versus 59%, p< 0.01). Among those with a choice of plan, 60% of respondents tried to determine if a specific provider was in-network before choosing a plan, and just over half (57%) reported that the result of the search affected their choice of plan. Of the 46% who used the provider directory once enrolled in the plan, 36% reported a problem either with inaccurate provider contact information or with a listed provider not actually taking their insurance or not taking new patients. Among the 16% who had a provider leave their network, 62-66% had their relationship with the provider disrupted and switched to new provider. Another 10-12% simply stopped treatment.
Conclusion(s): Consumers in private insurance plans report satisfaction with the breadth of their provider networks, however problems remain in the accuracy of provider directories and disruption in care from provider turnover. More respondents rated protection from surprise inpatient out-of-network bills as an important plan attribute compared to inclusion of top rated hospitals in the network. Insurers may consider in their product design strong consumer preferences for protections from surprise out-of-network bills and the inclusion of a specific provider in the network in their choice of a plan. In addition to monitoring network adequacy and accuracy of provider directories, additional policy efforts may be needed to ensure and continuity of care due to providers leaving a network. Addressing these provider network issues can preserve their function as a cost saving tool without compromising access and the consumer experience

Background: To date, 35 states have enacted dense breast notification (

OBJECTIVES/OBJECTIVE:To evaluate the association of state dense breast notification (DBN) laws with use of supplemental tests and cancer diagnosis after screening mammography. METHODS:We examined screening mammograms (n = 1 441 544) performed in 2014 and 2015 among privately insured women aged 40 to 59 years living in 9 US states that enacted DBN laws in 2014 to 2015 and 25 US states with no DBN law in effect. DBN status at screening mammography was categorized as no DBN, generic DBN, and DBN that mandates notification of possible benefits of supplemental screening (DBN+SS). We used logistic regression to examine the change in rate of supplemental ultrasound, magnetic resonance imaging, breast biopsy, and breast cancer detection. RESULTS:DBN+SS laws were associated with 10.5 more ultrasounds per 1000 mammograms (95% CI = 3.0, 17.6 per 1000; P = .006) and 0.37 more breast cancers detected per 1000 mammograms (95% CI = 0.05, 0.69 per 1000; P = .02) compared with no DBN law. No significant differences were found for generic DBN laws in either ultrasound or cancer detection. CONCLUSIONS:DBN legislation is associated with increased use of ultrasound and cancer detection after implementation only when notification of the possible benefits of supplemental screening is required. (Am J Public Health. Published online ahead of print March 21, 2019: e1-e6. doi:10.2105/AJPH.2019.304967).

Background/UNASSIGNED:Tobacco spending may exacerbate financial hardship in low-income populations by using funds that could go toward essentials. This study examined post-quit spending plans among low-income smokers and whether financial hardship was positively associated with motivation to quit in the sample. Methods/UNASSIGNED:= 410). Linear regression was used to examine the relationship between financial distress, food insecurity, smoking-induced deprivation (SID) and motivation to quit (measured on a 0-10 scale). We performed summative content analyses of open-ended survey questions to identify the most common plans among participants with and without SID for how to use their tobacco money after quitting. Results/UNASSIGNED:The top three spending plans among participants with and without SID were travel, clothing and savings. There were three needs-based spending plans unique to a small number of participants with SID: housing, health care and education. Conclusions/UNASSIGNED:Financial distress and food insecurity did not enhance overall motivation to quit, while smokers with SID were less motivated to quit. Most low-income smokers, including those with SID, did not plan to use their tobacco money on household essentials after quitting.

OBJECTIVE:/UNASSIGNED:Privately insured individuals frequently use out-of-network psychiatrists. Yet, whether treatment provided by psychiatrists who do not accept private insurance differs from treatment provided by those who do has not been studied. The investigators described provider characteristics, patient characteristics, and treatment patterns among psychiatrists who do not accept new patients with private insurance. METHODS:/UNASSIGNED:Data for this study came from the National Ambulatory Medical Care Survey (2011-2014), a nationally representative annual cross-sectional survey of physicians providing ambulatory care. Responses of psychiatrists who report accepting any new patients (N=440) were examined, representing 7,634 visits. RESULTS:/UNASSIGNED:Compared with psychiatrists accepting privately insured patients, those not accepting privately insured patients had fewer visits with patients with serious mental illness (42% versus 53%; p=0.016). These psychiatrists had a higher proportion of visits lasting longer than 30 minutes (48% versus 34%; p=0.026), and their patients were more likely to have had 10 or more visits in the past 12 months (41% versus 28%; p=0.013). There were no differences in the proportion of visits in which treatment included psychotherapy (48% versus 44%). CONCLUSIONS:/UNASSIGNED:Although psychiatrists not accepting patients with private insurance were less likely than other psychiatrists to treat patients with serious mental illness, their patients were more likely to have longer visits and a relatively high number of visits in the past year. The low rate of acceptance of insurance among psychiatrists may have the greatest effect among those most in need of services.