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A Randomized Trial

Catarina I. Kiefe, PhD, MD; Siripoom V. McKay, MD; Amir Halevy, MD; Baruch A. Brody, PhD

Arch Intern Med. 1994;154(11):1217-1224.

Abstract
Background
In 1991, Medicare began covering screening mammograms subject to copayment and deductible. This study evaluated the effectiveness of Medicare in removing financial barriers to screening mammography among low-income older women.

Methods
In an inner-city public hospital's General Medicine Clinic, 119 consecutive, eligible, and consenting Medicare-enrolled women without known risk factors for breast cancer other than age, and no mammogram in the previous 2 years, were entered into a randomized controlled trial with follow-up after 2 months. The mean age was 71 years; 77% were black, 92% had an annual income below $10 000, and 52% had had a previous mammogram. All patients were counseled concerning indications for screening mammograms and Medicare coverage, and all were referred to a low-cost mammography facility. Sixty-one subjects were randomly assigned a voucher for a free screening mammogram at the referral facility. Obtaining a mammogram within 60 days of study entry was the main outcome measure.

Results
Of the women given vouchers, 27 (44%) obtained screening mammograms, compared with six (10%) of those without vouchers (P<.001). Adjustment by multiple logistic regression confirmed this association, yielding an adjusted odds ratio of 7.4 (95% confidence interval, 2.5 to 21.4). Knowledge concerning mammography and breast cancer increased significantly overall (and within randomization groups) between initial interview and follow-up; fear did not change. For women without the voucher, the main reason for not obtaining a mammogram was financial; the main reason for women with the voucher was transportation.

Conclusion
In a low-income, inner-city population of older women, financial barriers to screening mammography persist despite Medicare coverage.

(Arch Intern Med. 1994;154:1217-1224)

Author Affiliations
From the Department of Medicine, Center for Ethics, Medicine and Public Issues, Baylor College of Medicine, Ben Taub General Hospital, Houston, Tex.

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