Accepte

ReprintMichigaAnn Arb

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� 2011

doi:10.1

Improving breast cancer care througha regional quality collaborativeTara M. Breslin, MD, FACS, Jamie Caughran, MD, Jane Pettinga, MD, Cheryl Wesen, MD,Ann Mehringer, MS, Huiying Yin, MS, David Share, MD, MPH, and Samuel M. Silver, MD, PhD,Ann Arbor, MI

Background. Regional collaborative organizations provide an effective structure for improving thequality of surgical care. With low complication rates and a long latency between surgical care andoutcomes such as survival and local recurrence, quality measurement in breast cancer surgery is ideallysuited to process measures. Diagnostic biopsy technique for breast cancer diagnosis is measurable andamenable to change at the provider level. We present initial results from our analysis of institutionalvariation in surgical and core needle biopsy use within a regional breast cancer quality collaborative.Methods. Established in 2006, the Michigan Breast Oncology Quality Initiative (MiBOQI) consists of18 hospitals collecting data on breast cancer care using the National Comprehensive Cancer CentersNetwork (NCCN) Oncology Outcomes Database Project platform to analyze and compare breast cancerpractices and outcomes amongst member institutions. Institutional review board approval is obtained ateach site. Data are submitted electronically to the NCCN and analyzed for concordance with practiceguidelines. Aggregate and blinded data are shared with project directors and institutions at collaborativemeetings, and ongoing practice patterns are observed for change. We analyzed variation in breast biopsytechnique for initial cancer diagnosis over time and between institutions. Diagnostic biopsies werecategorized as core needle, surgical excisional, surgical incisional, and other surgical biopsy.Results. Procedural data for 8,066 patients treated for breast cancer between November 1, 2006 andDecember 31, 2009 were analyzed. The mean patient age was 59.5 years (range, 25.4–90.0 years).Within MiBOQI, 21% of patients underwent surgical biopsy for initial diagnosis. The percentage ofpatients undergoing surgical biopsy ranged from 8% to 37%, and the majority of surgical biopsies wereclassified as excisional biopsies. Patients with ductal carcinoma in situ were more likely to undergosurgical biopsy compared to those with invasive cancer (30.4% vs 17.8%; P < .001). There was noassociation between biopsy type and patient age, race, or comorbidity. Data on biopsy technique wereshared with site project directors and a target surgical biopsy rate of <15% was chosen by consensus. Siteproject directors disseminated the data to their institutions and developed action plans for provider andpatient education. Over the study period, the percentage of cases undergoing surgical biopsy for the entireMiBOQI collaborative decreased from 21% to 15% (P < .001).Conclusion. The regional quality collaborative model can be used to collect, analyze, and disseminatesurgical breast care quality data to organizations and treating physicians. These data can be used todescribe patterns of care and make comparisons over time and between organizations. These data canalso be used to set regional quality standards and provide an avenue for physician-led qualityimprovement. (Surgery 2011;150:635-42.)

From the Michigan Breast Oncology Quality Initiative, Ann Arbor, MI

IMPROVING QUALITY AND CONTROLLING COST are at thecenter of national health care policy discussions.Despite advances in medical care and improve-ments in survival after treatment for breast cancer,there remains substantial variation in outcome.Efforts to understand the factors contributing to

d for publication July 22, 2011.

requests: Tara M. Breslin, MD, FACS, University ofn, 1500 East Medical Center Drive, 3217 Cancer Center,or, MI 48109-5932. E-mail: tarabres@umich.edu.

60/$ - see front matter

Mosby, Inc. All rights reserved.

016/j.surg.2011.07.071

this variation have uncovered differences in theprocesses of care and long-term oncologic out-come at the patient, provider, regional, and institu-tional levels.

The University of Michigan ComprehensiveCancer Center, in collaboration with the NationalComprehensive Cancer Network (NCCN) andBlue Cross Blue Shield of Michigan (BCBSM),established the Michigan Breast Oncology QualityInitiative (MiBOQI) in November of 2006. Thisunique partnership has a goal of monitoring andimproving the quality of breast cancer care athospitals and private practices across Michiganand extends the NCCN Breast Cancer Outcomes

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Table I. Inclusion and exclusion criteria for MiBOQI participation

Inclusion criteria

1. Newly diagnosed female breast cancer patients with histology consistent with at least 1 of the American JointCommittee on Cancer–defined histologic types (carcinoma not otherwise specified, ductal, lobular,nipple, and other)

2. Age 18 years or older at the time of diagnosis with primary breast cancer3. Patients must have been diagnosed with the new episode of breast cancer no more than 180 days before the

date of presentation to the MiBOQI institution4. Patients receive some or all of their primary breast cancer treatment (cancer-directed surgery,

chemotherapy, or hormonal therapy) at the participating institution5. Patients with a history of an invasive nonmelanomatous cancer diagnosis are eligible if the history includes

one of the following:a. Previous breast cancer episodes: There is no evidence of distant metastases or recurrence and werediagnosed at least 90 days before the diagnosis of the current breast cancer episode

b. Prior nonbreast cancer episodes: There are no distant metastases and there is no evidence of diseasepresently and were diagnosed at least 90 days before the diagnosis of the current breast cancer episode;or with distant metastases, which were treated successfully resulting in a complete response and there hasbeen no recurrence for at least 5 years

Exclusion criteria

1. Patients who present to the MiBOQI institution with or are diagnosed with cancer recurrence2. Patients who present to the MiBOQI institution with breast sarcoma or with simultaneous cancers

diagnosed within 90 days of each other3. Patients receiving all primary breast cancer treatment outside of the participating MiBOQI institution4. Patients presenting to the participating MiBOQI institution and receiving only bone marrow

transplantation or radiation therapy

MiBOQI, Michigan Breast Oncology Quality Initiative; NCCN, National Comprehensive Cancer Centers Network.

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Project to the community setting. The foundationof the program is a network-based data collection,reporting, and analytic system that is designed todescribe patterns of care, monitor concordancewith NCCN guidelines, and evaluate outcomes. Inorder to promote not only quality monitoring butquality improvement, the program includes afeedback process whereby participating institu-tions, physicians, and guideline developmentpanels can compare data across the network andbetween institutions.

The NCCN Breast Cancer Outcomes ProjectDatabase contains more than 300 data elementsincluding data on drug/biologic and diagnosticsuse and trends; specific treatment indications andsequencing; toxicity and reasons for discontinuation;complications and medical events; progression-freeand overall survival; comparative effectiveness andresource consumption; andpayor-specific data. Anal-yses of this dataset have led to multiple publicationsdescribing patterns of surgical and adjuvant therapyfor breast cancer1-4 and informed studies evaluatingquality measurement.5,6

The diagnostic period is the patient’s first con-tact with breast cancer care providers and institu-tions. Timely and accurate diagnostic evaluationrequires close collaboration between surgeons,

radiologists, and primary care providers. With lowcomplication rates and a long latency between di-agnostic procedures and outcomes such as survivaland local recurrence, quality measurement inbreast cancer diagnosis relies on process measures.One process measure that has received extensiveattention recently is diagnostic breast biopsy tech-nique. Core needle biopsy is preferred over opensurgical biopsy for diagnosing breast cancer, andThe National Accreditation Program for BreastCenters and the American Society of Breast Sur-geons require reporting of core needle biopsyrates for program participation.7,8 Previous studiesexamining trends in diagnostic breast biopsy indi-cate that core needle biopsy may be underused.9

As a quality measure, diagnostic biopsy is measur-able and potentially amenable to change throughprovider education and feedback. We present ini-tial results from our analysis of institutional varia-tion in diagnostic breast biopsy technique withina regional breast cancer quality collaborative.

METHODS

Established in 2006,MiBOQI is a voluntary groupof hospitals andprivate practices that collect data onbreast cancer care using the NCCN Oncology Out-comes Database Project. Institutional review board

Table II. Patient and tumor characteristics

Characteristic N (%)

Age (years)<39 439 (5)40–49 1,645 (20)50–59 2,248 (28)60–69 1,934 (24)70–79 1,228 (15)80–89 599 (7)

RaceCaucasian, non-Hispanic 6,417 (80)Hispanic 85 (1)African American, non-Hispanic 982 (12)Asian, Pacific Islander 124 (2)American Indian, non-Hispanic 11 (<1)Unknown/other, non-Hispanic 412 (6)

AJCC tumor stage0 1,631 (20)I 3,587 (44)II 2,180 (27)III 695 (9)

AJCC, American Joint Committee on Cancer.

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approval is obtained at each site. There are 42 acutecare (nonpsychiatric, nonrehabilitation) hospitalsor programs with sufficient breast cancer volumefor MiBOQI participation, and 18 centers currentlyparticipate. Data from the 14 participating hospitalswith sufficient patient numbers were analyzed forthis project. Each site designates a project directorand a research associate. Initially, potential partici-pating centers were invited to participate in Mi-BOQI by the coordinating center (UMCCC). As theprogram has matured, interested centers with suffi-cient case volume (100 breast cancer cases/year)may now apply for participation.

Funding for MiBOQI is provided by Blue CrossBlue Shield of Michigan (BCBSM), which covers80% of the recommended full-time equivalentsalary for data collection and submission. Partici-pating sites are responsible for the remaining datacollection costs, travel to meetings, and projectdirector and administrative expenses. Data aresubmitted electronically to the NCCN and ana-lyzed for concordance with practice guidelines.Data are abstracted from clinical charts 4 monthsafter patient presentation and are available imme-diately to individual centers; however, an analysisof treatment-specific information requires addi-tional measurement time for events to occur (180days for chemotherapy and 270 days for hormoneand radiotherapy). Center-specific benchmarkeddata are provided to project directors on a quar-terly basis. Aggregate and blinded data are sharedwith project directors and institutions at regularcollaborative meetings 3 times per year, and ongo-ing practice patterns are observed for change.

Criteria for inclusion in MiBOQI and the NCCNBreast Outcome Database are summarized in TableI. Only patients with at least 90 days of follow-upwere included in this analysis in order to capturethe diagnostic and surgical period. Data from 4 siteswere not included because they had recently joinedthe collaborative and had low case numbers.

We analyzed breast biopsy technique for initialcancer diagnosis over time and between institu-tions. Diagnostic biopsies were categorized as coreneedle, surgical excisional, surgical incisional, andother surgical biopsy. The other surgical biopsycategory included nipple or breast skin biopsies,fine needle biopsy, and axillary lymph node biopsy.The procedure resulting in the most advanceddiagnosis is designated as the diagnostic proce-dure. Chi-squared analysis was used to comparecategorical data. General linear modeling was usedto test group means. To confirm accuracy, allsurgical biopsy cases from a single institutionwere reviewed via direct chart review to confirm

coding and to understand indications for surgicalbiopsy.

RESULTS

Procedural data for 8,066 patients treated forbreast cancer at MiBOQI institutions betweenNovember 1, 2006 and December 31, 2009 wereincluded in this analysis. Patient and tumor char-acteristics are summarized in Table II. The meanpatient age was 59.5 years (range, 25.4–90.0 years).Twenty percent of patients had ductal carcinomain situ (DCIS), and 80% were diagnosed with inva-sive breast cancer.

Over the 3-year study period, 21% of patientsunderwent surgical biopsy for initial diagnosis.The percentage of patients at each of the 14institutions undergoing surgical biopsy rangedfrom 8% to 37% (Fig 1, A), and the majority of sur-gical biopsies were classified as excisional biopsies(Fig 1, B). Over time, there was a statistically signif-icant (P < .0001) decrease in the percentage of pa-tients undergoing surgical biopsy across theMiBOQI collaborative (Fig 2). Although therewas a net decrease in surgical biopsy use at 11 cen-ters, there was actually an increase at 3 centers.

Surgical biopsy use was significantly associatedwith a diagnosis of DCIS compared with invasivecancer (30.4% vs 17.8%; P < .001), and this findingwas fairly consistent across the collaborative. Pa-tients with a body mass index below 18 kg/m2 orhigher than 35 kg/m2 were also more likely to

Fig 1. (A) Surgical biopsy use across the MiBOQI collab-orative. (B) Breakdown of surgical biopsy type byinstitution.

Fig 2. Use of surgical biopsy in the Michigan Breast On-cology Quality Initiative collaboration.

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undergo surgical biopsy. There was no associationbetween biopsy type and patient age, race, or pa-tient medical comorbidity. Between 5% and 47%of surgical biopsies were performed before presen-tation at MiBOQI institutions.

Review of all surgical biopsy cases (n = 232) at asingle participating institution revealed that 47%of the surgical biopsies were performed at refer-ring institutions before presenting to the MiBOQIsite for care. Of the surgical biopsies performed atthat institution, 56% were performed because themammographic or sonographic abnormality wasnot amenable to image-guided core biopsy becauseof lesion size, location, or patient body habitus.The reasons for the remainder of the surgical biop-sies are summarized in Table III. Interestingly, 11%of the surgical biopsies (of the 123 performed at

the MiBOQI institution) represented cases ofDCIS diagnosed on core needle biopsy where inva-sive carcinoma was identified on surgical pathologyfrom the definitive surgical resection.

Specific interventions and changes in processesof care were left to the project directors andparticipating centers. Examples of the strategiesused included group education at hospital medicalstaff meetings, direct provider feedback to individ-ual surgeons with data on surgical vs core biopsyuse, and education aimed at primary care pro-viders referring patients for biopsy. Future inter-ventions will include ongoing project directorfeedback at the institution level and primarycare– and surgeon-targeted education sessions onbreast diagnosis at the Michigan State MedicalSociety annual meeting.

DISCUSSION

In this report, we describe institutional variationand a temporal shift in diagnostic breast biopsypractices at member institutions of a state widebreast cancer quality collaborative. This model canbe used to collect, analyze, and disseminate surgi-cal breast care quality data to organizations andtreating physicians in the community setting.10,11

In addition, these data can be used to describe pat-terns of care, monitor changes in practice, and setquality standards.

We chose to measure core needle biopsy ratesbecause several member institutions were inter-ested in using these data for breast program accred-itation. Core needle biopsy is accurate andrecognized by many as the preferred approach fordiagnosing breast cancer.12 Advantages of this ap-proach compared with surgical biopsy include im-proved multidisciplinary treatment planning,superior breast symmetry and cosmesis, and less fre-quent need for surgical margin re-excision.13,14 Arecent report from Gutwein et al15 describes the po-tential for substantial cost containment with

Table III. Results from chart review of 232 surgical biopsy cases performed at one MiBOQI institution

Biopsy location No. Percent Reason

Referring institution 109/232 47% —MiBOQI institution 123/232 53% —Single institution

audit results68/123 56% Unfavorable lesion location, size, patient body habitus17/123 14% Atypical ductal hyperplasia or other high-risk pathology

from core biopsy14/123 11% Ductal carcinoma in situ on initial core, invasive

carcinoma identified on subsequent operation13/123 10% Skin punch or incisional biopsy for locally advanced

breast cancer or mammary paget11/123 9% Other*

*Other includes patient preference, diagnosis via fine needle biopsy of primary tumor and metastatic lymph node, or previous nondiagnostic biopsyattempt.MiBOQI, Michigan Breast Oncology Quality Initiative.

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increased core needle biopsy use. We show that,over time, the use of surgical biopsy decreased andthe use of core needle biopsy for breast cancer diag-nosis increased.

With high-quality mammographic screening,the incidence of nonpalpable compared to palpa-ble breast cancers has increased. The majority ofthese screening detected lesions, and manypalpation-detected abnormalities are amenable tocore needle biopsy.16,17 However, there are severalreasonable indications for performing surgical bi-opsy. These indications include atypical or otherhigh-risk lesions diagnosed with core needle bi-opsy, small breast size, obesity, unfavorable lesionlocation close to skin, chest wall, or breast implant.Some patients may decline core needle biopsy be-cause of anxiety, difficulty tolerating the prone po-sition required for stereotactically guided biopsies,or personal preference. Small suspicious palpablebut radiographically occult lesions may be most ap-propriately diagnosed with surgical biopsy to avoida nondiagnostic biopsy.

We found that half of the surgical biopsiesreviewed from 1 participating center in this cohortwere performed before presentation to a MiBOQIinstitution. While practice patterns at nonpartici-pating institutions may not be directly amenable tochange at the surgeonor institution level, educationtargeting primary care providers and patients mayultimately influence referral patterns. Of the surgi-cal biopsies performed at that MiBOQI institution,52% were performed because the lesion was notconsidered amenable to image guided core needlebiopsy because of imaging or patient limitations.

An unexpected finding from the individual cen-ter audit was the discovery that 10% of the casescategorized as having undergone surgical excisionalbiopsy were actually DCIS cases diagnosed via core

needle biopsy where invasive carcinoma was identi-fied on surgical excision. These cases were correctlycoded in the database according toNCCNprotocol,which specifies that the procedure associated withthe most advanced diagnosis is designated as thediagnostic procedure. Although the surgical biopsycases at the other participating centers were notreviewed for this analysis, this finding highlights theimportance of auditing when using registry data foraccreditation.

The primary strength of this study is that theinformation is obtained from a rich dataset inwhich data are entered prospectively and uni-formly across institutions. Although data are onlyshared between MiBOQI institutions, data man-agement and analysis are supported by the NCCN,which has more than 10 years of experiencecollecting and analyzing these data. We observeda change in diagnostic biopsy practice associatedwith regular data review and feedback to memberinstitutions. The mechanism for the observedchange in surgical practice is likely multifactorial,including project director education, improvedaccess to image-guided biopsy procedures, institu-tional pressure to conform to national guidelines,and the Hawthorne effect, whereby behaviorchanges in response to observation rather thanexperimental manipulation.

This study has several important limitations.First, participating hospitals do so voluntarily andhave institutional support for improving breastcancer care, indicating a baseline motivation forquality improvement. This study may underrepre-sent variation in biopsy practice patterns becauseonly a small percentage of Michigan hospitalsparticipate in the program. Second, NCCN andMiBOQI only collect data on biopsy-confirmedbreast cancer cases and not benign biopsies; no

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conclusions can be made about statewide biopsypractice patterns for Michigan patients presentingwith palpable or image detected abnormalities.However, other population based studies show adecrease in the use of surgical biopsy, indicatingthat this trend may represent a more generalchange in practice.9,15

MiBOQI represents a unique partnership be-tween a payer---BCBSM, a professional organiza-tion---the NCCN, and academic and communityhospitals across Michigan with a common goal ofimproving breast cancer care across the state. Oneof the primary strengths of the MiBOQI program isthe opportunity for community breast cancer pro-grams, where the majority of breast cancer careoccurs, to collect and analyze treatment data andtarget and implement quality improvement pro-grams. Quality improvement benchmarks are in-formed by NCCN guidelines, National QualityForum, and the American Society of ClinicalOncology,18 and when no specific benchmark ex-ists, the group determines the benchmark throughliterature review, discussion, and consensus.

REFERENCES

1. Hassett MJ, Hughes ME, Niland JC, Edge SB, Theriault RL,Wong YN, et al. Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer. J Clin Oncol2008;26:5553-60.

2. Punglia RS, Hughes ME, Edge SB, Theriault RL, BookmanMA, Wilson JL, et al. Factors associated with guideline-concordant use of radiotherapy after mastectomy in the na-tional comprehensive cancer network. Int J Radiat OncolBiol Phys 2008;72:1434-40.

3. Yen TW, Kuerer HM, Ottesen RA, Rouse L, Niland JC, EdgeSB, et al. Impact of randomized clinical trial results in thenational comprehensive cancer network on the use of ta-moxifen after breast surgery for ductal carcinoma in situ.J Clin Oncol 2007;25:3251-8.

4. Edge SB, Niland JC, Bookman MA, Theriault RL, OttesenR, Lepisto E, et al. Emergence of sentinel node biopsy inbreast cancer as standard-of-care in academic comprehen-sive cancer centers. J Natl Cancer Inst 2003;95:1514-21.

5. Niland JC, Rouse L, Stahl DC. An informatics blueprint forhealthcare quality information systems. J Am Med InformAssoc 2006;13:402-17.

6. Hassett MJ, Hughes ME, Niland JC, Ottesen R, Edge SB,Bookman MA, et al. Selecting high priority quality measuresfor breast cancer quality improvement. Med Care 2008;46:762-70.

7. NationalAccreditationProgramforBreastCenters [cited2011February 24]. Available from http://accreditedbreastcenters.org/standards/standards.htm

8. American Society of Breast Surgeons Mastery of Breast Sur-gery Program [cited 2011 February 24]. Available fromhttp://www.breastsurgeons.org/mastery/index.php

9. Friese CR, Neville BA, Edge SB, Hassett MJ, Earle CC. Breastbiopsy patterns and outcomes in Surveillance, Epidemiology,and End Results-Medicare data. Cancer 2009;115:716-24.

10. MoscucciM, ShareD,Kline-RogersE,O’DonnellM,Maxwell-Eward A, Meengs WL, et al. The Blue Cross Blue Shield ofMichigan Cardiovascular Consortium (BMC2) collaborativequality improvement initiative in percutaneous coronary in-terventions. J Interv Cardiol 2002;15:381-6.

11. Birkmeyer NJ, Dimick JB, Share D, Hawasli A, English WJ,Genaw J, et al. Hospital complication rates with bariatricsurgery in Michigan. JAMA 2010;304:435-42.

12. Silverstein MJ, Recht A, Lagios MD, Bleiweiss IJ, Blumen-cranz PW, Gizienski T, et al. Special report: Consensusconference III. Image-detected breast cancer: state-of-the-art diagnosis and treatment. J Am Coll Surg 2009;209:504-20.

13. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors ofbreast asymmetry after breast-conserving operation forbreast cancer. J Am Coll Surg 2008;206:274-80.

14. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors ofre-excision among women undergoing breast-conservingsurgery for cancer. Ann Surg Oncol 2008;15:1297-303.

15. Gutwein LG, Ang DN, Liu H, Marshall JK, Hochwald SN,Copeland EM, et al. Utilization of minimally invasive breastbiopsy for the evaluation of suspicious breast lesions. Am JSurg 2011;202:127-32.

16. Bruening W, Fontanarosa J, Tipton K, Treadwell JR, Laun-ders J, Schoelles K, et al. Systematic review: comparative ef-fectiveness of core-needle and open surgical biopsy todiagnose breast lesions. Utilization of minimally invasivebreast biopsy for the evaluation of suspicious breast lesions.Ann Intern Med 2010;152:238-46.

17. Londero V, Zuiani C, Linda A, Battigelli L, Brondani G, Baz-zocchi M. Borderline breast lesions: comparison of malig-nancy underestimation rates with 14-gauge core needlebiopsy versus 11-gauge vacuum-assisted device. Eur Radiol2011;21:1200-6.

18. Desch CE, McNiff KK, Schneider EC, Schrag D, McClure J,Lepisto E, et al. American Society of Clinical Oncology/Na-tional Comprehensive Cancer Network Quality Measures.J Clin Oncol 2008;26:3631-7.

DISCUSSION

Dr Tina Yen (Milwaukee, WI): Dr Breslin shows nicelythat the percent of breast cancer cases undergoing diag-nostic surgical biopsy has decreased over time. My firstline of questions deals with the MiBOQI process.

What percent of hospitals in Michigan are MiBOQIhospitals, and how does a hospital become a MiBOQIhospital? Besides having at least 100 breast cancer casesannually, what other requirements and costs are associ-ated with being a member? And what is the lag timebetween data acquisition and availability of these resultsfor review by the institution?

The next set of questions deals with potential addi-tional predictors of having a core biopsy performed. Doyou have information related to tumor size or whetherlesion was palpable or not? And then, from a providerstandpoint, do you have information on hospital char-acteristics, such as academic affiliation, payor status,urbanicity, hospital size, number of breast cancer casesperformed annually at the hospital, or whether biopsydecisions are driven largely by surgeons or radiologists?

And then, at the surgeon level, do you have informa-tion on whether surgeons performing these breast

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cancer cases specialize in breast care, or are theysurgeons who have a very mixed practice?

The evaluation of these types of factors might helpexplain the30% interhospital variation in corebiopsy rates.

Lastly, you show an overall decrease in the diagnosticsurgical biopsy rates over the 3-year study period. Do all14 hospitals each show a decrease in diagnostic surgicalbiopsy rates over time? Furthermore, do you have infor-mation on surgical biopsy rates over this same timeperiod for non-MiBOQI hospitals?

Dr Tara Breslin (Ann Arbor, MI): The primary criteriafor participating in MiBOQI is breast cancer treatmentvolume. There are 42 institutions in Michigan with suffi-cient breast cancer treatment volume for participation,and 18 hospitals participate. The program is supportedby Blue Cross Blue Shield of Michigan. Each institutionhas a research associate who is responsible for data entryand a project director responsible for data review anddissemination. The data are reported to us quarterly,so there are a couple of months of lag time.

You asked about additional predictors includingtumor size. The main additional predictor of core biopsyuse was a diagnosis of ductal carcinoma in situ vs aninvasive cancer. It is difficult to tell whether or not thepatients had a truly palpable tumor vs a tumor whichshowed up both on imaging and on palpation in thecases that were diagnosed outside. So we have noinformation about those patients.

You asked about surgeon specialty and specializationin breast cancer care. The majority of the surgeonsproviding care are general surgeons.

You asked, ‘‘Do we have information about use ofdiagnostic surgical biopsy within the state of Michigan?’’ Ido not have access to those data specifically, although wecould potentially look at it through outpatient administra-tive records. There is a recent report from Gutwein et alshowing a decrease in the use of surgical biopsy in the stateof Florida, which might be useful for a comparison.

Dr Tina Yen (Milwaukee, WI) for Dr Anees Chagpar(New Haven, CT): Dr Chagpar was unable to attend. Iwill read her discussion.

I would like to thank the Central Surgical for theopportunity to discuss this innovative paper by Breslinet al from the University of Michigan, which evaluatesthe impact of regional collaborative organizations onimproving quality of surgical care. Increasingly, there is amandate for both transparency and improvement ofquality of care. And this study shows that simply bymonitoring outcomes and sharing data amongst institu-tions, quality can be improved.

I have several questions for the authors: first, you showthat surgical biopsy rates decreased over time. Presum-ably, some of this was related to theMiBOQI initiative. Butdo we have any data on other changes that occurred overthis period of time that could also account for some ofthese differences? For example, perhaps new, minimallyinvasive biopsy equipment was purchased, more radiolo-gists were hired, or surgeons obtained training in ultra-sound or stereotactic biopsy. Do youhave any data on this?

Second, did you notice any differences in rate ofreduction of surgical biopsy in terms of institutionalcharacteristics? Were academic institutions were morelikely to improve? What about larger hospitals vs smallerones?

And finally, some of the patients of the patients whowere classified as having an excisional biopsy did so forcompletely justifiable reasons; for example, following acore needle biopsy per atypical ductal hyperplasia. Doyou have any way to discern whether the reduction younoted in surgical biopsies was in these justifiable casesor in patients in whom an excisional biopsy was beingdone as an initial surgical procedure?

Dr Tara Breslin (Ann Arbor, MI): In response to thefirst question, there are certainly national trends andchanges in radiology practice indicating an increasedavailability and use of image guided core needle biopsy.I would assume that those practice changes are also be-ing seen in Michigan. There was no real difference in ac-ademic vs community practices. In fact, in our academicpractice, we had a very high surgical biopsy rate becausemany of our patients were referred from otherinstitutions.

You asked about the justifiable biopsy rate by institu-tion. And that would be interesting to look at, althoughonly one institution underwent a thorough chart audit.So that would be up to the other participatinginstitutions.

Dr Michael Edwards (Cincinnati, OH): I am in-trigued by the topic. You start off looking at a datasetand you are interested in quality. So how did you cometo choose surgical biopsy vs incisional biopsy with a can-nula or with a needle in terms of quality?

Are you suggesting that there is some superior diag-nostic efficacy? Or are you suggesting that it is less costly?Are you suggesting that it is associated with less cosmeticdeformity? I would ask you to consider the regionaliza-tion of care and to look at the more rural cases and thinkabout the skill that’s required to do stereotactic biopsy.And those resources may not actually be available in in-stitutions that practice with lower volumes than you seeand I see. So I would not be surprised to see a gravitationto more conventional needle localization, surgical exci-sional biopsy.

But the question is: they seem to have similar diag-nostic efficacy, so are we really talking about cost andcosmesis? And let us not forget that we are stimulated todo needle core biopsies by industry, by radiologists, andby others who have other biased motives in terms ofencouraging that direction.

Dr Tara Breslin (Ann Arbor, MI): I agree that diagnos-tic breast biopsy technique does not qualify as a qualitymetric as it cannot be directly linked to an outcomesuch as survival or local recurrence. However, as a processmeasure, diagnostic biopsy techniquemay reflect an insti-tution’s approach to the continuum of breast cancer diag-nosis and care. As you mentioned, core needle biopsy hasbeen associated with improved cosmesis and may be asso-ciated with a cost-containment advantage. And I would

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also agree that certain institutions with lower volumes orperhaps less radiology support may be unable to performcore needle biopsy in all cases.

On the other hand, there are advantages for surgeonsto refer more of their patients for core needle biopsy or

personally perform core needle biopsies. And that is thatoperating room time is precious. From a practiceefficiency standpoint, it makes sense to reserve expensiveand scarce operating room time for therapeutic proce-dures when possible.