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2. Breast Cancer
3. ACS Breast Cancer Screening Guidelines May 2003
4. Mammography Screening is Widely Accepted by American Women
5. Long wait times reported in the media Long waits are not acceptable to women or public health officials 6. Like it or not:
7. Breast Imaging Workforce Shortage
8. There is no organized network for mammography screening in the U.S.
9. Projected Trends in the Size of the Population of U.S. Women by Age Cohort Each year, the size of the population of U.S. women of mammography screening age increases by 1.25 million. Source: U.S. Census, Series P-25 10. Yearly mammography volumes in millions(60% compliance) 11. Breast Cancer, 1973-2000 SEER Age-Adjusted Rates,9 Registries White ALL Black Black White Incidence Mortality 12. Disparities in U.S. Breast Cancer Mortality ReductionSEER Age Adjusted Rates 1990-2000 White Black Hispanic Asian American Indian 13. US Mammography Use by Age & Poverty Status CA Cancer J Clin 2003;53:342-55 40-49 years 50-64 years 65 years & older 14. GAO Report
15.
General TrendsGAO Report GAO-02-532 16.
GAO-02-532 17.
GAO-02-532 18. GAO on Personnel last few years show a substantial decline in the number of new entrants to the fields Personnel includes radiologists and radiologic technologists GAO-02-532 19. Mammography Technologists
20.
How many radiologists interpret mammograms? 21. How many radiologists interpret mammograms? How many are specialists?
Self-reported info from respondents: 12% of radiologists interpreting mammograms are specialists 22. Society of Breast Imaging
23. Radiology Fellowship Match, Active Programs June 4, 2003, Appointment Year 2004-05 BI/WI represents only 6% of positions in the match.Only 25% of positions were filled, representing only 3% of filled fellowships. POSITIONS 36(75%) 12(25%) 48 Breast/Womens Imaging 358(47%) 411(53%) 769 All Programs Unfilled Filled# 24.
Attitudes of Radiology ResidentsRegarding Breast Imaging(BI) Survey: 211 of 224 accredited US programs Bassett et al, Radiology.2003 25. Compare interpreting mammography toCT of the abdomen with contrast 26. Resident responses as % of total Concern about missing a potentially important finding 27. Resident responses as % of total Concern about making appropriate recommendation to referring physicians 28. Resident responses as % of total Concern about malpractice liability 29. Compare interpreting mammography to other types of imaging examinations 30. Resident responses as % of total Rate the stress levels associated with possible misdiagnosis 31. Resident responses as % of total Rate patient stress related to the exam 32. Resident responses as % of total Mammography should be interpreted by breast imaging subspecialists 33. Resident responses as % of total like to spend> 25% of your time interpreting mammograms when in practice 34. Resident responses as % of total If not, what are the reasons? 35. Performance Parameters for Screening and Diagnostic Mammography:Specialist and General Radiologists Sickles et al, Radiology 2002;224:861-869 *Number per 1000 27.0 3.0 36.6 3.4 9.9 7.1 Generalists 43.9 5.3 59.0 6.0 15.8 4.9 Specialists DX SCR DX SCR DX rec bx % SCR recall % Stage 0-1 CA detection rate* CA detection rate* Abnormal rate 36. Expertise reflects complex multifactorial process
37. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography
Beam et al, Radiology 2003;229: 534-540 38. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography Beam et al, Radiology 2003;229: 534-540 Analyzed implications if the U.S. limited the workforce by accuracy -50% -11,400 Increase 10% -25% -6,000 Increase 5% -10% -2,200 Increase 1% 20,000 Current Service Capacity # Radiologists Accuracy 39. How can we measure interpretive skills & performance?
40. Audit data needs to remain non-discoverable
41. ACR Practice Cost Survey: Spring 2001 Screening Mammography
42. ACR Practice Cost Survey: Spring 2001Screening Mammography
43. Screening Mammography Reimbursement vs Costs *ACR survey, Spring 2001 $86.60 *2001 Cost at Office Facility$124.54 *2001 Cost at Hospital Facility $ Medicaid (varies by State) $80.94 Medicare (2004) 44. Operational costs are higher at hospital facilities
45. Providing Professional Mammography Services: Financial Analysis
Enzmann et al, Radiology 2001;219:467-473 To break even on diagnostic mammos: Revenue must go up 143% RVUs need adjustment by factor of 2.95 46. Providing Professional Mammography Services: Financial Analysis (contd)
Enzmann et al, Radiology 2001;219:467-473 47. CAD is reimbursed, but double reading is not! 48. Cost to Facility to Meet MQSA Requirements
49. PIAA Breast Cancer Study, Spring 2002:study of 450 current paid cases
50. 174.8 329 531 733 TOTAL 2.6 375 7 9 Pathology 1.2 144 8 20 Hospital 2.8 236 12 22 Other 8.9 247 36 46 Internal medicine 16.0 309 52 62 FP/GP 20.7 334 62 78 Surgical specialties 9.8 265 37 87 Corporations 49.0 369 133 167 Ob/Gyn 63.7 346 184 242 Radiologists Total indemnity ($millions) Average indemnity ($1000s) Paid Claims # Claims Specialty 51. PIAA: Physician Associated Issues1995 vs 2002 28.7% 35.5% Physical findings failed to impress 35.1% 25.8% Negative mammogram report 37.8% 22.7% Mammogram misread 2002 1995 52. Repercussions from Malpractice Crisis on Mammography Practice
53. When radiologists practice defensive medicine,more women.
And, the cost of medical care increases 54. Do radiologists who interpret mammograms pay higher malpractice premiums?
As reported in Hartford Courant, source Alan Kaye, MD, Chair Radiology, Bridgeport Hospital
55. What is the answer for the future? Remember the mission: minimize the morbidity and mortality from breast cancer We need ways, including incentives, to ensure that sufficient numbers of adequately trained personnel at all levels are recruited and retained to provide quality mammography services 56. MQSA being reviewed by GAO & IOM
57. Possibilities. Development of centers of excellence
Provide incentives for development