PAUL NAGY, PhD
QUALITY MATTERS
Quality Improvement Projects for Value-Based Care in Breast Imaging Dorothy A. Sippo, MD, MPH, Paul Nagy, PhD INTRODUCTION
The Mammography Quality Standards Act [1], finalized in 1999, provides a strong foundation for demonstrating value-based patient care. The act requires an outcomes audit that correlates pathologic results with positive mammographic findings, requires the review of falsenegative mammographic results, and mandates that mammographic reports include an overall assessment of findings using structured terminology based on the ACR’s BI-RADS [2]. Now in its fifth edition, the 2013 BIRADS Atlas is a mature reporting lexicon, including finding descriptors across modalities and guidance on performing a medical outcomes audit. Mammography is particularly well suited for value-based care, with its focus on screening healthy populations. This creates continuity of care, with patients returning on an annual basis. Radiologists frequently explain diagnostic mammography and breast ultrasound results directly to patients and perform imagingguided procedures. Breast imaging is frequently practiced at multidisciplinary breast care centers, where radiologists, surgical oncologists, medical oncologists, and plastic surgeons are collocated and work in an integrated practice. In breast imaging, direct patient contact and close working relationships with related subspecialists create opportunities to identify patient-centered quality improvement (QI) projects. The ACR’s Imaging 3.0 initiative is a program that seeks to engage radiologists, referring physicians, and patients in a team-based approach to maintain the health of the population with high-quality care [3]. Value in health care is the health outcome per dollar of cost [4]. With its long history
of patient outcomes assessment, breast imaging is poised for QI projects that focus on promoting value-based care. In this article, we describe 3 QI projects for value-based care in breast imaging using the 4-step plan-dostudy-act cycle [5]. PROJECT: IMPACT OF DIGITAL BREAST TOMOSYNTHESIS ON SCREENING MAMMOGRAPHY RECALL RATE
Digital breast tomosynthesis (DBT; or 3-D mammography) is a new mammographic technology that is rapidly being adopted, with approximately 1,100 of 13,500 mammography units in the United States able to perform tomosynthesis [6]. In a survey conducted by the Society of Breast Imaging, 62.3% of respondents not using DBT reported that they planned to obtain it [7]. As new technology is put into practice, it is important to assess its impact on patient outcomes. With each screening mammogram assigned a BI-RADS final assessment category, recall rate (number of positive examinations/total number of examinations) can be readily determined. Early investigations have shown that DBT combined with conventional 2D digital mammography (DM) improves performance, compared with DM alone, by reducing tissue overlap. Multiple studies have demonstrated a reduction in screening recall rate with the use of DBT [8,9]. Screening with DBT presents an opportunity to assess the impact of this new technology on recall rate at one’s own institution. After an initial run-in period during which breast imagers become familiar with using DBT, the screening recall rate using 3-D DBT can be compared with that for DM alone. If the
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.019
institution is performing all of its screening using DBT, the comparison can be made with historical data when DM alone was used. If the institution continues to perform both DBT and DM for screening, the comparison can be made contemporaneously. Comparison should be performed on a monthly basis identifying best practices for using DBT to reduce recall rates. Plan: The screening recall rate using DBT should be lower than that using DM, 6 months after consistent feedback is given about recall rates with and without the use of DBT. Do: On a monthly basis, compare screening recall rates, for patients screened with and without DBT. Study: Determine if the recall rate is lower for patients screened with DBT compared with those screened with DM alone. Act: If there are radiologists for whom the recall rate with DBT is not lower than that for DM, review recalled cases. Radiologists with lower recall rates using DBT may be able to share best practices. If a radiologist starts with a relatively low recall rate, the impact of DBT may be less significant. PROJECT: INDICATIONS FOR BREAST MRI
Radiologists are valuable consultants to referring physicians to ensure that appropriate imaging is performed. Breast MRI is a relatively high-cost breast imaging examination. The ACR Appropriateness Criteria [10] rate the appropriateness of different breast imaging examinations for clinical conditions. In particular, they indicate the appropriateness of breast MRI, compared with mammography 1189
1190 Quality Matters
and breast ultrasound, for breast cancer screening, to evaluate palpable breast masses, and for initial workup and surveillance of stage I breast cancer. The criteria indicate that screening mammography and breast MRI are usually appropriate for high-risk women. Screening mammography is usually appropriate, and screening breast MRI may be appropriate for intermediate-risk women. For women presenting with palpable masses, diagnostic mammography and breast ultrasound are more appropriate initial evaluations than breast MRI. The ACR Appropriateness Criteria can be incorporated into a QI project to ensure the optimal utilization of breast MRI. For specific clinical conditions, sufficient history needs to be obtained to determine if the examination is indicated. This information can be obtained from the referring physician at the time the examination is ordered or through a patient questionnaire. The appropriateness of the examination can be assessed before the examination is performed and feedback given to the ordering physician if it is not indicated. This can be done with decision support at the time of computerized physician order entry or by human review when the examination is protocoled. Plan: All breast MRI examinations performed for specific clinical conditions should be appropriate, 6 months after the implementation of a system to evaluate examination appropriateness before imaging is performed. Do: Collect data about the indications for breast MRI examinations and relevant clinical histories. Study: Determine if the imaging was appropriate on the basis of the ACR Appropriateness Criteria. Act: Identify root causes. If the goal is not met, identify what factors are leading to breast MRI’s being
performed despite feedback being given that it is not indicated. An alternative version of this project would be to identify women being screened with mammography who are at high risk for developing breast cancer but who are not receiving supplemental screening breast MRI. Radiologists could partner with referring physicians to ensure these women also receive screening breast MRI. PROJECT: COORDINATION OF PREOPERATIVE IMAGINGGUIDED LOCALIZATION
Before lumpectomy, breast cancer patients often require tumor localization with wires or radioactive seeds, placed under imaging guidance. They may also require the injection of a radionuclide tracer to identify the sentinel axillary lymph node. On her journey to the operating room, a patient will begin her day at the preoperative unit, travel to radiology for tumor localization, possibly travel to nuclear medicine for radionuclide injection, and then ultimately travel to the operating room. This multistep process requires careful coordination to ensure that the patient arrives at the operating room ready for surgery at the appointed time. This multidisciplinary service line can be the focus of a QI project with the goal that all patients requiring preoperative imaging-guided localization arrive on time for surgery. The project can begin by tracking patients through their preoperative journeys, with either electronic or paper-based time stamps. Review of these data will allow steps in the workflow to be identified where slowdowns occur so that can then be addressed. Plan: All patients requiring imaging guided localization before surgery will arrive at the operating room on time, 6 months after
mapping and optimization of this workflow. Do: Collect data with timestamps about how patients move through the steps of this process. Study: Determine if the patients are arriving at the operating room on time. Act: If some patients are arriving late, identify which steps in the process are responsible for the slowdowns and what changes are needed to address them.
REFERENCES 1. Mammography Quality Standards Act, 62 Fed Reg 559688, 1997. 2. D’Orsi CJ, Sickles EA, Mendelson EB, et al. Breast Imaging Reporting and Data System: ACR BI RADS. 2013 ed. Reston, Virginia: American College of Radiology; 2013. 3. American College of Radiology. Imaging 3.0 FAQ. Available at: http://www.acr.org/ FAQs/Imaging-3-FAQ. Accessed August 17, 2014. 4. Porter ME, Teisberg EO. Redefining health care creating value-based completion on results. Boston, Massachusetts: Harvard Business School Press; 2006. 5. American Board of Radiology. MOC: Maintenance of Certification: diagnostic radiology: guidelines for PQI projects. Available at: http://www.theabr.org/mocdr-pqiguides. Accessed June 22, 2014. 6. Grady D. 3-D mammography test appears to improve breast cancer detection rate. The New York Times. June 25, 2014:A1. 7. Hardesty LA, Kreidler SM, Glueck DH. Digital breast tomosynthesis utilization in the United States: a survey of physician members of the Society of Breast Imaging. J Am Coll Radiol 2014;11:594-9. 8. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014;311:2499-507. 9. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267:47-56. 10. American College of Radiology. ACR Appropriateness Criteria. Available at: http:// www.acr.org/Quality-Safety/AppropriatenessCriteria. Accessed August 17, 2014.
Dorothy A. Sippo, MD, MPH, and Paul Nagy, PhD, are from the Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Paul Nagy, PhD, Department of Radiology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
QUALITY MATTERS
Quality Improvement Projects for Value-Based Care in Breast Imaging Dorothy A. Sippo, MD, MPH, Paul Nagy, PhD INTRODUCTION
The Mammography Quality Standards Act [1], finalized in 1999, provides a strong foundation for demonstrating value-based patient care. The act requires an outcomes audit that correlates pathologic results with positive mammographic findings, requires the review of falsenegative mammographic results, and mandates that mammographic reports include an overall assessment of findings using structured terminology based on the ACR’s BI-RADS [2]. Now in its fifth edition, the 2013 BIRADS Atlas is a mature reporting lexicon, including finding descriptors across modalities and guidance on performing a medical outcomes audit. Mammography is particularly well suited for value-based care, with its focus on screening healthy populations. This creates continuity of care, with patients returning on an annual basis. Radiologists frequently explain diagnostic mammography and breast ultrasound results directly to patients and perform imagingguided procedures. Breast imaging is frequently practiced at multidisciplinary breast care centers, where radiologists, surgical oncologists, medical oncologists, and plastic surgeons are collocated and work in an integrated practice. In breast imaging, direct patient contact and close working relationships with related subspecialists create opportunities to identify patient-centered quality improvement (QI) projects. The ACR’s Imaging 3.0 initiative is a program that seeks to engage radiologists, referring physicians, and patients in a team-based approach to maintain the health of the population with high-quality care [3]. Value in health care is the health outcome per dollar of cost [4]. With its long history
of patient outcomes assessment, breast imaging is poised for QI projects that focus on promoting value-based care. In this article, we describe 3 QI projects for value-based care in breast imaging using the 4-step plan-dostudy-act cycle [5]. PROJECT: IMPACT OF DIGITAL BREAST TOMOSYNTHESIS ON SCREENING MAMMOGRAPHY RECALL RATE
Digital breast tomosynthesis (DBT; or 3-D mammography) is a new mammographic technology that is rapidly being adopted, with approximately 1,100 of 13,500 mammography units in the United States able to perform tomosynthesis [6]. In a survey conducted by the Society of Breast Imaging, 62.3% of respondents not using DBT reported that they planned to obtain it [7]. As new technology is put into practice, it is important to assess its impact on patient outcomes. With each screening mammogram assigned a BI-RADS final assessment category, recall rate (number of positive examinations/total number of examinations) can be readily determined. Early investigations have shown that DBT combined with conventional 2D digital mammography (DM) improves performance, compared with DM alone, by reducing tissue overlap. Multiple studies have demonstrated a reduction in screening recall rate with the use of DBT [8,9]. Screening with DBT presents an opportunity to assess the impact of this new technology on recall rate at one’s own institution. After an initial run-in period during which breast imagers become familiar with using DBT, the screening recall rate using 3-D DBT can be compared with that for DM alone. If the
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.019
institution is performing all of its screening using DBT, the comparison can be made with historical data when DM alone was used. If the institution continues to perform both DBT and DM for screening, the comparison can be made contemporaneously. Comparison should be performed on a monthly basis identifying best practices for using DBT to reduce recall rates. Plan: The screening recall rate using DBT should be lower than that using DM, 6 months after consistent feedback is given about recall rates with and without the use of DBT. Do: On a monthly basis, compare screening recall rates, for patients screened with and without DBT. Study: Determine if the recall rate is lower for patients screened with DBT compared with those screened with DM alone. Act: If there are radiologists for whom the recall rate with DBT is not lower than that for DM, review recalled cases. Radiologists with lower recall rates using DBT may be able to share best practices. If a radiologist starts with a relatively low recall rate, the impact of DBT may be less significant. PROJECT: INDICATIONS FOR BREAST MRI
Radiologists are valuable consultants to referring physicians to ensure that appropriate imaging is performed. Breast MRI is a relatively high-cost breast imaging examination. The ACR Appropriateness Criteria [10] rate the appropriateness of different breast imaging examinations for clinical conditions. In particular, they indicate the appropriateness of breast MRI, compared with mammography 1189
1190 Quality Matters
and breast ultrasound, for breast cancer screening, to evaluate palpable breast masses, and for initial workup and surveillance of stage I breast cancer. The criteria indicate that screening mammography and breast MRI are usually appropriate for high-risk women. Screening mammography is usually appropriate, and screening breast MRI may be appropriate for intermediate-risk women. For women presenting with palpable masses, diagnostic mammography and breast ultrasound are more appropriate initial evaluations than breast MRI. The ACR Appropriateness Criteria can be incorporated into a QI project to ensure the optimal utilization of breast MRI. For specific clinical conditions, sufficient history needs to be obtained to determine if the examination is indicated. This information can be obtained from the referring physician at the time the examination is ordered or through a patient questionnaire. The appropriateness of the examination can be assessed before the examination is performed and feedback given to the ordering physician if it is not indicated. This can be done with decision support at the time of computerized physician order entry or by human review when the examination is protocoled. Plan: All breast MRI examinations performed for specific clinical conditions should be appropriate, 6 months after the implementation of a system to evaluate examination appropriateness before imaging is performed. Do: Collect data about the indications for breast MRI examinations and relevant clinical histories. Study: Determine if the imaging was appropriate on the basis of the ACR Appropriateness Criteria. Act: Identify root causes. If the goal is not met, identify what factors are leading to breast MRI’s being
performed despite feedback being given that it is not indicated. An alternative version of this project would be to identify women being screened with mammography who are at high risk for developing breast cancer but who are not receiving supplemental screening breast MRI. Radiologists could partner with referring physicians to ensure these women also receive screening breast MRI. PROJECT: COORDINATION OF PREOPERATIVE IMAGINGGUIDED LOCALIZATION
Before lumpectomy, breast cancer patients often require tumor localization with wires or radioactive seeds, placed under imaging guidance. They may also require the injection of a radionuclide tracer to identify the sentinel axillary lymph node. On her journey to the operating room, a patient will begin her day at the preoperative unit, travel to radiology for tumor localization, possibly travel to nuclear medicine for radionuclide injection, and then ultimately travel to the operating room. This multistep process requires careful coordination to ensure that the patient arrives at the operating room ready for surgery at the appointed time. This multidisciplinary service line can be the focus of a QI project with the goal that all patients requiring preoperative imaging-guided localization arrive on time for surgery. The project can begin by tracking patients through their preoperative journeys, with either electronic or paper-based time stamps. Review of these data will allow steps in the workflow to be identified where slowdowns occur so that can then be addressed. Plan: All patients requiring imaging guided localization before surgery will arrive at the operating room on time, 6 months after
mapping and optimization of this workflow. Do: Collect data with timestamps about how patients move through the steps of this process. Study: Determine if the patients are arriving at the operating room on time. Act: If some patients are arriving late, identify which steps in the process are responsible for the slowdowns and what changes are needed to address them.
REFERENCES 1. Mammography Quality Standards Act, 62 Fed Reg 559688, 1997. 2. D’Orsi CJ, Sickles EA, Mendelson EB, et al. Breast Imaging Reporting and Data System: ACR BI RADS. 2013 ed. Reston, Virginia: American College of Radiology; 2013. 3. American College of Radiology. Imaging 3.0 FAQ. Available at: http://www.acr.org/ FAQs/Imaging-3-FAQ. Accessed August 17, 2014. 4. Porter ME, Teisberg EO. Redefining health care creating value-based completion on results. Boston, Massachusetts: Harvard Business School Press; 2006. 5. American Board of Radiology. MOC: Maintenance of Certification: diagnostic radiology: guidelines for PQI projects. Available at: http://www.theabr.org/mocdr-pqiguides. Accessed June 22, 2014. 6. Grady D. 3-D mammography test appears to improve breast cancer detection rate. The New York Times. June 25, 2014:A1. 7. Hardesty LA, Kreidler SM, Glueck DH. Digital breast tomosynthesis utilization in the United States: a survey of physician members of the Society of Breast Imaging. J Am Coll Radiol 2014;11:594-9. 8. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014;311:2499-507. 9. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267:47-56. 10. American College of Radiology. ACR Appropriateness Criteria. Available at: http:// www.acr.org/Quality-Safety/AppropriatenessCriteria. Accessed August 17, 2014.
Dorothy A. Sippo, MD, MPH, and Paul Nagy, PhD, are from the Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Paul Nagy, PhD, Department of Radiology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
