the field of mammography, already a relatively unattractive and risky service with low reimbursement. In the United Kingdom, for example, individual performance results are provided only to the radiologist. Finally, in practice, publicly released health care performance data are rarely used by consumers even when available. In contrast, health care providers do use performance data results to improve the quality of their health care services. Marshall and colleagues reviewed studies on the public disclosure of health care performance data and concluded that78

…the use of public performance data by consumers and purchasers or for regulation purposes will remain relatively less important for the foreseeable future than use of the data as a catalyst to stimulate and promote internal [italics added] quality improvement mechanisms at the level of the organizational provider.

Better Training

Continuing medical education is required for radiologists in the United States, but the content is not uniformly organized and almost never targets recall or cancer detection rates. There is a view that continuing quality assurance through feedback of results could improve performance. In contrast, the United Kingdom has established a program that is voluntary but is used by more than 90 percent of radiologists who practice mammography.

OTHER TECHNOLOGY OPTIONS

As noted earlier, no breast cancer screening tool has better sensitivity and specificity than screen-film mammography, although it could be better. However, even with similar sensitivity and specificity, there may be ways to improve storage, transmission, cost, ease of use, and other characteristics of mammography that would add value. Certainly, any new technology or refinement should have equal success in accurately detecting abnormalities and an equal or better effect on health outcomes compared to current screening mammography. Reviewed briefly below are some leading technologies that are FDA approved and are being examined for their roles in breast cancer detection and diagnosis. Digital mammography and CAD have been proposed for use in screening of average risk women, whereas MRI is not expected to improve outcomes for average risk women but is being tested for use in certain groups of high-risk women.

Digital Mammography

For more than 10 years, researchers have been developing digital mammography devices in the hope that digitizing radiographic data will im-



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