Improving Breast Imaging Quality Standards (2005) / Chapter Skim
Currently Skimming:
4 Ensuring an Adequate Workforce for Breast Cancer Screening and Diagnosis
4 Ensuring an Adequate Workforce for Breast Cancer Screening and Diagnosis
Pages 117-163
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 117... ...
. Although these reports depict alarming situations, they are largely anecdotal or impressionistic; however, it is clear that demand for breast imaging services is increasing and is likely to continue to do so over the coming decades, while there is little to suggest that the numbers of interpreting physicians and RTs will rise accordingly.
|
From page 118... ...
This individual is responsible for documenting the results, for notifying other interpreting physicians of their results and the facility aggregate results, and for documenting the nature of any follow-up actions. Radiologic technologist (RT)
|
From page 119... ...
The Committee examined a variety of factors that could limit the future supply of interpreting physicians, including concerns that reading mammograms, as compared with other areas of radiology, is less lucrative, more regulated, and carries greater medicolegal risk. It was also noted that the expanded use of nonmammographic imaging technologies for breast cancer detection and diagnosis are likely to increase future demand for breast imaging, and thereby the workload of some interpreting physicians.
|
From page 120... ...
The supply of interpreting physicians was approximately 14,400 full-time equivalent (FTE) radiologists, which translates to approximately 2.4 FTE radiologists interpreting mammograms per 10,000 women aged 40 and older.
|
From page 121... ...
The number of entries in this new table was assumed to equal the number of interpreting physicians for that particular year. Approximately 10 percent of the entries are still likely to be duplicates, largely due to name misspellings or other variations in name entry during the data entry process.
|
From page 122... ...
In fact, the vast majority of radiologists who interpret mammograms spend a significant portion of their time reading other types of images. The actual number of full-time equivalent interpreting physicians is thus much lower.
|
From page 123... ...
conducted by D'Orsi and coworkers (2005) in 2001 2002 found shortages of interpreting physicians relative to mammography volume in 44 percent of these facilities.
|
From page 124... ...
also play an essential role in the breast imaging workforce, but supply/demand issues for these professionals are less well understood than those of interpreting physicians and RTs. A 1993 report written by the National Mammography Quality Assurance Advisory Committee showed that there were 511 medical physicists qualified under the interim rules to perform mammography surveys, and concluded that this number was sufficient to support mammography across the United States (National Mammography Quality Assurance Advisory Committee, 1996)
|
From page 125... ...
As a result of concerns about the increasing number of mammography facility closures, the U.S. Government Accountability Office (GAO)
|
From page 126... ...
, 24 percent had patient-scheduled diagnostic appointment wait times longer than 7 days, and 21 percent had physician-scheduled appointment wait times longer than 7 days. Reports of lengthy wait times for mammograms indicate that some breast cancer screening facilities are operating at or near full capacity (IOM, 2001)
|
From page 127... ...
. interpreting physicians at facilities with long wait times that they limited the number of mammograms they read in order to limit their exposure to medical malpractice lawsuits (The Florida Legislature: Office of Program Policy Analysis & Government Accountability, 2004)
|
From page 128... ...
FUTURE PROJECTIONS: WORKFORCE DEMAND OUTSTRIPS SUPPLY In an effort to predict the future supply and demand of the mammography workforce, the Committee commissioned Paul Wing, of the Center for Workforce Studies at the State University of New York School of Public Health in Albany, to model the possi 7Provided by T Haran, Chief, Information Management Branch, Mammography Program Reporting and Information System Program Manager, Division of Mammography Quality and Radiation Programs, Center for Devices and Radiological Health, FDA, October 2004.
|
From page 129... ...
. The model of the projected supply of interpreting physicians depicted in Table 4-4 predicts that the number of radiologists interpreting mammograms will remain essentially flat through 2025.
|
From page 130... ...
s States, Census 5 8 5 5 8 7 449 668 320 196 41 83 7 radiologist e.
|
From page 131... ...
or .puo e,id fo grega retire, % Total -- 34.0 5.5 0.0 36.7 by will # Workload 65 6 5 45 onersiti atth rto act Total (000s) 5,400 31,9 5,42 8,65 51,4 pr w ne # cohegana Rad 0 0 4 of of Mammography -- oni Avg.
|
From page 132... ...
Measures proposed later in this chapter intended to increase the number of new entrants to the field of breast imaging, to retain the current mammography workforce, and to increase productivity of new and existing practitioners could improve future access to mammography. However, a predicted impending shortage of all physicians and the nation's lack of capacity to expand medical class sizes may severely restrict growth in thenumber of interpreting physicians for several years to come (Cooper et al., 2003; RSNA, 2004b)
|
From page 133... ...
These include the increased use of additional breast imaging technologies, as well as potential changes in MQSA to increase continuing experience (minimum volume) requirements or to require double reading for all screening mammograms.
|
From page 134... ...
. Despite the fact that the value of these technologies for breast cancer screening has yet to be confirmed (Kopans, 2004; Lee, 2004; Irwig et al., 2004)
|
From page 135... ...
A recent study conducted by researchers at Michigan State University found that on average, radiologists spent nearly twice as long interpreting a digital screening mammogram as compared with a film image; moreover, this difference persisted even after approximately 2 years of experience with digital mammography (Aben et al., 2004)
|
From page 136... ...
76090 0.96 36.38 1.11 42.07 Unilateral diagnostic mammography (digital) G0206 0.96 36.38 2.08 78.83 CAD (screening mammography)
|
From page 137... ...
, an increase in the current workforce of radiologists interpreting mammograms, or an increase in the number of mammograms read by interpreting physicians, or both, will be needed to implement double reading of mammograms in the United States. The magnitude of the need for an increased workforce or greater productivity will depend on the number of facilities currently performing double reads (a number that is not readily available)
|
From page 138... ...
Distribution of Interpreting Physicians Based on data obtained from the 2003 ACR survey, Sunshine and coworkers (2004a) examined the distribution of interpreting physicians among 5 different types of
|
From page 139... ...
radiologists who interpret mammograms working in each of these community types. This analysis indicates that large metropolitan main cities have significantly fewer interpreting physicians per 1,000 women than do other types of communities, a finding that may reflect greater specialization among urban radiologists.
|
From page 140... ...
Effects of Increased Interpretation Volume on Access to Mammography Any change in access resulting from an increase in MQSA-mandated continuing experience (minimum volume) requirement for interpreting physicians would be imposed upon the patterns of access to mammography identified above.
|
From page 141... ...
However, it is important to note that, unlike screening mammography, breast cancer diagnosis is not readily adaptable to remote exams. While the strategies described below offer greater access to screening mammograms, women may still have to travel long distances to a central facility for follow-up procedures, including biopsies, as well as for treatment.
|
From page 142... ...
If additional views or diagnostic mammograms are indicated, patients must travel to Rapid City. This service, which generally operates 4 days per week, 51 weeks per year, provided screening mammograms for more than 3,400 women in 2003.
|
From page 143... ...
FACTORS LIMITING THE SUPPLY OF INTERPRETING PHYSICIANS Breast imaging specialists generally consider their chosen field to be challenging, diverse, and interesting, but they interpret less than 12 percent of mammograms in the United States; most are read by general radiologists.15 FDA regulations do not require interpreting physicians to be radiologists, but most are. Generally the non-radiologists who read mammograms are breast surgeons or OB/GYNs.
|
From page 144... ...
Those who said they wanted to spend little or no time interpreting mammograms chose the following explanations for their preference: that mammography was not an interesting enough field (45 percent) ; that they feared lawsuits (37 percent)
|
From page 145... ...
. In the highly charged atmosphere surrounding mammography, it is perhaps not surprising that interpreting physicians are the most frequently named parties in lawsuits concerning missed breast cancer diagnoses (Physician Insurers Association of America, 2002)
|
From page 146... ...
either agreed or strongly agreed that they are concerned about the impact medical malpractice is having on their practice of mammography. In addition, about one-quarter of radiologists surveyed said they considered withdrawing from interpreting mammograms at least on a monthly basis, and 16 percent considered withdrawing weekly or daily because of concerns about malpractice (Elmore et al., in press)
|
From page 147... ...
For example, a radiologist who receives a professional reimbursement of $36.38 from Medicare for interpreting screening mammography would receive the same amount for interpreting a unilateral diagnostic mammogram, $84.51 for interpreting a unilateral breast MRI, and $123.17 for interpreting a brain MRI with and without contrast. Interpreting physicians in hospital practices receive only this professional component of reimbursement; the hospital receives an additional sum, the technical component of reimbursement, to compensate for all other costs related to the procedure (see Table 4-7)
|
From page 148... ...
The physician fee schedule consists of three parts: relative value, geographic adjustment, and conversion factor. Relative Value: The Current Procedural Terminology (CPT)
|
From page 149... ...
CAD has been reimbursed under the physician fee schedule as an add-on payment for screening and diagnostic mammography services since January 2004. In contrast, there is no addon payment for double reading.
|
From page 150... ...
Among other issues relasted to malpractice insurance, which are discussed in detail in Chapter 5, tail coverage20 for interpreting physicians may be especially expensive or hard to obtain because cancer occurrences may take years to become evident after a negative mammogram. STRATEGIES TO ENSURE AN ADEQUATE MAMMOGRAPHY WORKFORCE Improvements in breast imaging technology, as well as in the delivery of cancer screening services, could perhaps increase women's access to breast cancer screening in the future (IOM, 2005)
|
From page 151... ...
In order to target breast imagers to the highest need areas, the Health Resources and Services Administration should establish a process to identify and designate shortage areas for breast imaging specialists. The Committee also notes educational incentives such as proposals to sequence residency training that would expose radiology residents to breast imaging earlier in their education and training (Bassett et al., 2003)
|
From page 152... ...
As a first step, demonstration projects could test the performance of both RAs and nontechnical personnel in a variety of responsibilities and tasks. Integrating Radiologist Assistants into Breast Imaging Increasing demands on radiologists -- as well as the need to establish a career path by which to attract and retain RTs -- have been recognized by the American College of Radiology and American Society of Radiologic Technologists, which recently collaborated to develop training and practice guidelines for a new type of physician extender, the radiologist assistant (Advanced Practice Advisory Panel, 2002; Williams and Short, 2004; RSNA, 2004a)
|
From page 153... ...
Improving Workplace Design and Organization The incorporation of key elements of successful breast cancer screening programs in other countries, including centralized expert interpretation of all breast imaging modalities and a thorough quality assurance process, could increase the quality and effectiveness of breast cancer detection in the United States. Such improvements are discussed throughout this report, and are collected in the description of Breast Imaging Centers of
|
From page 154... ...
Quality standards for cytology laboratories performing Pap testing are described below.
|
From page 155... ...
Basic inspections: The Centers for Medicare and Medicaid Services (CMS) or a CMS agent may interview personnel, require the facility to analyze test samples, observe personnel performing all phases of the testing process, or examine records and data.
|
From page 156... ...
SUMMARY AND CONCLUSIONS Because early detection of occult breast cancer is a key element for reducing breast cancer morbidity and mortality, it is important to accurately monitor the capacity of mammography services and to ensure adequate access for women. The paucity of robust national and regional data on the supply of and demand for mammography services necessitated an assessment of the mammography workforce based on estimates and projections and informed by anecdotal and regional reports of unfilled positions, facility closures, wait times, and barriers to access.
|
From page 157... ...
Likewise, the added costs of the proposed new medical audit procedures, whether covered by increased reimbursements or not, could disproportionately affect access by low income women. Initiatives to expand the mammography workforce face a spectrum of factors that discourage today's radiology residents from choosing breast imaging as a subspecialization in radiology and general radiologists from interpreting mammograms.
|
From page 158... ...
2005. The association between mammographic breast density and breast cancer tumor characteristics.
|
From page 159... ...
2004a. Medicare program: Revisions to pay ment policies under the Physician Fee Schedule for calendar year 2005.
|
From page 160... ...
2005. Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diag nosis.
|
From page 161... ...
1994. Europe Against Cancer Breast Cancer Screening Programme in France: The ADEMAS Programme in Bas-Rhin.
|
From page 162... ...
Presentation at the meeting of the Institute of Medicine Committee on Improving Mammography Quality Standards, Washington, DC. Sunshine JH, Maynard CD, Paros J, Forman HP.
|
From page 163... ...
2000. The cost of breast cancer screening in France.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.