Patient satisfaction with screening mammography: online vs off-line interpretation

Online or Offline: Does It Matter? A Review of Existing Interpretation Approaches and Their Effect on Screening Mammography Metrics, Patient Satisfaction, and Cost

The ideal practice routine for screening mammography would optimize performance metrics and minimize costs, while also maximizing patient satisfaction. The main approaches to screening mammography interpretation include batch offline, non-batch offline, interrupted online, and uninterrupted online reading, each of which has its own advantages and drawbacks. This article reviews the current literature on approaches to screening mammography interpretation, potential effects of newer technologies, and promising artificial intelligence resources that could improve workflow efficiency in the future.

Batch Reading and Interrupted Interpretation of Digital Screening Mammograms Without and With Tomosynthesis

OBJECTIVE

To compare batch reading and interrupted interpretation for modern screening mammography.

METHODS

We retrospectively reviewed digital mammograms without and with tomosynthesis that were originally interpreted with batch reading or interrupted interpretation between January 2015 and June 2017. The following performance metrics were compared: recall rate (per 100 examinations), cancer detection rate (per 1,000 examinations), and positive predictive values for recall and biopsy.

RESULTS

In all, 9,832 digital mammograms were batch read, yielding a recall rate of 9.98%, cancer detection rate of 4.27, and positive predictive values for recall and biopsy of 4.40% and 35.5%, respectively. There were 49,496 digital mammograms that were read with interrupted interpretation, yielding a recall rate of 11.3%, cancer detection rate of 4.44, and positive predictive values for recall and biopsy of 3.92% and 30.1%, respectively. Of the digital mammograms with tomosynthesis, 7,075 were batch read, yielding a recall rate of 6.98%, cancer detection rate of 5.37, and positive predictive values for recall and biopsy of 7.69% and 38.0%, respectively. Of the digital mammograms with tomosynthesis, 24,380 were read with interrupted interpretation, yielding a recall rate of 8.30%, cancer detection rate of 5.41, and positive predictive values for recall and biopsy of 6.52% and 33.3%, respectively. For both digital mammograms without and with tomosynthesis, recall rates improved with batch reading compared with interrupted interpretation (P < .001), but no significant differences were seen for other metrics.

DISCUSSION

Batch reading digital mammograms without and with tomosynthesis improves recall rates while maintaining cancer detection rates and positive predictive values compared with interrupted interpretation.

Impact of Immediate Interpretation of Screening Tomosynthesis Mammography on Performance Metrics

RATIONALE AND OBJECTIVES

This study aimed to compare performance metrics for immediate and delayed batch interpretation of screening tomosynthesis mammograms.

MATERIALS AND METHODS

This HIPAA compliant study was approved by institutional review board with a waiver of consent. A retrospective analysis of screening performance metrics for tomosynthesis mammograms interpreted in 2015 when mammograms were read immediately was compared to historical controls from 2013 to 2014 when mammograms were batch interpreted after the patient had departed. A total of 5518 screening tomosynthesis mammograms (n = 1212 for batch interpretation and n = 4306 for immediate interpretation) were evaluated. The larger sample size for the latter group reflects a group practice shift to performing tomosynthesis for the majority of patients. Age, breast density, comparison examinations, and high-risk status were compared. An asymptotic proportion test and multivariable analysis were used to compare performance metrics.

RESULTS

There was no statistically significant difference in recall or cancer detection rates for the batch interpretation group compared to immediate interpretation group with respective recall rate of 6.5% vs 5.3% = +1.2% (95% confidence interval -0.3 to 2.7%; P = .101) and cancer detection rate of 6.6 vs 7.2 per thousand = -0.6 (95% confidence interval -5.9 to 4.6; P = .825). There was no statistically significant difference in positive predictive values (PPVs) including PPV1 (screening recall), PPV2 (biopsy recommendation), or PPV 3 (biopsy performed) with batch interpretation (10.1%, 42.1%, and 40.0%, respectively) and immediate interpretation (13.6%, 39.2%, and 39.7%, respectively). After adjusting for age, breast density, high-risk status, and comparison mammogram, there was no difference in the odds of being recalled or cancer detection between the two groups.

CONCLUSIONS

There is no statistically significant difference in interpretation performance metrics for screening tomosynthesis mammograms interpreted immediately compared to those interpreted in a delayed fashion.

Screening Mammography Utilization and Medicare Beneficiaries' Perceptions of Their Primary Care Physicians

RATIONALE AND OBJECTIVES

To assess associations between screening mammography utilization and Medicare beneficiaries' relationships with, and impressions of, their primary care physicians.

MATERIALS AND METHODS

Using the Medicare Current Beneficiary Survey Access to Care Public Use File, we retrospectively studied responses from a national random cross section of Medicare beneficiaries surveyed in 2013 regarding perceptions of their primary care physicians and their screening mammography utilization. Statistical analysis accounted for subject weighting factors to estimate national screening utilization.

RESULTS

Among 7492 female Medicare beneficiaries, 62.0% (95% confidence interval 59.8%-64.2%) underwent screening mammography. Utilization was higher for beneficiaries having (vs. not) a regular medical practice or clinic (63.2% vs. 34.6%) and a usual physician (63.8% vs. 50.3%). Utilization was higher for beneficiaries very satisfied (vs. very dissatisfied) with the overall quality of care they received (66.0% vs. 35.8%), their ease of getting to a doctor (67.7% vs. 43.2%), and their physician's concerns for their health (65.7% vs. 53.4%), as well as for beneficiaries strongly agreeing (vs. strongly disagreeing) that their physician is competent (66.0% vs. 54.1%), understands what is wrong (66.3% vs. 47.1%), answers all questions (67.0% vs. 46.7%), and fosters confidence (66.0% vs. 50.6%). Independent predictors of screening mammography utilization (P < .05) were satisfaction with quality of care, having a regular practice or clinic, and satisfaction with ease of getting to their physician.

CONCLUSIONS

Screening mammography utilization is higher among Medicare beneficiaries with established primary physician relationships, particularly when those relationships are favorable. To optimize screening mammography utilization, breast imagers are encouraged to support initiatives to enhance high-quality primary care relationships.

Risk Factors for Late Screening Mammography

BACKGROUND

Breast cancer has the highest incidence of cancers in women in the United States. Previous research has shown that screening mammography contributes to reduced breast cancer mortality. This study aimed to clarify why late screening might occur in an at-risk population.

MATERIALS AND METHODS

This study was a prospective cross-sectional study including 758 patients presenting to our radiology department for routine screening mammography who completed a 30-question survey regarding personal characteristics and mammography history. Univariate and multivariate logistic regression were performed to determine whether survey responses correlated with late screening.

RESULTS

Of the 758 patients, 184 (24%) were noncompliant with screening mammography guidelines. Risk factors for late screening included younger age (P = 0.001), white race/ethnicity (P = 0.03), self-reported lack of financial means or health insurance (P = 0.005), lack of satisfaction with a previous mammogram experience (P = 0.001), inadequate mammography education by a physician (P = 0.001), and lack of awareness/comprehension of screening mammography guidelines (P = 0.002).

CONCLUSION

Many factors contribute to late screening mammography. Although some are outside physician control, others can be influenced: patient education regarding screening mammography guidelines, and patient satisfaction with the mammography experience. This study highlights the importance of communication with and education of patients.

Integrating Customer Intimacy Into Radiology to Improve the Patient Perspective: The Case of Breast Cancer Screening

OBJECTIVE

The customer intimacy business model has emerged as a key operational approach for health care organizations as they move toward patient-centered care. The question arises how the customer intimacy approach can be implemented in the clinical setting and whether it can help practitioners address problems and improve quality of care.

CONCLUSION

Breast cancer screening and its emphasis on the patient perspective provides an interesting case study for understanding how the customer intimacy approach can be integrated into radiologic practice to improve the patient experience.

Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women

BACKGROUND

American Indian/Alaska Native (AI/AN) women have lower breast cancer (BCA) screening and 5-year survival rates than non-Hispanic Whites. Understanding reasons for low screening rates is important to combatting later stage diagnoses. The purpose of this study was to assess mammography experiences and satisfaction among AI/AN women.

METHODS

Nine focus groups were held with rural (N = 15) and urban (N = 38) AI/AN women 40 years and older in Kansas and Kansas City, Missouri, living both near and far from Indian Health Service (IHS) and tribal facilities, to examine experiences and satisfaction with mammography. Transcripts were coded and themes identified using a community-based participatory research approach.

FINDINGS

Themes were classified under knowledge, communication, and awareness of BCA; barriers to mammography; mammogram facility size; impressions of mammogram technologist; motivations for getting a mammogram; and how to improve the mammogram experience. Participants had knowledge of prevention, but described cultural reasons for not discussing it and described better experiences in smaller facilities. Participants indicated having a mammogram technologist who was friendly, knowledgeable, respectful, competent, and explained the test was a determining factor in satisfaction. Other factors included family history, physician recommendation, and financial incentives. Barriers included transportation, cost, perceptions of prejudice, and time constraints. Participants on reservations or near IHS facilities preferred IHS over mainstream providers. Suggestions for improvement included caring technologists, better machines with less discomfort, and education.

CONCLUSIONS

Interventions to enhance the professionalism, empathy, and cultural awareness of mammogram technologists; reduce barriers; and provide positive expectations and incentives could improve satisfaction and compliance with screening mammography.

An assessment of American Indian women's mammography experiences

BACKGROUND

Mortality from breast cancer has increased among American Indian/Alaskan Native (AI/AN) women. Despite this alarming reality, AI/AN women have some of the lowest breast cancer screening rates. Only 37% of eligible AI/AN women report a mammogram within the last year and 52% report a mammogram within the last two years compared to 57% and 72% for White women. The experiences and satisfaction surrounding mammography for AI/AN women likely are different from that of women of other racial/ethnic groups, due to cultural differences and limited access to Indian Health Service sponsored mammography units. The overall goals of this study are to identify and understand the mammography experiences and experiential elements that relate to satisfaction or dissatisfaction with mammography services in an AI/AN population and to develop a culturally-tailored AI/AN mammography satisfaction survey.

METHODS AND DESIGN

The three project aims that will be used to guide this work are: 1) To compare the mammography experiences and satisfaction with mammography services of Native American/Alaska Native women with that of Non-Hispanic White, Hispanic, and Black women, 2) To develop and validate the psychometric properties of an American Indian Mammography Survey, and 3) To assess variation among AI/AN women's assessments of their mammography experiences and mammography service satisfaction. Evaluations of racial/ethnic differences in mammography patient satisfaction have received little study, particularly among AI/AN women. As such, qualitative study is uniquely suited for an initial examination of their experiences because it will allow for a rich and in-depth identification and exploration of satisfaction elements.

DISCUSSION

This formative research is an essential step in the development of a validated and culturally tailored AI/AN mammography satisfaction assessment. Results from this project will provide a springboard from which a maximally effective breast cancer screening program to benefit AI/AN population will be developed and tested in an effort to alter the current breast cancer-related morbidity and mortality trajectory among AI/AN women.

Digital Mammography: Current Capabilities and Obstacles

Digital mammography represents an exciting new technology for breast imaging and possibly breast screening. The decoupling of functional components in digital mammography translates into potential operational efficiencies compared with screen-film mammography (SFM). Digital mammography is a platform for advanced applications not possible with traditional SFM. However, for digital mammography to replace SFM in daily clinical practice, operational and clinical hurdles will have to be overcome.

Comparison of recall and cancer detection rates for immediate versus batch interpretation of screening mammograms

PURPOSE

To retrospectively compare recall and cancer detection rates between immediate and subsequent batch methods for interpretation of screening mammograms.

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was waived. Retrospective analysis was performed for 8698 screening mammograms obtained between January 1 and October 31, 2001, which were interpreted either immediately (n = 4113) or subsequently with batch method (n = 4585). Data were collected from data reporting system and patient billing records. Patients with high risk factors were excluded; 3441 patients were in the immediate group, and 3932 were in the batch group. The two groups were compared with respect to age, breast density, and availability of comparison films with Wilcoxon rank sum test. Recall rates and cancer detection rates for each group were determined and compared with Pearson chi(2) test; false-negative rates were compared with Fischer exact test.

RESULTS

A significant difference (P < .001) was noted in recall rates between immediate (18%) and batch (14%) groups; however, no significant difference (P = .7) was noted in cancer detection rates (immediate, 0.5%; batch, 0.4%). Mean age of patients was 56.8 years (age range, 21-96 years) in the immediate group and 56.2 years (age range 24-98 years) in the batch group (P = .02). Comparison of breast densities between groups indicates no statistically significant difference (P = .4). The batch group had significantly fewer comparison mammograms (3106 [79%]) available than the immediate group (2856 [83%]) (P < .001). There was no significant difference in false-negative rates between the immediate group (0.1%) and the batch group (0.1%) (P > .99).

CONCLUSION

Immediate interpretation of screening mammograms resulted in a statistically significant increase in recalls and additional clinical work-ups of perceived abnormalities; however, no significant difference in cancer detection rate was detected between groups.

Poor patient comprehension of abnormal mammography results

BACKGROUND

Screening mammography for women 50 to 69 years of age may lead to 50% having an abnormal study. We set out to determine the proportion of women who understand their abnormal mammogram results and the factors that predict understanding.

METHODS

We surveyed 970 women age 40 to 80 years identified with abnormal mammograms from 4 clinical sites. We collected information on demographic factors, language of interview, consultation with a primary care physician, receipt of follow-up tests, and method of notification of index mammogram result. This study examines the following outcomes: the participant's report of understanding of her physician's explanation of results of the index mammogram, and a comparison of the radiology report to the participant's report of her index mammogram result. Multivariate models controlled for age, education, income, insurance status, and clinical site.

RESULTS

The majority (70%) reported a "full understanding" of their physician's explanation of their abnormal mammogram, but a significant minority (30%) reported less than a full understanding (somewhat, not at all, did not explain). Among women of Asian ethnicity, only 63% reported full understanding. Asian ethnicity was a negative predictor (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.3 to 0.7), and consultation with a primary care physician was a positive predictor (OR, 2.3; 95% CI, 1.7 to 3.3) of reported full understanding. Of the 304 women with a suspicious abnormality, only 51% understood their result to be abnormal. Women notified in person or by telephone were more likely than women notified in writing to understand their result to be abnormal (OR, 2.3; 95% CI, 1.2 to 4.8).

CONCLUSION

Almost half of women with the most suspicious mammograms did not understand that their result was abnormal. Our data suggest that direct communication with a clinician in person or by phone improves comprehension.

Professional and economic factors affecting access to mammography: A crisis today, or tomorrow?

BACKGROUND

Objective data and anecdotal reports have suggested that access to mammography may be declining because of facility closures and difficulty in recruiting and retaining radiologists and radiologic technologists. To gain insight into the practice patterns, use of emerging technologies, and concerns of breast imagers in current practice, the Society of Breast Imaging (SBI) conducted a national survey of breast imaging practices in the U.S.

METHODS

Between October 2003 and April 2004, the SBI conducted a survey of the SBI membership database, and received completed surveys from 575 breast imaging practices in the U.S. Responses to the survey regarding practice characteristics, the utilization of standard and emerging technologies, staffing, malpractice, finance, and morale were analyzed.

RESULTS

Job vacancies for radiologists who read mammograms were reported in 163 practices (29%), 59 of which (10%) had 2 or more openings. A higher proportion of practices with job openings had long appointment waiting times for asymptomatic women when compared with fully staffed practices. Unfilled fellowship positions also were common, with 41 of 65 practices that offer fellowships reporting 47 openings. Among 554 responding practices, 55% reported that someone in their practice was sued because of a mammography related case within the past 5 years, and 50% of practices reported that the threat of lawsuits made radiologist staffing "moderately" or "a lot" more difficult. Of 521 responding practices, 35% reported financial losses in 2002. One in 5 respondents reported that they would prefer to spend less time in mammography, and fewer than 1 in 3 would recommend a breast imaging fellowship to a relative or friend. Emerging technologies, such as breast magnetic resonance imaging and screening ultrasound, currently are being performed in many practices.

CONCLUSIONS

The survey results provide support for anecdotal reports that breast imaging practices face significant challenges and stresses, including shortages of key personnel, a lack of trainees, malpractice concerns, financial constraints, increased workload due to emerging technologies, low appeal of breast imaging as a career specialty, and the steady rise in the population of women of screening age.

Adverse effects of screening mammography

The main risks and other adverse consequences from screening mammography include discomfort from breast compression, patient recall for additional imaging, and false positive biopsies. Although these risks affect a larger number of women than those who benefit from screening, the risks are less consequential than the life-sparing benefits from early detection. Radiation risk, even for multiple screenings, is negligible at current mammography doses. Anxiety before screening or resulting from supplementary imaging work-up, short-term follow-up, cyst aspiration, and biopsy has not dampened the enthusiasm of most women for the value of early detection.

Breast imaging flow models

Economically efficient and clinically effective breast imaging can be achieved through combinations and permutations of four fundamental breast imaging flow models: (1) the traditional flow model, (2) the online flow model, (3) the women's imaging flow model, and (4) the combination-care flow model. The structure, strengths, and weaknesses of these four individual breast imaging flow models are described and compared.

Patient expectations and costs of immediate reporting of screening mammography: talk isn't cheap

OBJECTIVE

Our purpose was to determine whether patients prefer immediate or delayed results of screening mammography and to determine the cost of immediate reporting at our institution.

MATERIALS AND METHODS

A survey was anonymously and randomly distributed to 129 women who were 35-70 years old during a visit to their primary care physician, asking the women's preference for receiving mammography results by one of two systems: by letter with a return visit for any additional tests; or by speaking at once with the radiologist, with the option of additional tests being performed during the same visit. Patients' willingness to pay for the latter service was also determined. A cost identification model was constructed using commercially available software. We considered the impact on radiologists' and technologists' time and the need for additional equipment and space, and we analyzed the effect on the cost of immediate reporting.

RESULTS

One hundred twenty (93%) surveys were completed. Eighty women (67%) preferred immediate reporting, and 62 (78%) of these 80 patients would wait 30-60 min. The additional cost of immediate reporting is $28.22 per patient. Only 11% of patients were willing to pay this additional cost. When new equipment and space were not required, the cost would increase by $4.38. This cost was most influenced by the time required to give patients normal results.

CONCLUSION

Most surveyed patients preferred speaking with a radiologist immediately but were unwilling to pay additional fees. Radiologists, hospital administrators, and health care planners must be aware of the costs of immediate reporting and must factor these costs into any change in hospital or national policy.