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Bassett LW, Hendrick RE, Bassford TL. Quality Determinants of Mammography. Rockville (MD): Agency for Health Care Policy and Research (AHCPR); 1994 Oct. (AHCPR Clinical Practice Guidelines, No. 13.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Quality Determinants of Mammography

Quality Determinants of Mammography.

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4Activities After the Examination

Communicating Results

Recommendation: The referring health care provider and the interpreting physician should be sensitive, supportive, and appropriate in communicating results, as well as prompt and accurate. (B)

Strong Recommendation: An appropriate professional at the mammography facility, usually an interpreting physician, should send the woman's health care provider a written report documenting the specific findings, followup recommendations, and the name of the interpreting physician. The facility should directly telephone the referring provider if the result is suspicious for cancer. (B)

Strong Recommendation: The mammography facility personnel should give the woman written notification of the results of her mammography and other breast imaging, either on site or by mail. The results should be in simple language, document the name of the interpreting physician, be given in a timely fashion, and include further steps to be taken. (B)

Recommendation: If a facility accepts women who have no health care provider, facility personnel should give the woman a list of qualified providers who are willing to provide care. The name, address, and phone number of the provider chosen should be recorded, if possible. (C)

Strong Recommendation: The facility personnel should directly telephone the woman who has no health care provider if the result is suspicious for cancer. (B)

Many women believe that mammography results are normal if they are not contacted after their examination. This impression that "no news is good news" can have serious adverse consequences for women with an abnormal examination. The interpreting physician, the referring health care provider, and the woman are all responsible for ensuring that mammography results are communicated in an effective and timely manner and that recommendations are carried out. Timely communication is necessary whether results are normal or abnormal Table 3

Table 3. Reporting the results by mammography facility.

Table

Table 3. Reporting the results by mammography facility.

An increasing number of mammography facilities have begun to report both normal and abnormal results directly to the woman. This can be accomplished without disrupting the woman's relationship with her referring provider. Studies have shown that direct communication of results to the woman by the mammography facility produces a dramatic improvement in compliance with followup recommendations (Cardenosa and Eklund, 1991; Monsees, Destouet, and Evens, 1988; Rubin, Frank, Stanley et al., 1990). To be most effective, results should be presented clearly and promptly (Aalders and Schade, 1991; Bird and McLelland, 1986; Dershaw, Liberman, and Lippin, 1992; Kessler, Rimer, Devine et al., 1991; Monsees, Destouet, and Evens, 1988; Rubin, Frank, Stanley et al., 1990). Traditional communication procedures, where the facility communicates only with the referring provider, result in inadequate compliance with followup recommendations (Robertson and Kopans, 1989).

Communicating normal results directly to the woman as soon as possible eliminates anxiety, reinforces the woman's role as a responsible participant in the process, reminds the woman of the importance of regular screening, and is a quality assurance safeguard. Effective communication is most crucial when results are abnormal and additional imaging or other followup is required. If findings are abnormal, the written results should detail steps the woman should take next.

Problems in communicating abnormal results have included confusion concerning the appropriate steps to be taken; inappropriate or insensitive communication, resulting in avoidable anxiety and confusion; delay in receipt of results; and failure to communicate results to the woman at all-for example, when reports are misfiled or filed unread. These problems have caused delays in diagnosis and treatment, with consequences that include limited treatment options and death (Brenner, 1992a and 1992b; De Neef and Gandara, 1991; Robertson and Kopans, 1989; Unger, 1990). Providing results directly to the woman is a sound risk-management procedure, reducing the prospect of medicolegal complications for both the interpreting physician and the referring health care provider (Rubin, Frank, Stanley et al., 1990.)/P>

Any written communication must have language that is carefully constructed to impart results without causing undue anxiety, to promote a relationship between the woman and a health care provider, and to encourage the woman to take the next step. Examples of letters communicating results directly to women are shown on the following pages. These are only examples. They should be adapted to local populations in a manner that is sensitive to cultural diversity and to prearranged protocols between the mammography facility and the referring provider. Examples of communication of normal results are shown in a short form in Sample Letter A and in a longer version in Sample Letters B (for a screening mammogram) and C (for a diagnostic mammogram). Examples of communication of an abnormal result with a recommendation for short-interval followup are shown in a brief form in Sample Letter D and a longer version in Sample Letter E. Examples of notification to women of abnormal results with a recommendation for additional imaging or biopsy are shown in brief form in Sample Letter D and in longer form in Sample Letters F and G.

Mammography facilities may accept self-requesting and self-referred women for mammography. Interpreting physicians have additional responsibilities for ensuring the effective communication of results for these women.

  • Self-requesting woman. This woman comes for mammography on her own initiative but is able to name a personal physician or health care provider. Whether the woman is having screening or diagnostic mammography, the interpreting physician should document that the designated provider accepts responsibility for the woman's breast care before sending the mammography report. In cases where the provider declines to accept the mammography report from the mammography facility, the facility should treat the woman as if she were self-referred.
  • Self-referred woman. This is a woman who comes for mammography but has no personal health care provider or for whom the provider declines responsibility. Whether the woman is having screening or diagnostic mammography, the interpreting physician assumes responsibility for the woman's breast care, including education, physical examination, and communication of mammography results directly to the patient in understandable language. Mammography facility personnel should give the woman a list of qualified providers. If the woman chooses a provider from a list provided by the mammography facility, the interpreting physician should ensure that the chosen clinician will assume responsibility for the woman's breast care. Although self-referral has improved access to mammography, it has increased the responsibilities of the interpreting physician and created more possibilities for failure to communicate abnormal results.

Strong Recommendation: At the time of the examination, mammography facility personnel should inform all women of the time period in which they will receive their results and of the possibility that prior films may need to be obtained. The woman should also be instructed to call the mammography facility or her health care provider if she does not receive her results within the stated time period. The facility should report results to the woman's provider and to the woman within the shortest practical time period. (B)

Recommendation: The facility should use its best efforts to send a report to the referring health care provider and to send results to the woman as soon as possible, usually within 10 business days. The reporting period should not exceed 30 days. (B)

Strong Recommendation: The interpreting physician or designee should telephone the results of an abnormal examination that requires needle or open biopsy to the referring (or designated) health care provider's office in a timely manner. (B)

Recommendation: The interpreting physician or designee should telephone the results of an abnormal examination that requires additional views and/or ultrasonography in a timely manner to the referring (or designated) health care provider's office. (B)

Option: The interpreting physician or the referring (or designated) health care provider may telephone the woman directly to explain abnormal findings, their significance, and recommended next steps. (B)

Mammography facility personnel should telephone the referring or designated health care provider because the written report may not reach the provider or may not arrive in time for the provider to respond to questions from the patient. A telephone call also enables the provider to ask questions about the report and to discuss followup options with the interpreting physician (Brenner, 1992b; Cardenosa and Eklund, 1991; Dershaw, Liberman, and Lippin, 1992; McLelland, 1987; Monsees, Destouet, and Evens, 1988; Robertson and Kopans, 1989; Rubin, Frank, Stanley et al., 1990).

When mammography results are abnormal, a telephone call to the woman's designated health care provider before a report is sent may identify and resolve any vagueness in the provider-patient status. For a self-requesting woman with an abnormal finding, this call will significantly reduce the chance that she will slip through the cracks.

If the woman does not have a provider or if the provider declines to accept the report, the interpreting physician or designee should call the woman directly to explain the result and the recommended next steps. This telephone communication is in addition to the written report and should offer the option to have the results explained in person. Information should not be left on an answering machine or given to another individual without the woman's express prior permission. Particularly for the woman without a referring provider, the mammography facility may choose to send written notification of abnormal results by certified mail or with return receipt requested. Mammography facility personnel should document the communication to the referring provider or the woman in the woman's medical record. Recommended reporting is outlined in Table 3. For more information on the communication responsibilities of the interpreting physician, see Chapter 6.

Followup, Tracking, and Monitoring

The primary concern in monitoring and tracking of women with normal results is compliance with regular screening guidelines. The responsibility for that effort should lie with the woman's health care provider, who interacts regularly with the woman and can inform her of the schedule appropriate for her. Ultimately, the responsibility for compliance with screening guidelines lies with the woman herself (Aalders and Schade, 1991).

Option: Women may be sent a reminder before their next appropriate screening date. (B)

For referred and self-requesting women, this reminder may be communicated by the referring health care provider rather than by the mammography facility, according to prearranged protocols. If a woman does not have a health care provider, the mammography facility is responsible for monitoring and tracking.

Both written reminders (personal letter or postcard) to the woman and facilitated scheduling during an office visit increase use of screening mammography (Chambers, Balaban, Carlson et al., 1989; Hurley, Jolley, Livingston et al., 1992; Nattinger, Panzer, and Janus, 1989; Wolosin, 1990). Computerized patient records that prompt physician compliance with screening recommendations also have a positive effect on patient referral to mammography (Harris, O'Malley, Fletcher et al., 1990; McDonald, Hui, Smith et al., 1984; McPhee, Bird, Fordham et al., 1991). Computerized patient records and computer-generated letters offer efficiencies in many practice settings (Gann, Melville, and Luckman, 1993; Haug, Tocino, Clayton et al., 1987; Payton, 1991). Other approaches may be needed to increase the use of screening mammography by low-income and non-English-speaking patient populations (Coll, O'Connor, Crabtree et al., 1990; Lacey, Phillips, Ansell et al., 1989; Lane, Polednak, and Burg, 1992; Lovejoy, Jenkins, Wu et al., 1989; Stein and Fox, 1990; Vernon, Vogel, Halabi et al., 1992).

Strong Recommendation: The primary responsibility for communicating a recommendation for short-interval followup, diagnostic mammography, or adjunctive diagnostic procedures rests with the referring health care provider or, for women without a provider, with the mammography facility. (B)

For women without a health care provider, the mammography facility that performed the initial mammography examination should be responsible for performing or arranging for the future examination or the immediate additional views and/or procedures to be performed. This should be followed by onsite consultation with the woman or prompt communication by mail to report the results and recommended next steps. The woman herself is responsible for complying with followup recommendations. However, it is important that she receive written results and recommendations in lay language using culturally relevant terms.

When the health care provider named by the woman does not accept the report, the mammography facility should treat the woman as if she does not have a provider and should assist her in identifying a provider who will accept her as a patient and to whom all reports should be sent. Important issues to the patient in identifying a provider are location, hours of operation, transportation, cost, and acceptance of insurance, Medicaid, or Medicare.

Strong Recommendation: The referring health care provider is responsible for the followup, monitoring, and tracking of the woman whose result is abnormal and for whom a biopsy is recommended. The mammography facility should assist self-referred women in finding a health care provider who will assume followup responsibility. (B)

A recommendation that biopsy be considered introduces the involvement of other medical specialists and additional considerations that are best evaluated, discussed, and decided upon by the patient and her health care provider, with the interpreting physician providing consultative support. Decisions about referrals to appropriate medical personnel, such as a surgeon, should be made by the woman in consultation with her provider.

The mammography facility should maintain a tracking system to monitor patient compliance with recommendations for biopsy. Compliance may be monitored through direct communication with the woman's referring or designated health care provider.

The interpreting physician and other mammography facility personnel should continue to be available to the woman and her provider to discuss the interpretation of abnormal findings. Both the woman's provider and the mammography facility should implement tracking systems, which have been shown to improve patient compliance with followup recommendations (Aalders and Schade, 1991; Chambers, Balaban, Carlson et al., 1989; Elsenhans, 1991; Haug, Tocino, Clayton et al., 1987; Monticciolo and Sickles, 1990; Robertson and Kopans, 1989).

Option: The mammography facility may choose to schedule and track recommended followup breast imaging examinations. If so, the mammography facility should clearly communicate this arrangement to the referring health care provider and notify the referring health care provider if the woman does not comply with the followup recommendation. (C)

Recommendation: Recommended diagnostic mammography, including additional views and recommended adjunctive diagnostic procedures, should be performed by the mammography facility as soon as possible. If the mammography facility does not schedule these additional procedures directly with the woman, it should contact the woman's health care provider with information about the abnormal result and recommended followup. (C)

The performance of additional mammographic views is not considered a medical emergency. Nonetheless, additional views and adjunctive diagnostic procedures should be done as soon as possible-at least within 1 month.

Facilities that have only screening services provide an important and cost-efficient service to asymptomatic women, most of whom do not need additional diagnostic imaging. However, quality care is facilitated by immediate, onsite performance of additional studies made necessary by an abnormal screening mammogram. Assistance with scheduling necessary additional studies facilitates the highest compliance with followup of breast imaging recommendations (Cardenosa and Eklund, 1991; Monsees, Destouet, and Evens, 1988; Rubin, Frank, Stanley et al., 1990).

There are some reports that Medicare regulations (Department of Health and Human Services, 1990) may be interpreted to prevent immediate diagnostic followup of an abnormal screening mammogram, especially in cases where the woman is self-referred or self-requesting. However, this interpretation of Medicare regulations is not correct. Medicare covers immediate diagnostic followup of problems identified in a screening mammogram. The panel recommends that the Health Care Financing Administration regional or central offices be notified about any problems identified in this regard. Interpreting physicians should document that a finding present on the screening examination required additional imaging before a diagnosis could be made.

Mammography Report

Strong Recommendation: The official mammography report should be arranged with a brief initial statement concerning the reason for the examination, followed by a description of the breast composition, a description of significant findings, a statement regarding comparison with prior examinations, and an impression that should include overall assessment and recommendations. The report should use standardized terminology. (B)

Breast composition may be described as (1) almost entirely fat; (2) there are scattered fibroglandular densities that could obscure a lesion on mammography; (3) breast tissue is heterogeneously dense, which may lower the sensitivity of mammography; (4) breast tissue is extremely dense, which lowers the sensitivity of mammography. An implant code should be added if an implant is present. Description of findings should use standardized terminology:

  • Masses-describe:
  • Shape
  • Margin characteristics
  • Density
  • Location (clock face)
  • Size
  • Calcification-describe:
    • Element morphology
    • Distribution
    • Location (clock face)
  • Other-describe:
    • Architectural distortion
    • Asymmetry
    • Skin and/or nipple retraction
    • Skin and/or trabecular thickening

A concise and understandable report increases the use of screening and diagnostic mammography (Hindle, 1991). The American College of Radiology (ACR) has developed a Breast Imaging Reporting and Data System (BI-RADS[trademark]) containing standardized terminology and recommendations (Kopans, 1992a; Kopans and D'Orsi, 1992; Kopans, D'Orsi, Adler et al., 1993). Using this terminology, three experienced interpreting physicians produced almost identical receiver operator characteristics curves on 300 test cases (D'Orsi, Getty, Swets et al., 1992). Uniform terminology with a structured delivery should eliminate confusion in communicating results (D'Orsi and Kopans, 1993; Homer, 1984; Kopans, 1992a; Kopans and D'Orsi, 1992; Sierra, Bisesi, Rosenbaum et al., 1992).

Strong Recommendation: Any clinical question raised by the referring health care provider should be addressed in the report. (B)

This represents good medical practice and is universally accepted. Clinical concerns usually relate to a palpable, focal, asymmetric mass or area in the breast, nipple discharge, focal persistent pain, and nipple or skin change. Radiopaque markers such as BBs placed on focal, palpable findings or areas of localized pain may enhance further patient management. Nipple discharge or skin and/or nipple change do not require markers, but a statement in the report indicating the presence (or absence) of mammography findings that support (or do not support) the clinical impression is helpful. Ductography may be helpful in identifying intraductal lesions. If no findings are present on the mammograms when clinical findings are evident, a statement should be added urging the clinician to address these areas of clinical concern independent of mammography results.

Strong Recommendation: The mammography report should include an overall assessment of the findings and recommendations for further action, if warranted. (B)

The report should include one of the assessments and recommendations for future action listed below, as warranted:

  • Needs Additional Evaluation (A)-This may take the form of additional mammographic views and/or ultrasonography or other procedure.
  • Negative (N)-(Routine followup.) Nothing to comment on. If there is a clinical finding, a statement indicating that this finding should be dealt with independently of the negative mammogram should be added.
  • Benign Finding (B)-(Routine followup.) Also negative, but the interpreting physician may wish to describe a typically benign finding: e.g., calcified fibroadenoma.
  • Probably Benign Finding (P)-Short-interval followup suggested. A finding with a very high probability of being benign and not expected to change over the followup interval.
  • Suspicious Finding (S)-Biopsy should be considered. A finding without the characteristic morphology of breast cancer but having a definite probability of being malignant.
  • Highly Suggestive of Malignancy (M)-Appropriate action should be taken. These findings have a high probability of being cancer.

These assessments and recommendations are from the American College of Radiology's Breast Imaging Reporting and Data System, or BI-RADS[trademark] (Kopans, D'Orsi, Adler et al., 1993). A classification system will aid in patient management, increase use of mammography, and instill confidence in both patient and clinician. The clear description of levels of confidence for the presence of malignancy, as outlined in the assessment scales, can aid understanding of the report, enhance effective assignment of patients, and simplify long-term tracking (Kemp and Jackson, 1987; Rosenbaum, 1990; Schutte, 1985).

Results of second-opinion examinations should be treated the same as results of diagnostic examinations. A report should be sent to the health care provider and results passed on to the woman. If the results of the first report and second opinion are substantially different and will affect the woman's further care, this should also be communicated directly to the health care provider. If an oral second opinion is given to the referring health care provider, a brief note in a log documenting the interchange may be prudent. The note should include the name of the original facility, the determination, whether the impression is substantially different, and recommendations.

Option: A computer system is not required for implementation of any guideline recommendations. However, the use of a computer system is encouraged to facilitate data collection and tracking of women. (B)

For any system to be useful it must be reliable and easy to use (Baron and Strange, 1990; Robbins, Vincent, Shaffer et al., 1988). A coding system will ease production of computerized reports and greatly simplify quality assurance. It will also facilitate comparison of data among interpreting physicians and help highlight areas requiring further training (American College of Radiology, 1993a; Bramble, Chang, and Martin, 1989).

Recordkeeping

Recommendation: The interpreting physician should keep data on each patient that cover patient characteristics, mammography and other breast imaging, mammography interpretation and reporting of results, and other information such as whether a biopsy was recommended. (C)

This information can be collected before, during, and after the mammography examination. It should be kept in the form of a medical record for that patient. Information retention permits a better mammography audit, boosts confidence in accuracy of interpretation, increases the likelihood of compliance with recommendations for followup and/or subsequent management (Elsenhans, 1991; Monticciolo and Sickles, 1990; Sickles, 1990a and 1992), encourages women and physicians to follow guidelines for screening (Sickles, 1990b; Tocino, 1989), and encourages third-party payers to reimburse for screening mammography (Clark, King, and Worden, 1989; Haug, Tocino, Clayton et al., 1987; Laszlo, 1985).

The following data can be included:

  • Patient-related data:
  • Demographic (age, race, ethnicity, sex).
  • Prior mammography (date, location).
  • Patient's personal history (cancer risk profile-history of prior breast cancer, date, treatment; history of prior breast surgery, date, outcome, hormonal status).
  • Family history relevant to breast cancer (first-degree relative; pre- or post-menopausal).
  • For a diagnostic study, pertinent clinical data (complaints, symptoms, clinical breast examination results).
  • Mammography and other breast imaging data:
  • Whether a screening or diagnostic examination was performed.
  • Which technologist performed the mammogram.
  • Whether or not comparison was made with a prior study.
  • For a diagnostic study, what diagnostic views or imaging procedures were performed.
  • Mammography interpretation and reporting data:
  • Film interpretation, report.
  • For a diagnostic study, what specific attention was paid to the area or breast for which abnormal clinical breast examination results were found by the referring health care provider.
  • Recommendation for further followup (if indicated).
  • Documentation of reporting (including the date the report was sent or communicated): written report or recommendation to the referring health care provider; written report, letter, or recommendation to the patient; any telephone communications.
  • Other data:
  • Patient education offered or given.
  • Date for followup or next screening examination.
  • For biopsy, pathology report, surgical outcome, and staging information.

OPTION: Retaining information in a computerized format has been promoted in the recent literature, but other formats permitting ease of access and retrieval may also be acceptable. (C)

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