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Workforce Shortage in Breast Imaging (.ppt) Opens in new window.

  1. 1. Addressing the Workforce Shortage in Breast Imaging Barbara Monsees, M.D. St. Louis, MO
  2. 2. Breast Cancer Common disease Public health problem of growing magnitude (as the population ages) No health behavior known to either cause or prevent the disease Early detection plays a pivotal role in control of this disease more favorable stage distribution & decrease in breast cancer death rate
  3. 3. ACS Breast Cancer Screening Guidelines May 2003 Yearly screening mammograms starting at age 40, continuing as long as in good health High risk women should discuss screening Beginning earlier More frequently Using US or MRI, in addition to mammography
  4. 4. Mammography Screening is Widely Accepted by American Women Tolerant of recalls & biopsies for benign disease Eager for new or additional screening techniques for breast cancer, especially for high risk women
  5. 5. Long wait times reported in the media Long waits are not acceptable to women or public health officials
  6. 6. Like it or not: There is no better screening technique on the horizon Mammography screening will remain the mainstay of breast cancer control for the forseeable future If we aren’t proactive, organized and methodical, we will lose the ground that we have gained against this disease
  7. 7. Breast Imaging Workforce Shortage Growing target population Additional workload, same workforce Image guided needle biopsies Increased use of US and MR Other technologies? Workforce instability Fewer entrants to the field Individuals retiring Poor reimbursement Medicolegal liability
  8. 8. There is no organized network for mammography screening in the U.S. Quality has improved but is still quite variable Usual market forces will not solve this problem, because there are too many disincentives to offering the service
  9. 9. Projected Trends in the Size of the Population of U.S. Women by Age Cohort Each year, the size of the population of U.S. women of mammography screening age increases by 1.25 million. Source: U.S. Census, Series P-25
  10. 10. Yearly mammography volumes in millions (60% compliance)
  11. 11. 0 20 40 60 80 100 120 140 160 1975 1978 1981 1984 1987 1990 1993 1996 1999 Breast Cancer, 1973-2000Breast Cancer, 1973-2000 SEER Age-Adjusted Rates,SEER Age-Adjusted Rates, 9 Registries9 Registries WhiteWhite ALLALL BlackBlack BlackBlack WhiteWhite Incidence Mortality
  12. 12. 0 10 20 30 40 50 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Disparities in U.S. Breast Cancer Mortality Reduction SEER Age Adjusted Rates 1990-2000 WhiteWhite BlackBlack HispanicHispanic AsianAsian American IndianAmerican Indian
  13. 13. US Mammography Use by Age & Poverty Status 0 10 20 30 40 50 60 70 80 1987 1990 1991 1993 1994 1998 1999 2000 Below Poverty At or above Poverty 40-49 years 0 10 20 30 40 50 60 70 80 90 1987 1990 1991 1993 1994 1998 1999 2000 50-64 years 0 10 20 30 40 50 60 70 80 1987 1990 1991 1993 1994 1998 1999 2000 65 years & older CA Cancer J Clin 2003;53:342-55
  14. 14. GAO Report U.S. General Accounting Office April, 2002 (GAO-02-532) The work for the report performed from June 2001 through March 2002.
  15. 15. Mammos increased 15% (35 to 40 million) Facilities decreased 5% Machines increased 11% RT’s (able to perform mammos) increased 21% “increase in mammography equipment and personnel has been sufficient to meet the increase in demand…” General Trends…GAO Report GAO-02-532GAO-02-532
  16. 16. State and local officials frequently raised concerns about the adequacy of the Medicare reimbursement rate. Many radiology practices state that recent modest increases in reimbursement don’t cover the actual costs of practice. GAO-02-532GAO-02-532
  17. 17. Most availability problems in certain metropolitan areas Increase in demand, capacity declined High demand at some facilities • Reputation • Referral patterns • Large workload due to public assistance programs • Restrictions due to insurance coverage GAO-02-532GAO-02-532
  18. 18. GAO on Personnel “last few years show a substantial decline in the number of new entrants to the fields” Personnel includes radiologists and radiologic technologists GAO-02-532GAO-02-532
  19. 19. Mammography Technologists Job physically challenging Bend, lift, reach, on feet all day Work closely with anxious patients Expected to do large volume per day More paperwork and QC
  20. 20. Data limited regarding the number currently interpreting mammograms FDA database unable to determine the total number of radiologists who are qualified under MQSA and currently interpreting How many radiologists interpret mammograms?
  21. 21. How many radiologists interpret mammograms? How many are specialists? 2002/2003, ACR sent member record update requests to 16,147 paying members 56% responded (9,048) 54% general radiologists reported doing mammography (4,924) 7% members reported being specialists in mammography (654) Self-reported info from respondents: 12% of radiologists interpreting mammograms are specialists
  22. 22. Society of Breast Imaging 82 Fellows of Society 1457 General members Membership requires board certification and an interest in Breast Imaging
  23. 23. Radiology Fellowship Match, Active Programs June 4, 2003, Appointment Year 2004-05 POSITIONS # Filled Unfilled All Programs 769 411 (53%) 358 (47%) Breast/Women’s Imaging 48 12 (25%) 36 (75%) BI/WI represents only 6% of positions in the match. Only 25% of positions were filled, representing only 3% of filled fellowships.
  24. 24. 20 minute telephone survey 4th or 3rd year residents who had completed rotations in BI Questions addressed: Training Attitudes about mammography Interest in performing BI in the future Attitudes of Radiology Residents Regarding Breast Imaging (BI) Survey: 211 of 224 accredited US programs Bassett et al, Radiology….2003
  25. 25. Compare interpreting mammography to CT of the abdomen with contrast
  26. 26. Resident responses as % of total Concern about missing a potentially important finding
  27. 27. Resident responses as % of total Concern about making appropriate recommendation to referring physicians
  28. 28. Resident responses as % of total Concern about malpractice liability
  29. 29. Compare interpreting mammography to “other types of imaging examinations”
  30. 30. Resident responses as % of total Rate the stress levels associated with possible misdiagnosis
  31. 31. Resident responses as % of total Rate patient stress related to the exam
  32. 32. Resident responses as % of total Mammography should be interpreted by breast imaging subspecialists
  33. 33. Resident responses as % of total …like to spend >25% of your time interpreting mammograms when in practice
  34. 34. Resident responses as % of total If not, what are the reasons?
  35. 35. Performance Parameters for Screening and Diagnostic Mammography: Specialist and General Radiologists Sickles et al, Radiology 2002;224:861-869 Abnormal rate CA detection rate* Stage 0-1 CA detection rate* SCR recall % DX rec bx % SCR DX SCR DX Specialists 4.94.9 15.815.8 6.06.0 59.059.0 5.35.3 43.943.9 Generalists 7.17.1 9.99.9 3.43.4 36.636.6 3.03.0 27.027.0 *Number per 1000
  36. 36. Expertise reflects complex multifactorial process Specialist vs General Radiologists Training, experience, talent Quality feedback Auditing Multidisciplinary conferencing Double reading Reading a high volume of films Specialty breast center Has all of the above CME
  37. 37. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography 110 radiologists interpreted the same enriched set of screening mammograms (64 CA’s/148 mamms) Participants from randomly sampled facilities Analyzed implications if the U.S. limited workforce by accuracy Beam et al, Radiology 2003;229: 534-540
  38. 38. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography Beam et al, Radiology 2003;229: 534-540 Accuracy # Radiologists Service Capacity CurrentCurrent 20,00020,000 Increase 1%Increase 1% -2,200-2,200 -10%-10% Increase 5%Increase 5% -6,000-6,000 -25%-25% Increase 10%Increase 10% -11,400-11,400 -50%-50% Analyzed implications if the U.S. limited the workforce by accuracy
  39. 39. How can we measure interpretive skills & performance? Self-assessment testing? Is there a valid test? Volume requirement? More CME? Can audit data be used? Numbers too small in low volume practices Audit results will vary by institution • Nature of practice may vary!
  40. 40. Audit data needs to remain non-discoverable Discoverability a big issue Will provide further disincentive to radiologists to interpret mammograms Lawsuits already burdensome
  41. 41. ACR Practice Cost Survey: Spring 2001 Screening Mammography 37 practices surveyed; 21 responded Data from 37 different hospital & office sites 15 hospitals, 22 offices/freestanding 253,000 screening mammograms Average number units • Hospitals responding = 4.5 • Offices responding = 2.1 • Average number units/facility in U.S. = 1.5
  42. 42. ACR Practice Cost Survey: Spring 2001 Screening Mammography Costs: Clinical staff, supplies, equipment, indirect costs Included, but not part of survey: ACR accreditation fee (per unit) FDA inspection (annual) Physician work based on 2 methods
  43. 43. Screening MammographyScreening Mammography Reimbursement vs CostsReimbursement vs Costs Medicare (2004) $80.94 Medicaid (varies by State) $ ** 20012001 Cost at Hospital Facility $124.54$124.54 ** 20012001 Cost at Office Facility $86.60$86.60 *ACR survey, Spring 2001*ACR survey, Spring 2001
  44. 44. Operational costs are higher at hospital facilities Most Medicare patients get their mammograms at hospital facilities Most teaching facilities are at hospitals Trainees see stressed staff & hear tales of economic woes Trainees get to choose what field to enter!
  45. 45. Providing Professional Mammography Services: Financial Analysis 7 university-based programs: all incurred professional losses due to diagnostic mammograms & breast US Economic disadvantage to breast centers with a good reputation: higher proportion of difficult diagnostic & outside mammograms and US Enzmann et al, Radiology 2001;219:467-473 To break even on diagnostic mammos: Revenue must go up 143% RVU’s need adjustment by factor of 2.95
  46. 46. Providing Professional Mammography Services: Financial Analysis (cont’d) Growth in screening is followed by growth in diagnostic mammography Breast centers with a good reputation will have a higher proportion of diagnostic mammograms and difficult outside mammograms. Both are provided at a financial loss. There are economic disincentives to concentrate high- quality mammography talent. Enzmann et al, Radiology 2001;219:467-473
  47. 47. CAD is reimbursed, but double reading is not!
  48. 48. Cost to Facility to Meet MQSA Requirements Written notification of results to patients, (estimated @ $0.94 per examinee notification Medical audit: acquire & maintain data, and analyze patient outcomes Regular quality control tests, including related non-mammography equipment Annual physicist fees and survey Accreditation fee FDA inspection $1,749 for one facility & one unit $204 for each additional unit Follow-up inspection fee = $991 (States can charge an additional fee)
  49. 49. PIAA Breast Cancer Study, Spring 2002: study of 450 current paid cases #1 condition for which patients file a medical malpractice claim Radiologists most frequent defendants 2nd most expensive condition in terms of indemnity 88% of patients had at least one mammogram 80%, 1st mammo was negative/equivocal
  50. 50. SpecialtySpecialty #Claims PaidClaims Averageindemnity($1000’s) Totalindemnity($millions) RadiologistsRadiologists 242242 184184 346346 63.763.7 Ob/GynOb/Gyn 167167 133133 369369 49.049.0 CorporationsCorporations 8787 3737 265265 9.89.8 Surgical specialtiesSurgical specialties 7878 6262 334334 20.720.7 FP/GPFP/GP 6262 5252 309309 16.016.0
  51. 51. PIAA: Physician Associated Issues 1995 vs 2002 1995 2002 Mammogram misreadMammogram misread 22.7%22.7% 37.8%37.8% Negative mammogram reportNegative mammogram report 25.8%25.8% 35.1%35.1% Physical findings failed to impressPhysical findings failed to impress 35.5%35.5% 28.7%28.7%
  52. 52. Repercussions from Malpractice Crisis on Mammography Practice Lawsuits, even unsuccessful ones, are a reason that radiologists will not agree to interpret mammograms The threat of malpractice causes radiologists to overcall, causing: More recalls for evaluation More biopsies for benign disease
  53. 53. When radiologists practice defensive medicine, more women…. Get unnecessary breast work-ups Have unnecessary biopsies And, the cost of medical care increases
  54. 54. Do radiologists who interpret mammogramsDo radiologists who interpret mammograms pay higher malpractice premiums?pay higher malpractice premiums? Asked for quotes with and without mammoAsked for quotes with and without mammo 4 companies presented rates to one4 companies presented rates to one Connecticut practiceConnecticut practice As reported in Hartford Courant, source Alan Kaye, MD,As reported in Hartford Courant, source Alan Kaye, MD, Chair Radiology, Bridgeport HospitalChair Radiology, Bridgeport Hospital Rate without mammo: 1) 14% less 2) No difference 3) 29.5% less 4) 17% less
  55. 55. What is the answer for the future? Remember the mission: minimize the morbidity and mortality from breast cancer We need “ways, including incentives, to ensure that sufficient numbers of adequately trained personnel at all levels are recruited and retained to provide quality mammography services”
  56. 56. MQSA being reviewed by GAO & IOM Facility closures? Are there access issues? Rural? Urban? Low income women? Workforce trends Which regulations are beneficial? What additional regulatory requirements should be added to improve quality? Eliminate requirements that don’t positively modify outcomes
  57. 57. Possibilities…. Development of centers of excellence Patient care More efficient; lower cost Higher sensitivity Fewer recalls Better outcomes Hubs for training of new highly qualified personnel Provide incentives for developmentProvide incentives for development