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Workforce Shortage in Breast Ima

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									                  Workforce Shortage in Breast Imaging
                           Barbara Monsees, M.D.
  Professor & Chief of Breast Imaging, Washington University Medical Center
                                St. Louis, MO

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
    decrease in breast cancer death rate



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

 Tolerant of recalls & biopsies for benign disease
 Eager for new or additional screening techniques for breast cancer, especially
  for high risk women

Mammography
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

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




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

Projected Trends in the Size of the Population of U.S. Women by Age Cohort
 Projected Trends in the Size of the Population of
           U.S. Women by Age Cohort
         Millions

25

20                                                                Age-Group
                                                                   30-39
15                                                                 40-49
                                                                   50-59
10                                                                 60-69
                                                                   70-79
 5

 0
         1960       1970    1980    1990    2000   2010    2020
                                    Year
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.


Yearly mammography volumes in millions
(60% compliance)

Disparities in U.S. Breast Cancer Mortality Reduction: U.S. Mammography Use
by Age & Poverty Status
 160
 140
 120
 100
  80
  60
  40
  20
   0
             75

             78

             81

             84

             87

             90

             93

             96

             99
          19

          19

          19

          19

          19

          19

          19

          19

          19




         Disparities: U.S. Breast Cancer
              Mortality Reduction
 50
 40                                Black
 30                                 White
 20             Hispanic
 10
                      Asian              American Indian
     0
     90


                92


                            94


                                    96


                                            98


                                                    00
19


            19


                           19


                                   19


                                           19


                                                   20




                SEER Age Adjusted Rates 1990-2000




GAO Report
 U.S. General Accounting Office
 April, 2002
 (GAO-02-532)
 The work for the report performed from June 2001 through March 2002
“last few years show a substantial decline in the number of new entrants to the
fields”

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

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)


Radiology Fellowship Match, Active Programs
June 4, 2003, Appointment Year 2004-05: Results
                         # Positions    Filled                    Unfilled
All programs             769            411 (53%)                 358 (47%)
Breast/women’s imaging   48             12 (25%)                  36 (75%)

Attitudes of Radiology Residents Regarding Breast Imaging (BI)
Survey: 211 of 224 accredited US programs
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

Two-thirds said:
    Mammograms should be interpreted by a subspecialist
    Would not consider doing BI fellowship
    Do not want to spend >25% time interpreting mammograms
Reasons:
not interesting enough field, fear of lawsuits, too stressful, work too hard, pay too
low

Performance Parameters for Screening and Diagnostic Mammography:
Specialist and General Radiologists
                                  CA detection Stage 0-1 CA
               Abnormal rate
                                     rate*     detection rate*
              SCR        DX
                                  SCR    DX     SCR      DX
              recall % rec bx %

Specialists    4.9      15.8      6.0    59.0    5.3    43.9

Generalists    7.1       9.9      3.4    36.6    3.0    27.0

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

    Accuracy   # Radiologists   Service Capacity
Current           20,000
Increase 1%       -2,200             -10%
Increase 5%       -6,000             -25%
Increase 10%     -11,400             -50%

Mammography 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


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
 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


Screening Mammography Reimbursement vs Costs

Medicare (2004)                                    $80.94
Medicaid (Varies by State)
*2001Cost at Hospital Facility                     $124.54
*2001Cost at Office Facility                       $86.60

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!



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
    nd
 2    most expensive condition in terms of indemnity
 88% of patients had at least one mammogram
             st
    80%, 1 mammo was negative/equivocal
                       # Claims

                                  Paid Claims

                                                ($thousands)
                                                ($thousands)
                                                indemnity
                                                Average

                                                               ($millions)
                                                               indemnity
                                                               indemnity
                                                               Total
Specialty
Radiologists           242        184                 346          63.7
Ob/Gyn
Ob/Gyn                 167        133                 369          49.0
Corporations            87         37                 265           9.8
Surgical specialties    78         62                 334          20.7
FP/GP                   62         52                 309          16.0
Internal medicine       46         36                 247           8.9
Other                   22         12                 236           2.8
Hospital                20          8                 144           1.2
Pathology                9          7                 375           2.6
TOTAL                  733        531                 329         174.8


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

?Difference in malpractice premiums

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

								
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