How to halve your mammography recall rate: Baylor Radiology’s resounding success

Legislation, including Affordable Care Act (ACA), has underscored the virtue of a well-oiled breast imaging department. As mammography utilization increases and value-based reimbursement continues to occupy a larger fraction of hospitals’ revenue, department leaders are looking for ways to tighten the screws on screening programs.

A group of faculty and staff from the Baylor College of Medicine’s Department of Radiology implemented a quality improvement project, intending to make the screening program faster and more accurate. Their four-step program generated conclusive improvements in recall rates and shortened the time between screening and treatment, and they published their results in the Journal of the American College of Radiology.

“In 2010, our program’s recall rate was too high at 17 percent, and our program’s positive predictive value was too low at 2.6 percent,” wrote Sedgewick et al. “These outcomes indicated that women were being recalled for additional unnecessary imaging, and women were undergoing unnecessary breast biopsies.”

In addition, the screening program was moving too slowly: patients waited an average of 89 days between abnormal results on a screening mammography and a biopsy, and an average of 121 days between abnormal results and their first treatment such as radiotherapy or surgery.

The first step of the program was overhauling their team of radiologists, hiring specialized breast imaging radiologists who either had formal training or interpreted more than 5,000 mammograms a year. According to Sickles et al, breast imaging specialists recall two-thirds of the women recalled by general radiologists and detect twice as many cancers.

They followed a similar philosophy for imaging technologists and nurses, hiring dedicated mammography technologists from a local community college where department leaders served as instructors. Additional breast ultrasound technicians were added, stipulating they obtain breast ultrasound certification within one year of hiring.  Two nursing positions were assigned to scheduling and coordinating the screening process, in an attempt to reduce the time between appointments.

Equally as important as the personnel changes was the implementation of a weekly stakeholder meeting to review protocols, procedures, and common problems in workflow, according to the authors.

“From the patient’s perspective, the perception of quality improvement usually results from multiple small and complementary interventions,” wrote Sedgewick et al. “These projects must be overseen by a team that ensures that the projects do not work at cross purposes, as a solution to one problem may result in a slowdown or redundancy in another process.”

The final step of their quality improvement program was smoothing the referral process: Instead of writing orders for each step of the process, the breast imaging radiologist is able to proceed to the next step without waiting for the order from the referring physician, who is notified via EMR of any action relating to the patient.

This program was a resounding success, more than halving the recall rate and increasing the positive predictive value to 8 percent. Baylor’s mammography capacity doubled to almost 32,000 patients a year and they improved the time between mammography and treatment by 67 percent.

“Through a series of quality improvement projects, we were able to provide same-day workup and biopsy for women who came to the central diagnostic breast center, significantly shorten the time from cancer diagnosis to treatment, and increase capacity to care for more patients,” wrote Sedgewick et al.