Fine-tuning breast imaging workflow reduces wait times

Women complain that waiting for definitive results after a breast imaging exam is a nerve-racking experience. Staff at one hospital system have identified bottlenecks in the process and have reduced the critical wait time between an abnormal mammogram and a final diagnosis.

"When a woman who could possibly have breast cancer waits for the results of her radiographic exam, the speed of this process is the first thing on her mind," said Prerna Singh Kahlon, project manager for radiology quality management and patient safety in a large Massachusetts-based healthcare system.

To better identify holdups in the system, Kahlon and colleagues documented existing practices at six breast imaging centers between February and April 2004. Results of the study were presented at the 2004 RSNA meeting.

The investigators measured the amount of time required to complete each step in the breast imaging and cancer diagnosis process, including screening mammogram, diagnostic mammogram, core biopsy, biopsy result, and communication of biopsy results to the patient.

Kahlon and colleagues reported that the critical wait time (defined as the time between an abnormal mammogram and final tissue diagnosis) varied from four to 24 days among the breast imaging centers, with an average of 12.5 days.

The total critical wait time was broken down step by step:

• time between a screening and diagnostic mammogram: 0 to 13 days (average 4.5 days);

• access to biopsy appointment: 1.5 to 13 days (average seven days);

• pathology turnaround time: one to three days (average two days); and

• biopsy results communicated to patients: 0.5 to 1.5 days.

Because the study was conducted in a large hospital system, different factors affected different hospitals.

"Scheduling, radiologist/technologist staffing, and communication of biopsy results promptly to a patient by radiologist or primary-care physician were the most common factors causing the longest delays," Kahlon said.

The process could be streamlined in several ways, including tailoring the schedule to avoid delays in obtaining a study, she said. Prompt biopsy specimen delivery would also shave time off the waiting period. Expediting film transport, providing prompt patient follow-up on biopsy reports, and allowing for scheduling flexibility are additional tools that departments can use to reduce the wait time.

"Providing high-quality care to patients in a timely manner is key," Kahlon said. "The anticipated overall result of reducing critical wait time is a decrease in patient anxiety and an increase in patient satisfaction."

Making breast imaging department operations faster, however, may add to the expense of the system, ultimately resulting in decreased access to services, said Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center.

"There are many issues in setting up a system to facilitate rapid throughput," he said. "To build more rapidity into a system requires a greater level of resources at each level of service, increasing costs. The higher costs may prohibit some patients from obtaining services or discourage others from seeking them."

The focus, according to Dershaw, should not be on trying to make a system faster but on optimizing the availability of services. To do this, departments can consider operational factors, such as how many biopsies are generated and how many abnormal mammograms are identified, and then develop a scheduling system capable of handling the resulting biopsies in a timely fashion.

Dershaw also suggested reexamining the quality of film interpretation to ensure that radiologists aren't ordering an excessive number of workups.

"Improving wait times doesn't automatically mean buying new equipment or investing in electronic fixes. It just requires looking at your facility's numbers, figuring out in your particular situation if there is a bottleneck, and then trying to alleviate the situation if you can," he said.