Report urging changes to breast standards draws fire

The American College of Radiology, the Society of Breast Imaging, and individual breast imagers have criticized a report prepared for Congress that calls for sweeping changes to the Mammography Quality Standards Act. Even though the report includes recommendations to offset financial burdens incurred by centers adopting these new measures, mammographers want to see the money first.

"We have to balance access and quality. If the benefits are increased minutely, while the bureaucracy increases dramatically, we haven't achieved anything for patients," said Dr. James P. Borgstede, chair of the ACR board of chancellors.

The report, Improving Mammography Quality Standards, which was prepared by the Institute of Medicine, includes a key recommendation that would expand current MQSA medical auditing regulations, requiring breast centers to collect data on physician performance and patient outcomes. Facilities would need to track their cancer detection rates, the ratio of biopsy to cancer diagnosis, and the percentages of their patients with abnormal mammograms.

Providing ways for radiologists to obtain feedback on their breast cancer detection performance through data tracking is critical in terms of increasing mammography quality, said Dr. Etta Pisano, director of breast imaging at the University of North Carolina, Chapel Hill and a member of the IOM report committee. But others say there aren't enough resources to do the job.

"The big breast centers are already tracking their positive predictive values and stages of breast cancer," said Dr. William Poller, associate director of breast imaging at Allegheny General Hospital in Pittsburgh. "To ask smaller centers that don't have the personnel or the volume to do that is just asking them to close."

The IOM also recommends that Congress institute an advanced voluntary audit. Through this program, sites would collect tumor staging information from pathology reports and collect a range of patient demographic data. A data center would store the information and provide feedback to individual physicians. To encourage participation, the IOM suggests establishing a no-fault medical liability system to handle misdiagnoses. Participating physicians would first need to demonstrate a record of high-quality performance. Facilities whose data show high levels of accuracy would be designated "breast imaging centers of excellence" and could be rewarded through additional reimbursement.

"I don't have a problem with demonstration projects at centers of excellence. But we have to see where this is headed. Ultimately, it will be very difficult at current reimbursement levels to get people to go along with these increased requirements," Borgstede said.

Speaking for the Society of Breast Imaging, Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center, said that additional compensation should be in place before breast imaging centers incur more regulatory burdens.

"If they want it, they should make sure that it will be paid for," Dershaw said.

The ACR will take the issue to Capitol Hill and advise members of Congress to be careful when interpreting the report. It's imperative that lawmakers understand the consequences of increased regulations on a specialty that is already plagued by a workforce shortage and low reimbursement, Borgstede said.

But such a move might be in vain. The report will likely carry considerable weight, according to Dr. Howard Forman, an associate professor of diagnostic radiology at Yale University and a member of the IOM committee.

"When Congress spends the money to prepare a report of this nature, it's a tip that they see it as being a critical guide," Forman said.

Deborah R. Dakins contributed to this article