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1 All authors: Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215.
Received March 10, 2000;
accepted after revision March 20, 2001.
Presented at the annual meeting of the American Roentgen Ray Society, New
Orleans, May 1999.
Abstract
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MATERIALS AND METHODS. A survey was anonymously and randomly distributed to 129 women who were 35-70 years old during a visit to their primary care physician, asking the women's preference for receiving mammography results by one of two systems: by letter with a return visit for any additional tests; or by speaking at once with the radiologist, with the option of additional tests being performed during the same visit. Patients' willingness to pay for the latter service was also determined. A cost identification model was constructed using commercially available software. We considered the impact on radiologists' and technologists' time and the need for additional equipment and space, and we analyzed the effect on the cost of immediate reporting.
RESULTS. One hundred twenty (93%) surveys were completed. Eighty women (67%) preferred immediate reporting, and 62 (78%) of these 80 patients would wait 30-60 min. The additional cost of immediate reporting is $28.22 per patient. Only 11% of patients were willing to pay this additional cost. When new equipment and space were not required, the cost would increase by $4.38. This cost was most influenced by the time required to give patients normal results.
CONCLUSION. Most surveyed patients preferred speaking with a radiologist immediately but were unwilling to pay additional fees. Radiologists, hospital administrators, and health care planners must be aware of the costs of immediate reporting and must factor these costs into any change in hospital or national policy.
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We developed a cost identification model to compare the costs incurred when a radiologist speaks with each patient after screening mammography with the cost for our current practice, in which a radiologist does not speak with the patient after the screening. The model was developed from the point of view of the hospital. The model was constructed so that it could be applied to different practice settings. In particular, we wanted to ensure that our model could be generalized to practices in which the program could be implemented with or without the hiring of additional technologists, with or without purchasing additional mammography or sonography units, and with or without acquiring additional space in the hospital or clinic. The model included such variables as the frequency of screening mammograms with normal and those with abnormal findings in a practice, the time required to talk with a patient about normal or abnormal findings, the frequency with which patients are recalled for additional images under the standard screening procedures, and the cost of the radiologist's and technologist's time, as well as fixed expenses such as the cost of space in the radiology department and equipment.
We assumed the following: that extra time will be needed for the radiologist to convey results to the patients at the time of the mammogram; that a separate, private space or room will be required where the radiologist can discuss mammography results with patients, especially when the results are not simply normal; and that given our current practice we would need added technical staff, radiologist time, and mammography and sonography rooms to accommodate immediate workup of any abnormalities detected on screening mammograms.
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One hundred eighteen patients reported their annual household income. Of these, 32 (27%) had an income between $50,000 and $74,999, 31 (26%) had an income of $25,000-49,999, 29 (25%) reported $100,000 or greater annual income, 13 (11%) had an income of less than $25,000, and 13 (11%) had an income of $75,000-99,999.
Regarding reporting of mammography results, 80 (67%) of the total 120
patients preferred immediate reporting and 40 (33%) preferred delayed
reporting. Reporting preferences categorized by patient age and household
income are presented in Tables
1 and
2. No statistically significant
difference (p > 0.05, two-sided Fisher's exact test) was seen in
the preference for immediate versus delayed reporting between older patients
(
50 years old) and younger patients (<50 years old). No statistically
significant difference (p > 0.05, two sided Fisher's exact test)
was seen in the preference for immediate versus delayed reporting between
patients in the higher income brackets ($50,000/year) and patients in the
lower income brackets (<$50,000/year.)
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Of the 80 respondents who selected immediate reporting, 62 (78%) were willing to wait 30-60 min for the results, 48 (60%) were not willing to pay an additional fee for immediate results, 19 (24%) would pay an additional $10, and nine (11%) would pay an additional $25. None of the respondents reported a willingness to pay an additional $50 for this service.
Cost Analysis
Because our mammography facilities are being used at full capacity,
modifying our practice to provide immediate interpretations would require
adding space, equipment, and staffing. Given this fact and using our cost
identification model, we calculated that this change would cost an additional
$28.22 per screening mammogram. In a setting in which additional mammography
and sonography rooms are not necessary and only a patient consultation room is
needed, the extra cost would be $10.57 per screening mammogram interpreted
immediately. If additional space is not required, the extra cost is only
$4.38, representing simply the extra time spent by the radiologist in talking
with the patient.
For our practice and current volume of 12,000 screening mammographic examinations per year, the total additional cost of immediate interpretation would be $338,640 annually. If we could provide immediate results without additional space and equipment, the extra cost would be $52,560 per year. We tested our model by using a wide range for each of the variables used in the model. The process is shown in Figure 1, and our results are presented in Table 3. For example, when the time required to speak with a patient about normal mammographic findings increased from 2 to 10 min, the cost of immediate reporting increased by $17.11 over traditional screening. In contrast, when the time required to speak with a patient about abnormal mammographic results increased from 2 to 60 min, the cost of immediate reporting was essentially unchanged. The fact that the cost of immediate reporting was not affected by the time required to speak with patients about abnormal findings can be explained by the fact that, in our practice, only 6% of screening mammographic findings are abnormal. Thus, even if a great deal of the radiologist's time is required to speak with a patient about abnormal mammographic findings, this happens so infrequently that it has little impact on the cost of the new screening program of immediate reporting and workup.
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The cost of the new screening program was also greatly affected by whether an additional mammography room was needed. If a new room was not necessary, then the cost of immediate reporting (compared with traditional screening) was only $18.82. However, if a new mammography room was required, then the additional cost could increase as much as $33.57, for a maximum room cost of $100,000, compared with the traditional system of batch interpretation. Similarly, if acquiring additional space to speak with patients (consultation room) was not necessary, then the cost of immediate reporting was $22.02 greater than for traditional reporting.
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A number of surveys and studies have addressed different aspects of this issue. Liu et al. [4] surveyed 307 women undergoing mammography at their facility and found that most favored direct on-site notification of normal and abnormal results by the radiologist. Hoffman et al. [5] published their perspective on the subject in 1994, stating that they consistently provided their patients with immediate reports at their facility and provided additional workup as necessary at the same visit. In an article published in 1995, Bassett et al. [3] described a survey they conducted of their referring doctors and nurse practitioners to understand their attitudes regarding reporting of screening mammographic findings. These researchers found that most referring physicians (85%) were receptive to direct reporting of mammography results to patients by the radiologist. However, when results were abnormal, fewer physicians (58%) thought that the radiologist should communicate this information directly to patients. However, the survey by Bassett et al. did not discuss the idea of immediate on-site reporting and the performance of any recommended additional workup during the same visit. Hulka et al. [8] published a study in 1997, in which they described a patient survey showing that 75% of 167 respondents favored delayed reporting when double interpretation was to be performed. Similarly, Slanetz et al. [9] found that 90% of 278 physician survey respondents preferred delayed double interpretation over immediate reporting. These latter studies emphasize the benefits of double interpretations, an issue not addressed in our study. Our survey confirms the findings of others that most screening mammography patients would prefer to be given their results immediately. Because only a minority of our survey respondents were willing to assume the extra cost of this service, if the program were adopted this cost would have to be absorbed by the institution.
An additional cost of immediate interpretation of screening mammograms is the institutional loss in reimbursement for the supplemental studies that would otherwise be paid if the workup were performed on a different day. In the past, many insurers did not pay for additional examinations performed on the same day as the screening mammography. Recently, however, changes in many payors' reimbursement policies have allowed payment when screening mammography is converted to a bilateral diagnostic examination at the interpreting radiologist's request. Some payors have even allowed reimbursement for same-day sonographic examination of a lesion found at screening mammography. However, if a sonographically guided procedure is performed on the same day as the sonography, only the former procedure is reimbursed, not the sonography itself. Thus, interpreting screening mammograms immediately also incurs additional indirect cost in two ways: the loss of reimbursement for the initial screening mammogram and subsequent diagnostic mammogram performed another day (reimbursement is now only for a bilateral diagnostic mammogram), and the loss of reimbursement to the hospital for a sonographic examination if a sonographically guided procedure such as aspiration or biopsy is performed on the same day.
These costs are offset somewhat by the savings from not having to recall patients. The costs of callbacks include scheduling a new appointment, reregistering the patient when she returns, filing and then subsequently retrieving the patient's radiology records, and re-reviewing the mammograms. For the purposes of this analysis, we estimated the hospital's cost of callbacks at $10 per patient. However, the impact of the cost of recalling patients was minimal. When the cost of each callback increases from $0 to $50, the maximum cost of talking with patients immediately changes by only $3. Again, this fact reflects the small number of screening mammographic findings that are interpreted as abnormal and requiring further evaluation.
This cost analysis is solely from the perspective of the hospital and does not take into account other less quantifiable costs that are incurred when patients are recalled for additional studies, such as patient anxiety and inconvenience. A recent study assessed the degree of stress experienced by patients when they were asked to return for additional workup of screening mammography with false-positive findings compared with patients who had the additional tests performed after immediate interpretation at the time of screening [10]. These authors found that providing immediate diagnostic evaluation can reduce the stress and anxiety associated with being recalled when questionable abnormalities are detected on the screening mammogram. In addition, patients themselves must again assume related costs such as transportation and parking fees, possible child care fees, and the cost of missed work hours.
From the radiologists' perspective, several other issues must be considered. First, interpretation of screening mammograms immediately increases demands on the radiologist. In a typically busy practice, the radiologist must interpret and make decisions about diagnostic mammography studies, speak to each diagnostic patient, perform interventional breast procedures, provide consultation for outside studies of referring clinicians, and provide interpretation and results for every screening examination. Immediate interpretation causes significant disruption of the workflow and hinders the radiologist's ability to concentrate, which may result in an increased number of misinterpretations.
Second, in a high-volume, fast-paced office in which time is at a premium, it is often easier to perform additional imaging than to scrutinize multiple prior examinations or obtain the old studies for comparison. In the setting of immediate interpretation and reporting of mammographic results directly to patients, these pressures and demands are increased and may result in a more additional images being obtained. Furthermore, double interpretation of mammograms, which is deemed beneficial by many mammographers and preferred by many referring doctors [8, 9], could not be efficiently performed in this setting.
Third, in a teaching hospital's mammography section, a "read-out" session provides the opportunity to teach important points of mammographic interpretation to residents and fellows while reviewing a batch of cases at once, allowing salient points to be illustrated with multiple examples. This process of teaching and learning is sacrificed to some degree when screening examinations are interpreted one at a time.
Although it seems intuitive that increased time spent talking with patients about the results of their screening mammograms would cost more, our study points out the significant impact (in cost) of talking with patients about normal mammographic results compared with the minimal effect on cost from discussing abnormal results. The reason for this discrepancy is the greater frequency of normal over abnormal results on screening mammography. The current system of batch interpretation of screening mammograms correctly presumes that most will show normal findings and that this information can be simply conveyed in a letter to the patient and a report to the referring doctor. Our analysis shows that the cost of providing direct and immediate screening mammography results is clearly driven by the cost of speaking with patients about normal—rather than abnormal—findings. It is unfortunate that time spent speaking with patients must be considered a luxury; and given the current health care environment, it is unlikely that health insurers will agree to pay for this extra level of service. Our patient survey indicates that although most respondents prefer to hear their results immediately and to have any additional testing performed on the spot, only a few are willing to pay for this service.
In conclusion, we believe that immediate interpretation of screening mammograms and immediate evaluation of detected abnormalities have many benefits. However, a number of important concerns and costs should be carefully assessed before this practice is widely adopted.
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