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Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02215
There are numerous advantages to immediately reporting screening mammograms [1], with patients and their physicians being the most obvious beneficiaries. However, because women disproportionately influence health care decisions for their family and friends, when screening is performed in a hospital setting, that institution often has the greatest stake in providing the good will that this service can engender. Because of institutional competition and related political pressures, all major teaching hospitals in Boston currently offer some form of online interpretation of screening mammograms. In fact, the recent insightful article assessing the monetary costs of immediate reporting of screening mammograms by my colleagues, Raza et al. [2], was prompted by these institutional pressures.
As everyone is now aware, screening mammography is inadequately reimbursed, and this is particularly true in the hospital setting, which is usually less efficient than the stand-alone imaging facility. The lack of financial incentive for radiologists in private practice to provide this service, and the impetus for larger medical institutions to do so, accounts in part for the fact that more than half of Medicare screening mammograms are obtained in hospital outpatient departments.
It seems contradictory that the federal government should mandate online interpretation of diagnostic mammograms, and that society should encourage online screening mammography, when patients with more urgent or serious disease undergo imaging examinations with little or no interaction with the radiologist. This situation is a result of breast cancerophobia, effective lobbying, and, probably, the overselling of screening mammography to the public. It seems obvious that successful screening examinations that involve large portions of the population, such as mammography, colonoscopy, and CT screening for lung carcinoma and coronary calcifications, should be performed as cost-effectively as possible. These examinations cannot support immediate feedback from physicians unless the individual pays out of pocket for this service. The survey by Raza et al. [2] suggests that most women are unwilling to pay this premium for screening mammography. Offering online interpretation is even less tenable in smaller departments and offices in which the number of screening mammograms cannot support a full-time mammographer, or when immediate review precludes double interpretation [3].
Raza et al. [2] found that only 6% of patients undergoing screening mammography in our practice required additional imaging. This rate is an appropriate trade-off between sensitivity and positive predictive value [4]. However, it is our anecdotal experience that the rate of additional imaging increases when problem-solving mammography, sonography, or imaging-guided aspiration or biopsy are immediately available. These add-on examinations also interfere with scheduled examinations.
If the decision is made to offer online screening mammography, a compromise will ameliorate some of the additional professional costs described by Raza et al. [2]. We have added additional nonprofessional women to our staff whose duties include informing patients of their normal screening examinations. Unless the patient requests otherwise, the radiologist speaks personally with only those 6% percent of women who require additional imaging.
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