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Original Research |
1 All authors: Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109.
Received June 1, 2006;
accepted after revision September 12, 2006.
Address correspondence to C. E. Blane
(cblane{at}umich.edu).
Abstract
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MATERIALS AND METHODS. This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases.
RESULTS. For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was $4,724 divided by 30,286 screening patients, or 16 cents per screening patient.
CONCLUSION. The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.
Keywords: breast cancer • mammography • screening
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By definition, screening means evaluation of a population for occult disease that may be infrequent. The practical value of screening is earlier, preclinical detection of a disease for which preclinical treatment is cheaper, more effective, or preventive. Diseases with highly effective treatment after clinical onset of the symptoms are not targets for screening tests.
Screening mammography has been tested and proven to decrease breast cancer mortality in women older than 40 years [1, 2]. In the screening scenario, women who are assigned a BI-RADS code 0 or incomplete must return for the additional diagnostic imaging. Radiologists are required to inform patients of their results in writing and also to send referring physicians written reports. The costs associated with these requirements are considered part of the usual process and were not included in our calculation of the additional costs.
Several publications have addressed the issues of compliance. Cardenosa and Eklund [3] studied a 6-month period and were able to achieve 99.7% compliance with screening mammograms given a BI-RADS category 0 or incomplete. In a rural-based study for recall or incomplete mammograms, an initial patient compliance rate was documented at 57% [4]. As reported by Helvie et al. [5], patient compliance with short-term follow-up, BI-RADS category 3, was initially 88% at the first short-term follow-up but decreased to 47% compliance at the last 2-year follow-up. One article combined compliance for abnormal and incomplete mammograms and found a patient compliance rate of 73% [6].
Although direct comparisons are difficult because the end point was different in each of these the studies, studies with high compliance (> 95%) had a specific mechanism in place to ensure greater compliance [3]. The radiology department in this article assumed the responsibility of notifying the patient of the incomplete mammogram and the need to schedule a diagnostic study. The referring physician was notified of the events in a letter, but there was no reliance on the referring physician to take the initiative and make the arrangements for a diagnostic study. It was our intent to apply a similar organizational structure to achieve high patient compliance with recall for the diagnostic study after an incomplete screening examination at this institution.
The purpose of this study was to document the hidden additional costs of achieving better compliance with patient recall from a batch-read screening mammography program.
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Patients were informed to bring any previous outside mammography films with them to the screening examination. If there were outside studies the patient neglected or was unable to obtain before the screening mammogram, attempts were made to obtain these outside films for comparison before recalling a patient for additional imaging.
Each day a sheet with the list of patients accompanied the paperwork for the radiologist. The radiologist handwrote the BI-RADS code and added a sticker for incomplete examinations. Two distinctive sticker sets were created, one indicating BI-RADS category 0 when requesting outside films for comparison and a second for BI-RADS category 0, indicating the patient needed to be scheduled for a diagnostic study. Each BI-RADS category 0, an incomplete study, was flagged on the day sheet by the interpreting radiologist with one of these bright orange or green eye-catching stickers and computer-coded in the final report for recall. From the day sheets, a clerk noted the case and initially contacted the patient by telephone within 2 working days of the screening interpretation to schedule the diagnostic study. In addition, a letter was sent to both the patient and the referring physician indicating the need for additional imaging. Diagnostic slots were purposely left open to accommodate these cases within a week of contacting the patient. Knowing our recall rate and the number of off-site screening examinations allowed us to calculate the average number of diagnostic slots required on a weekly basis. An ongoing computer tickler file of patients with no completed diagnostic code within 1 month of screening provided a final check for noncompliant patients and another safety net for potential errors.
To approximate the amount of clerical time involved, we prospectively measured the clerical time in 100 consecutive recalls to finally schedule a diagnostic study. One clerk used the automated telephone system to track the length of time of each call. Two columns were set up on the day sheet so that each patient encounter could be tabulated as an incomplete telephone call, diagnostic test not scheduled, or as a completed call with diagnostic study scheduled. No patient identifiers were associated with the sheets. When the clerk had completed telephone calls for 100 consecutive diagnostic studies, the average times were computed. The cost was calculated using the clerical salary plus the benefits average of $17 per hour for this institution. Estimation of the clerical time for sending and receiving the certified letter was provided by the clerk responsible for this task.
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An average of 2.2 telephone calls—an average 3.64 minutes of total clerical time—were recorded by our clerical staff on 100 consecutive recalled patients scheduled. The range in time was from 0.15 (busy signal) to 16.45 minutes. During the time of the study, 3,977 (98.8%) of 4,025 patients returned for a diagnostic study when originally contacted by telephone. The cost per case for compliant recalled women was calculated to be $1.03 using the calculation of clerical salary plus benefits average of $17 per hour. The total cost of these cases was thus $4,096 divided by 3,977 patients equals $1.03.
Forty-eight (1.2%) of 4,025 initially non-compliant patients received an average of six telephone calls for 4.7 minutes of total clerical time. Clerical costs for this group were $1.33 for the telephone calls, with the additional cost of $7.50 for a registered letter and 15 minutes for each case for assembling the registered letter and sending, receiving, and filing it for $4.25, for a total of $13.08 per case. For a total of $628, this noncompliant group had multiple telephone calls, canceled appointments, or missed appointments. In addition, a return receipt from the registered letter was placed in each file. An additional letter was sent to the referring physician indicating patient noncompliance.
In this group, after the registered letter, 28 (58%) of the 48 women finally returned for additional diagnostic imaging. One of these initially noncompliant patients went on to biopsy that revealed a stage I breast cancer. Twenty patients never returned and were lost to follow-up. Overall patient compliance for recall from screening for the 3 years from the beginning of 2002 through the end of 2004 was 4,005 of 4,025, or 99.5%. The total additional cost of this program over the 3 years was $4,724 for 30,286 screening patients or 16 cents per screening patient or ($4,724 / $4,025) $1.17 per recalled patient. Stated another way, one additional cancer was detected for an additional cost of $4,724.
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To achieve high compliance, one must track the noncompliant patient. We have several safety layers in place to ensure no patients are lost in the process. The day sheet recording the cases to be dictated is initialed for each patient with the BI-RADS category by the radiologist. If the case is incomplete BI-RADS category 0 because it is a recall for a diagnostic study or the final interpretation is delayed waiting for outside films for comparison, a large bright eye-catching sticker is placed next to the patient's name. The clerks who take down the films from the screening boards can then place the chart in one of two bins, for recall or awaiting comparison films.
The next safety layer is the initial BI-RADS category 0 formal report by the radiologist, which is given an incomplete computer code in the radiology information system (RIS). A routine weekly RIS computer check searches the database for this particular incomplete code and generates a list of cases having the code for more than 30 days. The clerks are responsible for pulling the charts from this list to determine why the case has an incomplete code. Most incomplete codes relate to the request for outside comparison films that have not yet been received. However, one incomplete code signals a noncompliant patient who has not completed the recommended diagnostic study to receive a final BI-RADS category of 1-5. Having two systems that work independently allows one system to complement the other and provides an additional safety net. The idea of multiple safety layers results in improved reliability of the overall system.
The scheduling clerks are also educated as to particular patient populations that are not suited to off-site screenings. Any patient who indicates a breast problem, such as a lump, personal history of breast cancer, nipple discharge, or other clinical symptom, is instructed to see her referring physician for a diagnostic mammography request and is scheduled into an on-site diagnostic slot. The scheduling clerks also question the patient regarding additional problems with an off-site screening mammogram appointment. Patients who have trouble with transportation to the mammography installation or who live far from the installation will have increased difficulty returning for a diagnostic study if that becomes necessary. Patients who need to bring a translator with them also have difficulties scheduling multiple appointments. Some patients with disabilities who would find a recall for a second diagnostic visit a particular hardship and group home patients who are often in a wheel-chair and need an accompanying adult are typical of the type of patient we try to schedule for on-site screening. With careful education and appropriate information, the scheduling clerk can ask pertinent questions and triage some patients to an on-site screening.
Our overall recall rate for 2 years was 13%. This is consistent with a recent study revealing a range of 7.7-17.2% in recall rate [7]. Recall rates vary according to the individual and length of experience of the 10 breast imaging radiologists. New breast imaging radiologists are encouraged to aim for high sensitivity even if recall rates are initially somewhat high as they gain sufficient experience. In addition, our patient population is a mixture of baseline and previously screened patients. Attempts were made to obtain outside films for comparison when they existed before recalling a patient for additional imaging.
Concern exists about the perceived clerical costs of providing additional support to ensure good compliance of patients recalled after screening mammography. We under-took this study to evaluate these hidden additional costs at this institution on the basis of our clerical salary structure. Clerical costs may vary depending on the location of the breast imaging center by city and state. This additional cost may be computed several ways. If one looks at the recalled population, the cost per case was $4,724 / $4,025, or $1.17 per patient with an incomplete mammogram at screening. Stated another way, one additional cancer was detected for a cost of $4,724.
We prefer to calculate these extra hidden costs per screening mammogram. The additional cost of 16 cents per screening mammogram seems a small price to pay for improving patient safety and maintaining high compliance. We think this had the side benefit of good patient care that reduces risk exposure.
In conclusion, the radiology department assumed responsibility for contacting patients who needed recall for diagnostic imaging after off-site screening mammography. With good clerical support, strict documentation of the patients requiring additional imaging, computer checks, and prompt scheduling, we achieved 99.5% compliance at the minimal additional cost of 16 cents per screening mammogram.
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