Technology
Mammography ReboundsDigital scans and speedier results, fired-up young docs and hospitals' commitment to improve workflow help head off a crisis in access.
Linda Hansen-Allen doesn’t mince words when she describes the weeks and weeks that women waited for mammograms—routine and otherwise—at her Florida hospital system several years ago. “It was outrageous,” says the director of women’s imaging at Baptist Health of Northeast Florida.
In 2005, it wasn’t uncommon for a woman to wait 20 weeks for a routine screening mammogram, Hansen-Allen says. If the radiologist identified a potential malignancy, the clock started again. Another six to nine anxious weeks might pass before the woman could get a diagnostic mammogram at Baptist Health. “For a person who is concerned about a problem, to have to go through that emotional stress …,” she says, her voice trailing off.
Hansen-Allen was recruited that year to tackle Baptist Health’s access difficulties. Their solution included consolidating breast imaging services and shifting from analog to digital mammography. Along the way, they made workflow changes, including scheduling and staffing adjustments to maximize the time that radiologists could devote to reviewing images.
By early 2007, the backlogs were eliminated at three of the system’s four acute care hospitals. The fourth hospital had a separate radiology group and only recently joined the effort. A woman who needs a routine screening today can get the test within a day or two. In cases where a worrisome finding is identified, she won’t wait more than four to seven working days and likely can be seen within 48 hours.
Dodging a Scare
Hospital leaders in Northeast Florida weren’t the only ones to sound the alarm several years ago about the long and stressful waits for women needing mammograms. Radiologists around the country also spoke out, citing the nation’s aging demographics and the declining clinical interest in breast imaging. One study, published in 2003 in the journal Radiology, found that two-thirds of residents didn’t want to even consider a fellowship in breast imaging.
The demographics remain daunting, with waves of boomers reaching prime screening age, say radiologists and hospital leaders. But several trends appear to have helped hospitals avert an access crisis, at least for the time being.
Physicians in training are showing renewed interest in the field—once practically considered a radiology stepchild—now that digital, ultrasound and MRI techniques meet their expectations to work in high-tech medicine.
Some states, including Florida, have passed malpractice laws to ease liability concerns associated with difficult-to-read mammograms. At the same time, digital mammography is reshaping the field, spurring hospitals to redesign their workflow as they make the transition to the new technology.
Hospital leaders can take some of the credit for improving the situation: A number of them adopted strategies similar to Baptist Health, taking steps to not just shorten wait times, but also to improve the overall patient experience.
In 2006, South Nassau Communities Hospital officials opened a breast imaging center four blocks away from the 441-bed nonprofit hospital in Oceanside, N.Y. Services include not only digital imaging, but also extended hours and, frequently, walk-in access.
For too long, U.S. hospitals have relegated mammography to institutional and unattractive quarters, says Abraham Port, M.D., South Nassau’s director of breast imaging. “Patients want to feel like they are healthy, going in for a screen and not because of a disease.”
A Shifting Marketplace
Overall, mammography access is adequate in most parts of the country, according to a 2006 report by the U.S. Government Accountability Office. But the report, which scrutinized data from 2001 to 2004, noted a gradual decline in the number of facilities providing the service, along with lengthening wait times in some areas. By late 2004, 865 counties, most of them rural, had no mammography machines.
From 2000 to 2007, the number of mammography facilities declined 11 percent, a trend that seems to be leveling off in recent years, according to an American College of Radiology analysis of Food and Drug Administration data. The FDA is responsible for inspecting all mammography facilities—both in hospital and outpatient.The number of units also declined during the same stretch, down nearly 4.6 percent by 2007.
But the number of procedures has increased, points out Brian Baker, senior vice president of Regents Health Resources, Nashville, Tenn. By September of this year, nearly 36.2 million mammograms were being performed annually compared with 32.2 million four years earlier, a 12 percent increase, according to FDA data.
“Why is that?” asks Baker, whose consulting firm specializes in the medical imaging industry. “The answer is that digital units are much more efficient in not only imaging the breast, but the delivery of the exam itself.”
Baker predicts more digital scans in the years ahead, even among small facilities for which the move represents a substantial investment. According to a Regents survey conducted this spring involving critical access hospitals, nearly 37 percent of respondents plan to add digital units within the next three years.
Breast imaging has drawn the interest of a new cadre of recent medical school graduates, thanks to the technological breakthroughs. “Our feeling, among people who have the bigger training programs, is there is renewed interest in breast imaging among the residents,” says Lawrence Bassett, M.D., who authored the 2003 Radiology study and is the Iris Cantor professor of breast imaging at UCLA’s David Geffen School of Medicine.
Tackling Backlogs
At Baptist Health, Hansen-Allen worried about the women who fell through the cracks after waiting weeks for a scan. Perhaps they might abandon the screening test. Or they might seek a mammogram elsewhere, turning to one of the “mammo-in-a-box” stand-alone facilities that had popped up in northeast Florida, she says. Or they might just be left in limbo, waiting.
Moving to digital technology allowed routine screenings to be scheduled in 15-minute time slots instead of every 30 minutes. That eliminated the screening backlog so suddenly that hospital leaders wondered if their patients had gone elsewhere. “I had administrators calling me and saying, ‘How come people can get in the next day—what’s wrong?’ ” she says.
But what has improved efficiency as much or even more is the effort to centralize services, Hansen-Allen says. Since 2005, working in stages, Baptist Health has been consolidating mammography readings at Baptist Medical Center Downtown in Jacksonville. The screening mammogram itself may be performed at one of the system’s other hospitals, but the image will be read by radiologists downtown. All diagnostic mammograms are performed at the system’s downtown campus.
Radiologists can now work in close proximity, typically splitting their shift between reading diagnostic images and routine screenings, says Barbara Sharp, M.D., an interventional mammographer at Baptist Health. Another radiologist is only a few steps away if there’s any uncertainty about an image. Assistants, called facilitators, help with paperwork, call patients whose results are benign and handle other time-consuming logistics to free up the radiologists.
Assessing the Bottom Line
New digital units require a significant up-front investment, ranging from slightly under $400,000 to more than $450,000 per unit, Baker says. (After the first year’s warranty, service costs vary from more than $30,000 annually to about $45,000 per unit, he says.) Traditionally, analog units cost between $75,000 and $100,000 apiece. But reimbursement runs much higher for digital—about $130 compared with roughly $50 for analog, Baker says. So what’s the break-even point?
Baker declined to provide a specific formula, saying related infrastructure and staffing can play a significant role in the return on investment. But one analysis Regents conducted for a client found that 1,200 procedures annually could pay off purchase and maintenance costs over five years. For a facility with greater infrastructure costs, that break-even point can be closer to 3,500 procedures, Baker says.
Hospitals with significant wait times—exceeding three weeks—will frequently transition to digital as part of an overall move to transfer breast imaging services outside the hospital walls, Baker says. That’s the strategy South Nassau Communities Hospital adopted by opening its Complete Women’s Imaging Center.
South Nassau is located in a competitive market, with at least five stand-alone facilities within a five-mile radius, says Cat Taylor, assistant vice president for oncology services.
Before the new center opened, women could wait four to five months to get a routine screening exam and seven to 10 days for a diagnostic scan, she says.
The 3,800-square-foot center opened with digital machines and a heightened focus on customer service, nearly immediately eliminating wait times, Port says. The center is open 8 a.m. to 7 p.m. five days a week. The organization has invested generously in staffing, including a floater technician who is available if a patient walks through the doors with a prescription in hand, Port says. Frequently, patients are given their results immediately, if they can stick around a few minutes. Port says he provides his cell phone number to newly diagnosed patients.
And if a malignancy is diagnosed, Port says, “We are the first person the patient asks, ‘What do I do next?’ Therefore, the downstream income to the hospital is tremendous.”
Patient response has been so positive that South Nassau officials plan to expand the center, adding 2,000 square feet. Baptist Health leaders also have found that efficiency pays off literally in more scans. In fiscal year 2008, the hospital system is projected to perform a total of more than 55,400 mammograms at three of its facilities, compared with 41,585 in fiscal year 2005.
Hansen-Allen is confident that Baptist Health can keep pace with demand. A 20,000-square-foot center is in the works to replace the roughly 8,000 square feet used for breast imaging at Baptist Medical Center Downtown. The new stand-alone center is scheduled to open by 2011.—Charlotte Huff is a freelance writer in Fort Worth, Texas.
This article 1st appeared in the November 2008 issue of HHN Magazine.
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