In testing women for breast cancer, some CNY hospitals may be doing too much and others too little,
View full sizeWhen it comes to testing women for breast cancer, some Central New York hospitals may be doing way too much and others too little, new federal statistics suggest.When it comes to testing women for breast cancer, some Central New York hospitals may be doing way too much and others too little, new federal statistics suggest.
The percentage of outpatients who had follow-up mammograms or ultrasound tests within 45 days after a screening mammogram ranged from a low of 2.8 percent at Crouse Hospital to a high of 21.7 percent at Upstate University Hospital, according to numbers released by the Centers for Medicare & Medicaid Services.
The agency, which published the data on its website (www.hospitalcompare.hhs.gov), said a rate much higher than 14 percent may mean there’s too much unnecessary follow-up, while a rate much lower than 8 percent may mean there’s not enough. The numbers, based on Medicare claims from 2008, are for hospital outpatients only and are applicable to women 65 and older.
In addition to mammogram data, the agency added information about the use of MRIs and CT scans. All these imaging tests are widely used by doctors to diagnose and treat many diseases. CMS added the measures to “shine a spotlight on the problem of unnecessary exposure to contrast materials and radiation, and will discourage overuse and waste,” said Dr. Barry Straube, the agency’s chief medical officer.
A mammogram is an X-ray of the breast to check for possible breast cancer. When a screening mammogram shows signs of possible breast cancer, the patient is asked to come back for a follow-up appointment. A follow-up usually means having more tests such as a mammogram, ultrasound or both.
CMS said medical research shows there may be a problem if a hospital has either very low or very high numbers of follow-ups. A low rate means it’s possible that signs of cancer are being missed. Too much can mean patients are being unnecessarily exposed to radiation and stress, the agency said.
Straube said there are many reasons why some hospitals may have high rates of follow-up tests. It could be because the initial X-rays were blurry and had to be repeated, he said. It also could reflect a lack of skill or experience interpreting the mammograms.
“There may be multiple radiologists who review the film and somebody may see something the first reviewer did not see and that might lead to a higher rate,” he said. The variations also can reflect differences in patient mix or the way doctors practice from hospital to hospital, Straube said.
“Our goal is not to label hospitals as good or bad, but provide insights to the hospital and the general public on what they are achieving in the care they render,” Straube said.
The information on the website can help consumers make health care decisions and hospitals improve quality, he said.
“But nobody should take one result or two results and choose to have their care at a hospital based on that one result,” Straube said. “This is just one piece of information that should be factored in with others.”
Dr. David Duggan, associate vice president for clinical affairs and medical director at Upstate University, said he does not know why his hospital’s rate is so high. The rates are not adjusted to account for differences among hospitals in patient populations, which makes it difficult to interpret the data, he said.
Upstate has a large breast cancer program and many patients who’ve had abnormalities on their mammograms, he said. Duggan said that could be why the rate is high, or it could be because the hospital has a more conservative group of radiologists. He said the hospital won’t know until it analyzes the data.
“We are very concerned about trying to avoid extra tests and X-rays,” he said.
Dr. Stephen Montgomery, director of breast imaging at Crouse, said his hospital’s rate is low because he’s more experienced than most mammographers. Montgomery estimated he’s read more than 160,000 mammograms over the last 22 years at Crouse.
“The more experienced mammographers have lower recall rates,” he said. “They are more confident when they see something on an image that it’s not a cancer and you don’t need to call the lady back.”
Having a low recalls rate is fine as long as your detection rate is good, Montgomery said. Crouse’s detection rate is 1.7 cancers per 1,000 women screened, he said.
Fear of malpractice lawsuits fuels overutilization of mammography, he said.
Cayuga Medical Center’s rate is low because it doesn’t make women come back for follow-up tests. Mammograms are reviewed immediately at the Ithaca hospital. If something looks suspicious, additional testing is done during the same visit, said Dr. David Evelyn, Cayuga’s vice president for medical affairs.
“This saves everybody money and gives our patients peace of mind,” Evelyn said.
James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com