Samir B. Patel

ACR Appropriateness Criteria Breast Cancer Screening

Mammography is the recommended method for breast cancer screening of women in the general population. However, mammography alone does not perform as well as mammography plus supplemental screening in high-risk women. Therefore, supplemental screening with MRI or ultrasound is recommended in selected high-risk populations. Screening breast MRI is recommended in women at high risk for breast cancer on the basis of family history or genetic predisposition. Ultrasound is an option for those high-risk women who cannot undergo MRI. Recent literature also supports the use of breast MRI in some women of intermediate risk, and ultrasound may be an option for intermediate-risk women with dense breasts. There is insufficient evidence to support the use of other imaging modalities, such as thermography, breast-specific gamma imaging, positron emission mammography, and optical imaging, for breast cancer screening. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria Palpable Breast Masses

A palpable breast mass is one of the most common presenting features of breast carcinoma. However, the clinical features are frequently nonspecific. Imaging performed before biopsy is helpful in characterizing the nature of the mass. For women with clinically detected breast masses, the vast majority will require evaluation with ultrasound. Diagnostic mammography is the initial imaging modality of choice for women aged ≥ 40 years; ultrasound is typically necessary unless a definitively benign mass is identified as the etiology of the clinical finding. For evaluating women aged <30 years and women who are pregnant or lactating, ultrasound is used for initial evaluation. For women aged 30 to 39 years, either ultrasound or diagnostic mammography may be used for initial evaluation. MRI is rarely indicated to evaluate a clinically detected finding. Biopsy is indicated for masses with suspicious features. Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma. Correlation between imaging and the clinical finding is essential. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR–AAPM–SIIM Practice Guideline for Determinants of Image Quality in Digital Mammography

This guideline was developed collaboratively by individuals with recognized expertise in breast imaging, medical physics, and imaging informatics, representing the American College of Radiology (ACR), the American Association of Physicists in Medicine (AAPM), and the Society for Imaging Informatics in Medicine (SIIM), primarily for technical guidance. It is based on a review of the clinical and physics literature on digital mammography and the experience of experts and publications from the Image Quality Collaborative Workgroup [1–3]. For purposes of this guideline, digital mammography is defined as the radiographic examination of the breast utilizing dedicated electronic detectors to record the image (rather than screen film) and having the capability for image display on computer monitors. This guideline is specific to two-dimensional (2D) digital mammography since the vast majority of digital mammography performed in the USA is 2D. Although some three-dimensional technologies are in use, they are not addressed in this guideline since they continue to evolve and are not yet in widespread clinical use. In many parts of this guideline, the level of technical detail regarding the determinants of image quality for digital mammography is advanced, and is intended to provide radiologists, qualified medical physicists, regulators, and other support personnel directly involved in clinical implementation and oversight an expanded knowledge of the issues pertinent to assessing and maintaining digital mammography image quality from the acquisition, display, and data storage aspects of the process. Where basic technical requirements for digital mammography overlap with those for digital radiography in general, users are directed to consult the referenced ACR practice guidelines [4, 5]. All interested individuals are encouraged to review the ACR digital radiography guidelines. Additionally, this guideline includes input from industry, radiologists, and other interested parties in an attempt to represent the consensus of the broader community. It was further informed by input from another working group of the Integrating the Healthcare Enterprise (IHE) Initiative [6]. Furthermore, the ACR Subcommittee on Digital Mammography is developing a quality control (QC) manual for digital mammography. Analysis of image quality has meaning primarily in the context of a particular imaging task [7]. This guideline has been developed with reference to specific imaging tasks required by mammography, using the information available in the peer-reviewed medical literature regarding digital mammography acquisition, image processing and display, storage, transmission, and retrieval. Specifically, the imaging tasks unique to mammography that determine the essential characteristics of a high-quality mammogram are its ability to visualize the following features of breast cancer: The characteristic morphology of a mass. The shape and spatial configuration of calcifications. Distortion of the normal architecture of the breast tissue. Asymmetry between images of the left and right breast. The development of anatomically definable changes when compared with prior studies. The primary goal of mammography is to detect breast cancer, if it exists, by accurately visualizing these features. At the same time, it is important that these signs of breast cancer not be falsely identified if breast cancer is not present. Two aspects of digital image quality can be distinguished: technical and clinical. It is possible to make technical measurements describing the above attributes, and it may be possible to infer a connection between these technical measures and clinical image quality. The extent to which these features are rendered optimally with a digital mammography system using current technology depends on several factors and is the major focus of this guideline.

Value Management Program: Performance, Quantification, and Presentation of Imaging Value-Added Actions

Health care is in a state of transition, shifting from volume-based success to value-based success. Hospital executives and referring physicians often do not understand the total value a radiology group provides. A template for easy, cost-effective implementation in clinical practice for most radiology groups to demonstrate the value they provide to their clients (patients, physicians, health care executives) has not been well described. A value management program was developed to document all of the value-added activities performed by on-site radiologists, quantify them in terms of time spent on each activity (investment), and present the benefits to internal and external stakeholders (outcomes). The radiology value-added matrix is the platform from which value-added activities are categorized and synthesized into a template for defining investments and outcomes. The value management program was first implemented systemwide in 2013. Across all serviced locations, 9,931.75 hours were invested. An annual executive summary report template demonstrating outcomes is given to clients. The mean and median individual value-added hours per radiologist were 134.52 and 113.33, respectively. If this program were extrapolated to the entire field of radiology, approximately 30,000 radiologists, this would have resulted in 10,641,161 uncompensated value-added hours documented in 2013, with an estimated economic value of

ACR Appropriateness Criteria Stage I Breast Cancer: Initial Workup and Surveillance for Local Recurrence and Distant Metastases in Asymptomatic Women

2.21 billion.

Original articleACR Appropriateness Criteria Breast Cancer Screening

Women newly diagnosed with stage 1 breast cancer have an early-stage disease that can be effectively treated. Evidence provides little justification for performing imaging to exclude metastasis in asymptomatic women with stage I breast cancer. No differences have been found in survival or quality of life in women regardless of whether they underwent initial workup for metastatic disease. These women generally prefer intensive follow-up to detect an early recurrence. However, survival rates do not differ between women who obtain intensive screening and surveillance, with imaging and laboratory studies, and women who undergo testing only as a result of development of symptoms or findings on clinical examinations. In addition, quality of life is similar for women who undergo intensive surveillance compared with those who do not. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients. Additional imaging may be needed if the patient has locoregional symptoms. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review by the panel include extensive analysis of current medical literature from peer-reviewed journals and application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures. When evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Implementing a Community Hospital Lung Cancer Screening Program: A Multidisciplinary Program and a Standardized Reporting System.

Mammography is the recommended method for breast cancer screening of women in the general population. However, mammography alone does not perform as well as mammography plus supplemental screening in high-risk women. Therefore, supplemental screening with MRI or ultrasound is recommended in selected high-risk populations. Screening breast MRI is recommended in women at high risk for breast cancer on the basis of family history or genetic predisposition. Ultrasound is an option for those high-risk women who cannot undergo MRI. Recent literature also supports the use of breast MRI in some women of intermediate risk, and ultrasound may be an option for intermediate-risk women with dense breasts. There is insufficient evidence to support the use of other imaging modalities, such as thermography, breast-specific gamma imaging, positron emission mammography, and optical imaging, for breast cancer screening. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® Stage I Breast Carcinoma

THE PROBLEM Elkhart, Indiana, has a regional population of approximately 150,000 people. The area has a long tradition of manufacturing in the recreational vehicle industry and in freight, shipping more primary metals than any other municipality in the United States[1].Thisstrongmanufacturing base was hard hit during the economic downturn of 2008, leaving a large unemployed population in its wake. Elkhart County’ sp opulation of smokers is among the state’s highest at 23.4% (Indiana’s rate is 17%) [2] .D ata from the Elkhart General Hospital Cancer Registry over the past 10 years show that 50% of lung cancers diagnosed in the area were diagnosed at stage IV, higher than the national average of 50% of lung cancers diagnosed at stage III or stage IV [3]. In 2011, the Elkhart County CommunityHealthAssessmentidentified smoking as a significant health

Developing Quality Measures for Diagnostic Radiologists: Part 2

Stage I breast carcinoma is classified when an invasive breast carcinoma is ≤2 cm in diameter (T1), with no regional (axillary) lymph node metastases (N0) and no distant metastases (M0). The most common sites for metastases from breast cancer are the skeleton, lung, liver, and brain. In general, women and health care professionals prefer intensive screening and surveillance after a diagnosis of breast cancer. Screening protocols include conventional imaging such as chest radiography, bone scan, ultrasound of the liver, and MRI of brain. It is uncertain whether PET/CT will serve as a replacement for current imaging technologies. However, there are no survival or quality-of-life differences for women who undergo intensive screening and surveillance after a diagnosis of stage I breast carcinoma compared with those who do not. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Report of the ACR’s Economics Committee on Value-Based Payment Models

The ACR convened a cross-specialty, multidisciplinary technical expert panel to identify and define new measures for quality improvement. These measures can be included in the ACRs National Radiology Data Registry and potentially used in the CMS quality reporting programs. The technical expert panel was tasked with developing measures that reflect the most rigorous clinical evidence and address areas most in need of performance improvement. The measures described in these articles represent a new phase in the ACRs efforts to develop meaningful measures for radiologists that promote population health through diagnostic accuracy, clinical effectiveness, and care coordination.