N o n i n t e r p r e t i ve S k i l l s • C l i n i c a l Pe r s p e c t i ve Carkaci et al. Mobile Mammography

FOCUS ON:

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Noninterpretive Skills Clinical Perspective

Selin Carkaci1 William R. Geiser 2 Beatriz E. Adrada3 Cindy Marquez 3 Gary J. Whitman3 Carkaci S, Geiser WR, Adrada BE, Marquez C, Whitman GJ

How to Establish a Cost-Effective Mobile Mammography Program OBJECTIVE. The purpose of this article is to describe how to establish a cost-effective mobile mammography program on the basis of examples from a 20-year experience with film-screen and digital mammography units. CONCLUSION. Mobile mammography programs can reduce many barriers to breast cancer screening faced by medically underserved women. Finding and maintaining resources, having appropriate equipment and infrastructure, and having a dedicated team with an efficient workflow are the key elements of establishing a cost-effective mobile mammography program.

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Keywords: digital mammography, mobile mammography, screening DOI:10.2214/AJR.12.9825 Received August 7, 2012; accepted after revision January 18, 2013. 1 Department of Diagnostic Radiology, The Ohio State University Medical Center, 395 W 12th Ave, Columbus, OH 43210. Address correspondence to S. Carkaci ([email protected]). 2 Department of Imaging Physics, The University of Texas M.D. Anderson Cancer Center, Houston, TX. 3 Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, TX.

CME/SAM This article is available for CME/SAM credit. WEB This is a web exclusive article. AJR 2013; 201:W691–W697 0361–803X/13/2015–W691 © American Roentgen Ray Society

esults of randomized clinical trials have shown the usefulness of screening mammography in reducing breast cancer deaths among women 40–75 years old [1–4]. Use of mammography and adherence to mammographic screening guidelines should be increased to reduce mortality due to breast cancer. Mammography remains underused by several demographic groups, including uninsured women, women with lower incomes, racial and ethnic minority women, and women who reside in rural areas [5, 6]. These women are at greater risk of advanced-stage breast cancer at diagnosis and lower survival rates [7–12]. Various health care interventions have been developed to overcome the barriers to screening mammography. One such intervention is the use of mobile mammography [13, 14]. Mobile mammography programs have been in practice for more than two decades and typically target women who lack access to preventive health care because of geographic, financial, or insurance limitations or lack of a regular source of medical care. Population studies have shown mobile mammography programs to be effective at increasing rates of breast cancer screening [15–22]. In this article, we discuss how to establish a costeffective mobile mammography program by sharing our 20 years of experience with filmscreen and digital mammography units. Mission and Organization The University of Texas M. D. Anderson Cancer Center mobile mammography pro-

gram was established in 1992 with the mission of increasing mammography screening rates at underserved sites in the greater Houston area. One of the key elements in running a cost-effective mobile mammography program is to have a dedicated and organized team. Mobile facilities vary widely in their staffing practices [14] and use different combinations of radiology technologists, clerks, nurses, and other personnel. Our mobile mammography program team is composed of a medical director, a medical physicist, a program coordinator (1 full-time equivalent [FTE]), two mammography technologists (2 FTEs), two diagnostic imaging coordinators (2 FTEs), a mobile patient services coordinator (1 FTE), and one diagnostic imaging assistant (1 FTE). Each of the team members has specific responsibilities. The medical director is a professor of radiology with 22 years of experience in breast imaging. Apart from working as a full-time faculty member in the breast center, he is also responsible for directing and overseeing the mobile mammography program, including fiscal operations, grants, and technologist, faculty, and staff activities related to the mobile mammography program. The program coordinator plays a key role and is responsible for administrative management, including preparation of financial and strategic models; maintaining the mobile mammography program calendar; managing equipment; making deposits to the company center for self-pay patients; creating, submitting, and following up on the status of payment for sites that are invoiced di-

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Carkaci et al. rectly; tracking and reconciling grant and philanthropic funds; and maintaining key metrics on operational, financial, and procedural volume data. Apart from obtaining screening mammograms, the technologists are responsible for the mobile unit inspection; driving to the scheduled sites; performing quality control tests; asking patient history questions and documenting findings; communicating with the site coordinators regarding issues that may arise, such as patient flow delays and mechanical and technical issues; troubleshooting equipment issues; and downloading images at the end of the day. The diagnostic imaging coordinators schedule patient appointments, fax reports to physicians and clinics, update the mobile mammography site log, mail patient letters, review and update all unresolved cases (those of patients with pending examinations), fax release of medical information documents to physicians, and resolve the cases of patients who have completed the recommended follow-up examinations, refused to undergo the follow-up examinations, or were unresponsive to two telephone call attempts and two certified letters. The duties of the mobile patient services coordinator include driving to and from the scheduled sites, organizing and reviewing the paperwork for each patient, asking and documenting patient history questions, inspecting the mobile unit before and after each trip, and documenting and reporting issues to the program coordinator. The diagnostic imaging assistant checks the voice mail and uses the voice mail log to call patients, picks up and delivers documents and mail, calls patients and physicians to verify or update mailing addresses, and folds, seals, and mails patient letters. The medical physicist is a faculty member in the department of medical physics. The medical physicist is part of the overall quality assurance team, along with the lead interpreting physician and the quality control technologist. The medical physicist is responsible for performing acceptance testing on the equipment, annual testing of the equipment to ensure compliance with Mammography Quality Standards Act guidelines, image quality assessment, quality assurance, quality control reviews, dose measurements, and reviews of the technologist quality control program. Operational Details Service Sites and Demographics Since the beginning of operation of the mobile mammography program, more than

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78,000 women, one third of whom are medically underserved, have undergone screening. Most of the sites that the mobile van visits are corporations and medical clinics. The mobile van travels an average of 26 miles (42 km) round trip each day. The patient population is mainly composed of white (38%) and Hispanic (35%) women; the others are African American (15%) and Asian (7%) or of unspecified race (5%). In 2011, with the current digital mammography system, the mobile mammography program was operational 146 days per year. We are planning on increasing the number of operational days to 168 during the next fiscal year. Inside the Van The current 38-foot (11.6 m) van (Fig. 1) is staffed by two rotating registered technologists and a patient services coordinator. The van includes a waiting area (Fig. 2A); a registration area, where checking in patients and updating demographic information is performed (Fig. 2B); a changing room; and a mammography room, which contains a digital unit (Selenia, Hologic) accredited by the American College of Radiology (Fig. 3). Appointments and Scheduling Appointments are made by telephone. Patients who are not employees of a corporation that the mobile van is scheduled to visit are informed of a location for screening mammography in their vicinity that is not restricted to employees. Uninsured patients living inside the city of Houston are advised to contact the Houston Department of Health and Human Services for more information on the Project Valet program, which provides funding for mobile screening mammograms for patients at city clinics. Patients living outside the city are referred to a designated nonprof-

it breast cancer organization that provides mammographic screening, diagnostic mammography, treatment, and support for all women regardless of ability to pay. All women are preregistered; no walk-in screenings are performed. There are eligibility requirements, including the name and the telephone number of a follow-up physician or a primary care provider and insurance information (if it is an insured site). Every mobile mammography program has different eligibility criteria. To lower costs and achieve faster throughput, we perform only screening mammography on the mobile van. Patients must be 35 years old or older with no breast problems, no breast implants, no current pregnancy, and not currently be breastfeeding. Patients with a history of breast cancer must be at least 5 years posttreatment. Patients with breast problems or with a history of breast cancer within the last 5 years are advised to undergo diagnostic mammography at a designated facility. Screening of patients with implants is not performed on the mobile van because the presence of implants requires additional images and time. Typical Work Day Our mobile mammography unit operates 4–6 days a week. A typical work day starts at 6:30 am and ends at approximately 5:00 pm (Table 1). Twenty patients are imaged on an average day with digital equipment versus 23 patients with film-screen mammography previously. The digital unit requires a warmup time of approximately 1 hour at each site. In addition, along with the change to digital mammography, the mobile mammography program changed the patient check-in procedures. Currently, patients are scheduled for a 10-minute check-in period before mammography to allow real-time checking

Fig. 1—Photograph shows mobile mammography van.

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Mobile Mammography

A

B Fig. 3—Photograph shows digital mammography unit in back part of mobile van.

Fig. 2—Interior of mobile mammography van. A, Photograph shows patient waiting area. B, Photograph shows technologist checking in patient.

in and tracking. Previously, with the filmscreen mammography system, the patient arrival process and the tracking process were completed the day after the mammograms were obtained. The current template allows 10 minutes for check-in and 15 minutes’ procedure time. During the day, all images are stored on a laptop computer. After the van returns to M. D. Anderson, the images are uploaded into the PACS, and breast radiologists interpret them within 1 day, unless there is a wait for previous images for comparison. Before the digital equipment was installed, all images were batch processed daily with a film processor in the mammography area at the medical center. Film-screen mammographic images were then placed on a mammography alternator and interpreted the next day by an attending breast imager. Mobile Mammography Program Follow-Up Process Communicating the results of mammographic examinations to referring health care providers and to patients is of utmost importance for a mobile mammography program. Patient letters and physician reports are printed daily. Normal and abnormal reports are separated. If the patient is from an insured site, the report is faxed to the physician, and an e-mail is sent to a clinical data specialist to schedule follow-up at M. D. Anderson. If the patient is from an uninsured site, the reports are faxed to the patient’s

clinic. Some clinics refer their patients for follow-up at M. D. Anderson, provide orders, and request follow-up imaging at M. D. Anderson. Some clinics provide orders for follow-up at a designated nonprofit facility, and

the diagnostic imaging coordinators fax reports to the scheduling coordinator at that facility and fax release forms to the M. D. Anderson film library. At other sites, the patient is informed to contact her physician to obtain

TABLE 1:  Mobile Mammography Schedule Activity

Start Time

End Time

Duration (h)

Preparation to leave for site

6:30 am

6:40 am

0:10:00

Drive to site

6:40 am

7:15 am

0:35:00

Parking at site

7:15 am

7:30 am

0:15:00

Warmup of digital unit

7:30 am

8:30 am

1:00:00 0:30:00

Daily quality control testing

8:30 am

9:00 am

Patient care

9:00 am

12:30 pm

3:30:00

Lunch

12:30 pm

1:00 pm

0:30:00

Patient care

1:00 pm

3:50 pm

2:50:00

Preparation to leave site

3:50 pm

4:00 pm

0:10:00

Mobile coach return and shut down

4:00 pm

4:25 pm

0:25:00

Image upload

4:25 pm

5:00 pm

0:35:00

End of shift

5:00 pm

Total

10:30:00

TABLE 2:  Number of Women Screened in Mobile Mammography Program Fiscal Year Funding

2009

2010

2011

2012

Insurance

2371

1630

1563

1672

Grant

1313

1401

1529

1247

Total

3684

3031

3092

2919

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Carkaci et al.

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results and is provided with her medical record number and the telephone number for the film library to request her images. Mobile Mammography Program Resolve Process Our program invests substantial time and effort in ensuring that women who receive a recommendation for follow-up after screening mammography obtain the care they need in a timely manner. Each abnormal result is closely tracked until there is a definitive negative (return to annual screening) or positive (breast cancer diagnosis) result. A database search is performed periodically to identify unresolved cases. The site at which each patient was screened is identified. An e-mail is sent to the site coordinator to ask whether the patient underwent a follow-up examination. If not, the patient is contacted and is advised to contact her clinic or physician. The patient is contacted a second time to ascertain the follow-up status. If follow-up is still not completed, up to two certified letters are sent. If the patient does not follow the mobile mammography program recommendations, the case is resolved as lost contact. For technical repeat examinations, the patients are contacted to schedule those examinations. Mobile Mammography Screening Outcomes In 2009, with film-screen mammography, a total of 3684 women underwent screening (Table 2). The recall rate was 16.17%, and the cancer detection rate was 2.29 cases of cancer per 1000 women. In 2011, after the installation of the digital mammography system, a total of 3092 women underwent screening (Table 2). The recall rate was slightly lower at 15.8%. The cancer detection rate was a slightly higher 2.89 cases of cancer per 1000 women. Challenges Mobile mammography programs provide an opportunity to increase access to screening mammography, but they face many obstacles, including financial barriers, such as costs of required maintenance for radiologic equipment [21, 23, 24], operating expenses [14, 25, 26], and tracking patient results [27]. Communication of the results and poor compliance with follow-up recommendations have been cited as major concerns in screening of women on a mobile mammography unit [25, 27]. Hospital systems can be overwhelming and difficult to navigate in the presence of language and cultural barriers [28–30]. Mobile mammography programs make screen-

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TABLE 3:  Financial Analysis Overview of Mobile Mammography Program Fiscal Year Expense vs Revenue

2010

2011

2012

Staffing

395,880

416,280

381,480

Service van

15,000

15,000

15,000

Service equipment

11,025

17,500

17,500

Expenses

Insurance

223

223

223

Operation expenses

7900

12,900

12,900

430,028

461,903

427,103

215,649

218,679

234,431

Totala Revenue Health insurance Grant funding

145,704

194,183

200,767

Total

361,353

412,862

435,198

–68,675

–49,041

8095

Operating income

Note—Values are U.S. dollars. aDoes not include the interpretation cost of the radiologist.

ing more accessible by going to work sites, health clinics, churches, synagogues, and even shopping centers to provide first contact in a safe community environment. However, in certain populations, inadequate English proficiency poses a barrier to preventive services. Communicating results to these patients can be difficult. Some of our service sites provide patients with translators in an attempt to overcome language barriers. A survey conducted in 1996 among 159 mobile mammography facilities to identify problems they encountered [14] showed that the most common reasons for downtime were maintenance of the mammography unit (77%), mechanical problems with the vehicle (71%), bad weather (65%), and not enough patients (60%). In keeping with these findings, in our experience, the most common reasons for downtime are maintenance and mechanical issues related to the digital mammography unit and the vehicle. Lack of availability of technologists can also be a problem. To overcome this problem, we have assigned four backup technologists (two of them hold a commercial driver’s license) in addition to the two mobile mammography

technologists and one mobile mammography patient services coordinator. We have a low no-show rate of approximately 13%. Digital Mobile Mammography Since 2000, full-field digital mammography has gained in popularity because of its many advantages over film-screen mammography. Digital mammography has been found to be more accurate than film-screen mammography in screening premenopausal and perimenopausal women, women younger than 50 years, and women with dense breasts, according to results of the largest trial of digital mammography to date, the Digital Mammographic Imaging Screening Trial [31]. With digital mammography, film processing, storage, copying, and retrieval are eliminated. The imaging process also is faster. In digital mammography units, technologists can see the images before the patient is discharged, thus lowering technical repeat rates. Images can be manipulated and postprocessed after acquisition. Digital mammography systems have a higher detective quantum efficiency and a greater dynamic range, leading to improved contrast resolu-

TABLE 4:  Screening Mammography Prices Fiscal Year

Trailblazer Medicare Rate (Technical and Professional)

Mobile Mammography Program Rate for Grant-Funded Sites

2010

132.30

104.00

2011

139.91

127.00

2012

140.21

161.00

Note—Values are U.S. dollars.

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Mobile Mammography tion but more limited spatial resolution compared with film-screen mammography. Digital mammography also allows more efficient use of computer-aided detection. The use of digital mammography on a mobile van has its challenges. One of the greatest challenges is image transfer. Image transfer can be performed with a wireless connection, which can be slow and not always available. Another option, used at our center, is to store the images on a laptop computer and transfer them from the laptop to the PACS at the end of the day. Another challenge is to achieve appropriate environmental conditions. Most systems have a narrow range of optimal temperatures. Extremely hot and extremely cold temperatures can damage the digital detector. Therefore, good air conditioning and heating are needed, and the temperature inside the mobile van should be monitored 24 hours a day, 7 days a week. Maintenance of the system is the same for film-screen and digital mammography and includes semiannual preventive maintenance, annual physics testing, and technologist quality control testing. The greatest difference between the cost of a mobile digital mammography unit and that of a mobile film-screen unit is the annual service contract, which is higher for a digital mammography unit, but the cost of mobile van maintenance remains the same [26]. The additional processing and printing costs of a filmscreen unit partially offset this difference. A digital mammography unit was implemented on our mobile van in May 2010. The transition from film-screen to digital mammography required a refit of the van to improve environmental conditions for the detector, including installation of new air conditioning and heating systems. Temperature and humidity monitors were installed to allow 24 hour a day, 7 day a week monitoring. The digital mammography system also needed an x-ray generator and a filtered power supply. In addition, two laptop computers were purchased for storage and transfer of the images to the PACS. The total cost of this transition was approximately $60,000 in addition to the cost of the new digital mammography unit, which was $220,000. Use of Computer-Aided Detection Systems Computer-aided detection systems for mammography are used to analyze images for microcalcifications and mass patterns suggestive of breast cancer. Computer-aided detection systems are intended to assist the radi-

ologist by marking suspicious areas that may warrant further review. These systems can be particularly useful when evaluation of mammograms by two readers is not possible. The computer-aided detection computer can be placed on the mobile van or at the main facility where the images are read. If the computeraided detection system is placed on the mobile van, the data collected should be transferred to a review station. If the computer is at the reading facility, the raw data should first be stored on a laptop computer and then sent to the computer-aided detection system. Cost Analysis Mobile screening mammography is considered to offer the same benefits as screening mammography at a permanent site. Both types of screening mammography programs screen women without symptoms at regular intervals with the goal of detecting cancers early, when they are easiest to treat, thereby reducing costs associated with therapy [25]. The success of a mobile mammography program depends on the ability to attract large numbers of women for screening and the ability to conduct the program in a cost-effective manner [22]. Unlike a fixed-site program, mobile mammography programs have hidden costs, such as van insurance, maintenance, overtime, marketing, educational services, and travel and liability insurance [26, 32, 33]. Therefore, it is important to understand the true costs of the operation through cost-based analysis (Table 3). This type of analysis should lead to clear understanding of the minimum cost per procedure to ensure resource cost coverage. Medicare reimbursement for technical and professional charges is available online through Trailblazer (official source for Medicare information), but this does not account for total operational costs. The results of a national survey performed in the United States showed that only 47% of the mobile facilities were either financially profitable or breaking even and that 52% reported minimal or substantial losses [14]. The financial goal of our mobile mammography program is to be self-sustaining and to be able to generate a small profit to cover operational costs and salaries. To achieve this goal, over 2 years, we gradually increased the screening mammography fees for grant-funded sites from below to slightly above the Medicare rate (Table 4). The cost for a screening mammographic examination varies depending on the site. For self-paying patients and invoiced corporate sites, the fee

is $166 per patient; the grant-funded sites are invoiced between $156 and $166 per patient (average, $161) (Table 4). The fee is based on the technical and direct costs, professional fees, computer-aided detection costs, depreciation, and institutional overhead. As a result of these changes, in fiscal year 2012, we saw an increase in operating income from –$68,675 to $8095 (Table 3). Although mobile mammography programs typically target women who lack access to preventive health care because of geographic, financial, or insurance limitations, in reality, to be able to be self-sustaining and continue offering screening services to underprivileged women, we must have a high volume. Therefore, we also extend mobile mammography service to insured women. Most of our patient population is insured women (58%); 27% of patients are covered by grants submitted by the clinics we serve; 14% are covered by grants to our mobile mammography program; and 1% are self-paying. However, it is our priority to find ways to increase our services to uninsured women, including offering more dates to current clinics and adding new grant-funded sites. Although the primary goal of mobile mammography programs is to increase the percentage of women undergoing regular screening mammography, for some practices, in addition to this goal, mobile mammography programs are also seen as a means of increasing the market share in breast cancer diagnosis and treatment, thus generating revenue [34]. We have not seen a significant increase in the overall use of mammography services at our institution as a result of having the mobile mammography program. Funding The primary barrier to implementation of a mobile mammography program is the cost. Most programs that offer mobile mammography benefit from philanthropic support. Our mobile mammography program is privately owned by the University of Texas M. D. Anderson Cancer Center, and we must offset 12% of our operating costs with grants and private funding to continue offering mammography to underinsured and uninsured women. Our team consistently works to determine funding needs and goals for future services to uninsured patients. We currently have a grant from the National Breast Cancer Foundation. Education Provider recommendations for cancer screening are among the strongest predictors

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Carkaci et al. of mammography use [5]. However, low-income, uninsured, and minority women have low levels of preventive health service utilization and therefore receive limited benefit from interventions that focus on provider recommendations [5, 35–38]. It has been suggested [39] that women who follow health recommendations are usually the ones who are informed about their personal risk and about how screening can be beneficial. Efforts to increase screening mammography may therefore benefit from providing simple, clear information about the risk of cancer and about the capabilities, successes, and importance of mammography in early detection. During our scheduled site visits, we not only obtain mammograms but also try to give our patients information about breast health by providing educational materials on board the mobile van. Some sites also conduct classes on how to perform breast self-examinations and on healthy nutrition and show videos on the importance of mammography. Conclusion Mobile mammography programs can reduce many of the barriers to breast cancer screening faced by medically underserved women. Our experience shows that the benefits of a mobile mammography program outweigh the limitations. Finding and maintaining resources, having appropriate equipment and infrastructure, and having a dedicated team with an efficient workflow are the key elements to establishing a cost-effective mobile mammography program. Acknowledgments We thank Michael Wedgeworth, Sandy Maxey, Debra Steinway, Dolores Garcia, and Deborah Thames for their contributions to this manuscript. We thank Patty Castro for assistance in manuscript preparation. References 1. Fletcher SW, Elmore JG. Clinical practice: mammographic screening for breast cancer. N Engl J Med 2003; 348:1672–1680 2. Nyström L, Andersson I, Bjurstam N, et al. Longterm effects of mammography screening: updated overview of the Swedish randomised trials. Lancet 2002; 359:909–919 3. Smith-Bindman R, Kerlikowske K, Gebretsadik T, et al. Is screening mammography effective in elderly women? Am J Med 2000; 108:112–119 4. Hellquist BN, Duffy SW, Abdsaleh S, et al. Effectiveness of population-based service screening with mammography for women ages 40–49 years:

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