eMeasure Name | Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Mammography Screening | eMeasure Id | AF71BEE7-F206-4D46-B4E5-2201B5150CF5 |
Version number | 1 | eMeasure Set Id | AEA58010-BD91-4F99-B1A9-1502C879B891 |
Available Date | No information | Measurement Period | January 1, 20xx through December 31, 20xx |
Measure Steward | American Medical Association - Physician Consortium for Performance Improvement | ||
Endorsed by | National Quality Forum | ||
Description | Percentage of final reports for screening mammograms that are classified as "probably benign" | ||
Copyright | © 2010 American Medical Association and/or National Committee for Quality Assurance. All Rights Reserved |
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Measure scoring | Proportion | ||
Measure type | Process | ||
Stratification | None |
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Risk Adjustment | None |
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Data Aggregation | |||
Rationale | Although a mammogram assessment category of "probably benign" is not recommended for use in interpreting screening mammograms, it is associated with up to 11% of screening mammograms and accounts for over 40%-50% of abnormal screening mammograms. (Yasmeen S, Romano PS, Pettinger M, et al.) A mammogram assessment category of "probably benign" is coupled with a recommendation for short-interval follow-up (typically 6 months), resulting in economic and emotional consequences for the women that receive them. |
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Clinical Recommendation Statement | Do not use Category 3 in interpreting screening examinations. (ACR, 2003) All the published studies emphasize the need to conduct a complete diagnostic imaging evaluation before making a probably benign (Category 3) assessment; hence it is inadvisable to render such an assessment when interpreting a screening examination. (ACR, 2003) The use of Category 3, probably benign, is reserved for findings that are almost certainly benign. It must be emphasized that this is NOT an indeterminate category for malignancy, but one that, for mammography, has a less than 2% chance of malignancy (i.e. is almost certainly benign). (ACR, 2003) Such findings are generally identified on baseline screening or on screening for which previous examinations are unavailable for comparison. Immediate evaluation with additional mammographic views and/or ultrasound is required to render a Category 3, probably benign assessment. (ACR, 2003) |
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Improvement notation | Lower score indicates better quality |
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Measurement duration | 12 month(s) |
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Reference | American College of Radiology (ACR) Breast Imaging Reporting and Data System Atlas (BI-RADS® Atlas). Reston, Va: © American College of Radiology; 2003. All rights reserved. |
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Definition | "Probably Benign" Classification: MQSA assessment category of "probably benign"; BI-RADS® category 3; or FDA-approved equivalent assessment category |
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Definition | Initial Patient Population(s): Patient Age: All patients regardless of age. Encounter: Screening Mammogram. Diagnostic Study: Screening Mammograms performed |
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Definition | Denominator(s): All final reports for screening Mammograms |
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Definition | Denominator Exception(s): N/A |
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Definition | Numerator(s): Final reports classified as "probably benign". |
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Definition | Denominator Exclusion(s): N/A |
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Guidance | Eligible cases for this measure include every final report for screening mammograms performed during the measurement period. Each final report for screening mammograms counts separately in the denominator. For performance, a lower percentage, with a definitional target approaching 0%, indicates appropriate assessment of screening mammograms (eg, the proportion of screening mammograms that are classified as "probably benign"). |
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Supplemental Data Elements | Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)". |
Measure set | CLINICAL QUALITY MEASURE SET 2011-2012 |