Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Mammography Screening (NQF 0508)

EMeasure Name Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Mammography Screening EMeasure Id AF71BEE7-F206-4D46-B4E5-2201B5150CF5
Version number 1 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
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
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.
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)
Improvement notation
Lower score indicates better quality
Measurement duration
12 month(s)
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.
Definition
"Probably Benign" Classification: MQSA assessment category of "probably benign"; BI-RADS® category 3; or FDA-approved equivalent assessment category
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").
    

Table of Contents


Population criteria

Data criteria (QDS Data Elements)

Summary Calculation

Calculation is generic to all measures:



Measure set CLINICAL QUALITY MEASURE SET 2011-2012