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## Complete Summary

#### TITLE

Radiology: percentage of final reports for screening mammograms that are
classified \"probably benign\".

#### SOURCE(S)

American College of Radiology, Physician Consortium for Performance
Improvement®, National Committee for Quality Assurance. Radiology
physician performance measurement set. Chicago (IL): American Medical
Association, National Committee for Quality Assurance; 2007 Oct. 42 p.
\[22 references\]

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Process

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of final reports for
screening mammograms that are classified as \"probably benign\".

#### 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. BI-RADS® Category 3 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.\*

\*The following clinical recommendation statements are quoted
[verbatim]{.underline} from the referenced clinical guidelines and
represent the evidence base for the measure:

Do not use Category 3 in interpreting screening examinations. (American
College of Radiology \[ACR\])

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)

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)

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)

#### PRIMARY CLINICAL COMPONENT

Screening mammography; \"probably benign\" assessment category

#### DENOMINATOR DESCRIPTION

All final reports for screening mammograms

#### NUMERATOR DESCRIPTION

Final reports classified as \"probably benign\"

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Use of this measure to improve performance

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Yasmeen S, Romano PS, Pettinger M, Chlebowski RT, Robbins JA, Lane DS,
Hendrix SL. Frequency and predictive value of a mammographic
recommendation for short-interval follow-up. J Natl Cancer Inst2003 Mar
19;95(6):429-36.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12644536)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Ancillary Services\
Hospitals\
Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

All patients, regardless of age

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Unspecified

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All final reports for screening mammograms

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All final reports for screening mammograms

**Exclusions**\
None

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Diagnostic Evaluation\
Encounter

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Final reports classified as \"probably benign\"

Definition of \"probably benign\" classification: Mammography Quality
Standards Act (MQSA) assessment category of \"probably benign\"; Breast
Imaging Reporting and Data System (BI-RADS®) category 3; or FDA-approved
equivalent assessment category.

**Exclusions**\
None

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Encounter or point in time

#### DATA SOURCE

Administrative data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

Unspecified

### Identifying Information

#### ORIGINAL TITLE

Measure #3: inappropriate use of \"probably benign\" assessment category
in mammography screening.

#### MEASURE COLLECTION

[The Physician Consortium for Performance Improvement® Measurement
Sets](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2002&doc=178)

#### MEASURE SET NAME

[Radiology Physician Performance Measurement
Set](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2002&doc=11934)

#### SUBMITTER

American Medical Association on behalf of the American College of
Radiology, the National Committee for Quality Assurance, and the
Physician Consortium for Performance Improvement®

#### DEVELOPER

American College of Radiology\
National Committee for Quality Assurance\
Physician Consortium for Performance Improvement®

#### FUNDING SOURCE(S)

Unspecified

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

William Golden, MD (*Co-Chair*); David Seidenwurm, MD (*Co-Chair*);
Stephen Amis, MD; Michael Bettmann, MD; Joseph P. Drozda, Jr, MD; James
H. Ellis, MD; Thomas C. Fenter, MD; George Fueredi, MD; Bruce R.
Greenspahn, MD, FACC; Carol H. Lee, MD; Richard Leithiser, Jr, MD, MMM;
Mark D. Morasch, MD; Robert Pyatt, Jr., MD; Robert Rosenberg, MD; John
Schneider, MD, PhD; Gary Schultz, DC, DACBR; Carl L. Tommaso, MD, FSCAI

Mark Gorden, MS, American College of Radiology; Diane Hayek, American
College of Radiology; Judy McKenzie, American College of Radiology;
Pamela Wilcox, American College of Radiology

Joseph Gave, MPH, American Medical Association; Kendra Hanley, MS, CHE,
American Medical Association; Karen Kmetik, PhD, American Medical
Association; Samantha Tierney, MPH, American Medical Association

Aisha Pittman, MPH, National Committe for Quality Assurance; Phil
Renner, MBA, National Committe for Quality Assurance

Sue Nedza, MD, MBA, FACEP, Centers for Medicare & Medicaid Service;
Sylvia Publ, MBA, RHIA, Centers for Medicare & Medicaid Service

Rebecca Kresowik, Consortium Consultant; Timothy Kresowik, MD,
Consortium Consultant

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

Conflicts, if any, are disclosed in accordance with the Physician
Consortium for Performance Improvement® conflict of interest policy.

#### INCLUDED IN

Ambulatory Care Quality Alliance

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2007 Oct

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

American College of Radiology, Physician Consortium for Performance
Improvement®, National Committee for Quality Assurance. Radiology
physician performance measurement set. Chicago (IL): American Medical
Association, National Committee for Quality Assurance; 2007 Oct. 42 p.
\[22 references\]

#### MEASURE AVAILABILITY

The individual measure, \"Measure #3: Inappropriate Use of \"probably
benign\" Assessment Category in Mammography Screening,\" is published in
the \"Radiology Physician Performance Measurement Set.\" This document
and technical specifications are available in Portable Document Format
(PDF) from the American Medical Association (AMA)-convened Physician
Consortium for Performance Improvement® Web site:
[www.physicianconsortium.org](http://www.physicianconsortium.org/).

For further information, please contact AMA staff by e-mail at
<cqi@ama-assn.org>.

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on February 1, 2008.
The information was verified by the measure developer on April 10, 2008.

#### COPYRIGHT STATEMENT

© 2007 American Medical Association and National Committee for Quality
Assurance. All Rights Reserved.

CPT® Copyright 2006 American Medical Association

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008