Improving the process of obtaining screening and diagnostic breast MRI: A quality improvement project at an urban VA hospital.
Authors: Podany Emily L , Wayant Cole , Patel Nikhil Anil , Simmons Kristen , Muthukumar Varsha , Wu Cindy Q , Lopez Elyse R , Parizi Mahdieh , Holmes Maurice A , Ansari Sarah , Bushan Sita 
Published: June 2022

e18641

Background: There are two million female veterans across the United States, a number increasing by more than 18,000 per year. 1 in 8 women will be diagnosed with breast cancer in their lifetime, and studies have shown that servicewomen are 40% more likely to get breast cancer than civilians. The American Cancer Society (ACS) recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and both primary care physicians and oncologists are now ordering these more frequently. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs screening mammograms and ultrasounds, but breast MRI is not currently available at the facility. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments, the outside MRI facility, and the patient. There are a significant number of MRI order cancellations per month, which can lead to delays in diagnosis or treatment. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We looked at all breast MRI orders starting in 12/2020 at the MEDVAMC and determined the rate of cancellation and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis to determine the most common cancellation reasons and p-charts of the percent of cancelled MRI orders per month and a run chart of the percent due to incorrect verbiage. Results: Of the 243 orders placed for MRI for 124 patients from 12/2020 to 1/2022, 64.2% were cancelled. Of the 57% of patients (71/124) with complete MRIs, 35.2% had non-benign findings requiring follow up, excluding known malignancies. Our Pareto analysis showed that most cancellations were due to incorrect verbiage in the order. An intervention in 6/2021 changed the MRI order from a free text box to clickable options, followed by an educational intervention in 12/2021. Cancellations due to incorrect verbiage decreased overall after June, however it has not yet reached significance. It is too early to determine if the educational intervention caused a significant change, however the cancellation rate has decreased. Conclusions: Providing discrete, clickable options within the MRI order has reduced the number of cancellations due to incorrect verbiage, though we have not yet reached significance. Early data suggests that the educational intervention has improved the cancellation rate. Fewer cancellations will lead to more timely studies, which will in turn lead to faster follow up of non-benign findings. Further directions include using a nurse navigator to reduce confusion and delays, further simplifying the ordering process, checking patient phone numbers in clinic, and sending patients home with information on the importance of screening MRI to reduce veteran cancellation.