Research studies, including eight large randomized clinical trials with 11- 20 years of followup, indicated that widespread use of mammography could reduce breast cancer mortality. The benefit of mammography has recently been challenged by two Danish researchers and an NCI advisory panel made up of independent experts; they cite serious flaws in six of the eight clinical trials that showed benefits. However, subsequent to the Danish report and the NCI panel’s statement, both NCI and the U.S Preventive Services Task Force reiterated their recommendations for regular mammography screening. While acknowledging the methodological limitations in these trials, the U.S. Preventive Services Task Force concluded that the flaws in these studies were unlikely to negate the reasonable consistent and significant mortality reductions observed in these trials. The effectiveness of mammography as a cancer detection technique is directly tied to the quality of mammography procedures. Concerned about the quality of mammography procedures provided by the nation’s mammography facilities, the Congress enacted the Mammography Quality Standards Act (MQSA) of 1992, which imposed standards effective October 1, 1994. FDA has major oversight responsibilities, including establishing quality standards for mammography equipment and personnel and certifying and inspecting each facility to ensure it provides quality services. For mammography personnel, such as radiologic technologists and interpreting physicians, FDA specifies detailed qualifications and continuing training requirements. Mammography technologists are required to be licensed by a state or certified by the American Registry of Radiologic Technologists in general radiography, and meet additional mammography-specific training and continuing education and experience requirements. Similarly, FDA specifies that all interpreting physicians be licensed in a state and certified in the specialty by an appropriate board, such as the American Board of Radiology, and meet certain mammography-specific medical training, as well as continuing education and experience requirements. FDA collects detailed information about each facility when a facility is initially certified. FDA has established a database that incorporates data from the certification process and from its annual inspection program. Besides facility identification information, the database contains information on the number of machines, personnel, and whether the facility is active or no longer certified. Medicare, the federal government’s health insurance program for people age 65 and above, is the nation’s largest purchaser of health services. Beginning in 1991, Medicare provided coverage of annual mammography screening for women beneficiaries. Medicare is administered by CMS. As a part of its health care improvement program, since 1999, CMS and a set of contractors, called peer review organizations, have been involved in monitoring and improving the quality of care, including increasing mammography screening rates among women Medicare beneficiaries. The nation’s overall capacity to meet the growing demand for mammography services is generally adequate. Between 1998 and 2000, the use of services, as measured by the number of mammograms provided to women age 40 and older, increased nearly 15 percent. The most recent data on capacity show that the total number of machines and radiologic technologists available to perform mammography services increased 11 percent and 21 percent respectively from October 1998 to October 2001. During this same period, the total number of mammography facilities decreased about 5 percent, indicating that facilities were consolidating or becoming somewhat larger. The average number of mammograms performed per machine increased slightly but was considerably below estimates of full capacity. The one potentially negative development is in personnel, where the number of new entrants into the field—as measured by the number of persons who sit for mammography technologist or diagnostic radiology examinations for the first time—has dropped each year since 1997. The use of mammography as a tool for detecting early cancer continues to increase. Data from CDC’s Behavioral Risk Factor Surveillance System indicate a continuing increase in national mammography screening rates. The proportion of women age 40 and over who had received a mammogram within the past year increased from 58 percent in 1998 to about 64 percent in 2000. These screening rate increases, coupled with the growth of this population, have resulted in significant increases in the number of mammograms provided each year. Based on CDC’s data on screening rates and Bureau of Census population data, we estimate that the total number of mammograms received by women 40 and above nationwide has increased nearly 15 percent, from about 35 million in 1998 to more than 40 million in 2000. These increases in mammography utilization extended across nearly every state. Using the screening rates and the Bureau of Census population data, we computed the number of mammograms received by women age 40 and above on a state-by-state basis. Between 1998 and 2000, screening rates for women in this age group increased in all but one state (i.e., Oklahoma) and the District of Columbia, and 39 states had an increase of more than 10 percent in the total number of women age 40 and above who had received a mammogram within the past year. The nation’s capacity to provide mammography services, as measured by the numbers of machines and radiologic technologists available to perform mammography services, has also increased. FDA’s data show that between October 1998 and October 2001, the total number of mammography machines and radiologic technologists available nationwide to perform mammography services increased 11 percent and 21 percent respectively (see table 1). While FDA’s data showed that the total number of certified facilities has decreased about 5 percent between 1998 and 2001, the average number of machines per facility increased from 1.22 in 1998 to 1.42 in 2001. Overall, the 5 percent decrease in facilities has been offset by the 16 percent increase in the number of machines per facility and the increase in personnel. The current average number of mammograms actually being performed per machine appears to be well below estimates of how many mammograms could be performed, if equipment is operating at full capacity. While there is no uniform standard on the number of mammograms that a mammography machine can do in a day, FDA officials estimated that one machine and one full-time technologist can potentially perform between 16 and 20 mammograms in an 8-hour work day, or between 4,000 to 5,000 mammograms a year (assuming 5 days a week and 50 weeks a year). Using CDC’s data on mammography screening rates, Bureau of Census data on the population of women age 40 and older, and FDA’s data on the number of machines, we computed the average number of mammograms performed per machine. At the national level, the average number of mammograms per machine was 2,759 in 1998. While this average number of mammograms per machine had increased to 2,840 in 2001, it was still well under 4,000, the lower end range of estimated full capacity. At the state level, the average number of mammograms per machine in 2001 ranged from a low of 1,790 in Alaska to a high of 3,720 in Maryland. While the number of radiologic technologists has increased in the past in general proportion with the increase in mammography utilization, certain trends bear monitoring. According to an American Hospital Association survey, the job vacancy rate for radiologic technologists was 18 percent in 2001, and 63 percent of hospitals reported that they had more difficulty recruiting radiologic technologists than the previous year. Data from ARRT show the rate of increase for certified mammography technologists through 2000 has slowed down substantially in recent years. Similarly, the number of new entrants to the field, as represented by the number of first- time examinees for the mammography certificate, declined substantially each year from 1996 through 2000 (see table 2). In addition, while comprehensive data are not available on the total number of radiologists available to interpret mammograms, the limited data available also indicate that the availability of radiologists may bear watching. For example, data from the employment placement service of the American College of Radiology show an increasing ratio of job listings per job seeker for radiologists –from 1.3 in 1998 to 3.8 in 2000. Also, data from the American Board of Radiology show that the number of first-time candidates who sit for diagnostic radiology examination has declined each year from 1997 through 2001 (see table 3). Because of local factors such as a shortage of personnel or closure of certain facilities, waiting times for routine mammograms could be several months in certain locations. Nationwide, 241 counties had a net loss of mammography machines between October 1998 and October 2001, with 121 of them losing more than 25 percent. Our follow-up at 55 rural and metropolitan counties where reductions occurred indicated that lengthy appointment waiting times for mammography services were primarily in metropolitan locations. Our county-by-county analysis of data on equipment shows that overall, 241 counties had a net loss in the number of mammography machines between October 1998 and October 2001. Of these counties, 121 lost more than 25 percent of their machines. This number represents counties spread throughout the nation. These counties together contained less than 1.9 percent of the total U.S. population in the 2000 census. We conducted an analysis to determine what had occurred in those counties close to the 121 counties that lost more than 25 percent of their machines. In general, the adjacent counties showed an increase in the number of machines, with nearly all of the 121 counties being within 50 miles of a county that gained machines. Thus, residents in most of the counties that lost services appear to be able to draw on increased resources nearby. Because data are not available to measure the effect of capacity loss on the mammography utilization rates at the county level, we randomly selected 37 of the 121 counties that lost more than 25 percent of their machines for in-depth analysis at the local level. These 37 counties are located in 19 states (see appendix I for a list of these 37 counties). Over three quarters of these counties are in nonmetropolitan areas. Eighteen of the counties we selected had one facility and 11 had no facility at all in 2001. We interviewed state and local officials familiar with conditions in these counties, asking them to assess the impact of the loss of facilities.