Breast Cancer Screening Recall Rates

Strengths:

• The developer cites evidence and guidelines from the American College of Radiology, which highlights the potentially negative consequences if the mammography and digital breast tomosynthesis (DBT) recall rate is either too high or too low. The developer posits that this measure “will guide breast cancer screening decision making in hospital outpatient departments.” In addition, this measure will potentially “reduce radiation received from mammography or DBT that may induce more cancers in younger people or those carrying deleterious gene mutations, as well as decreasing unnecessary imaging and biopsies. Alternatively, underuse of follow-up for screening mammography or DBT may result in missed cases of cancer.” The developer provides a logic model for this measure, but it does not capture the statements shared under “Anticipated Impact.” Across 3,391 facilities from July 1, 2021 – June 30, 2022, the mean measure performance for facilities meeting MCC (8.5%, standard deviation [S.D.], 6.7%) falls within the targeted recall rate range of 5% to 12%. However, variability exists across the distribution of facility scores, with more than 30% (33.4) of facilities having scores outside of the targeted recall rate range. The developer also reported statistically significant differences in performance by biological sex, racial or ethnic identity, age band, and dual eligibility status.
• The developer states that “while other measures evaluate rates of breast cancer imaging, this measure provides valuable information to facilities, consumers, researchers, clinicians, and policy-makers, with respect to recalling the appropriate number of patients for follow-up screening each year.

Limitations:

• The developer states that there are inconsistencies in the target recall rate for breast cancer screening. However, guidelines from the American College of Radiology recommend a target recall rate for mammography screening between 5% and 12%. In Europe, the International Agency for Research on Cancer sets a target recall rate at 5%. The developer does not describe the actions providers can take to ensure appropriate recall rates. The developer does not provide direct patient input on this measure. However, it does cite evidence of the negative consequences associated with additional screening, which include anxiety and stress to patients, as well as the risk of a delayed cancer diagnosis.

Rationale:

• The developer cites evidence and guidelines from the American College of Radiology, which highlight the potentially negative consequences if the mammography and digital breast tomosynthesis (DBT) recall rate is either too high or too low. The developer posits that this measure will "potentially reduce radiation received from mammography or DBT that may induce more cancers in younger people or those carrying deleterious gene mutations, as well as decreasing unnecessary imaging and biopsies.”
• However, the developer states that there are inconsistencies in the target recall rate for breast cancer screening. However, guidelines from the American College of Radiology recommend a target recall rate for mammography screening between 5% and 12%. The committee should consider if the range in recall rates is appropriate and perhaps have the developer further justify the range (benefits vs. harms) associated.
  A gap exists across the distribution of facility scores, with more than 30% (33.4) of facilities having scores outside of the targeted recall rate range. The developer also reported statistically significant differences in performance by biological sex, racial or ethnic identity, age band, and dual eligibility status.
• Lastly, the developer does not provide direct patient input on this measure. However, it does cite evidence of the negative consequences associated with additional screening, which include anxiety and stress to patients, as well as the risk of a delayed cancer diagnosis.

The developer does not address the significance of this population at risk of poor outcomes related to overuse of recall and/or underuse of recall post mammography or DBT. 

Agree with the input from the PQM folks and their rationale on this one.

The authors provided clear rationale about how this could be helpful moving forward.

Agree with staff assessment.

Potential negative consequences mentioned but from a patient standpoint I would rather be called than not.  If the recall rate is high, is there a problem with the equipment, technician competencies and radiologists reading the mammograms

There is strong evidence presented about the benefits of screening for breast cancer and follow up evaluations when needed. It is further presented that there are negative consequences when mammography and digital breast tomosynthesis (DBT) recall rate is either too high or too low. The measure developer establishes that this measure will support the reduction in radiation received. Nonetheless, there is no clear established connection between this measure and reduction of radiation.  It is unclear how this measure will support improved outcomes in the patients. The benchmark to compare to from ACR is the rate of recall, but there is no substantive research to support that this is still a current benchmark to compare the results to. Also, has this target rate been adjusted to different ethnical and racial parameters? In addition, it is unclear if this measure is unique and if there is meaningfulness perceived by the patient population.  

Setting a range to guide additional screening measures so that overuse of radiation and underdiagnosis don't occur is very important.  I don't understand the rationale for the 5%-12% range other than it's consistency with measures already adopted. How do we know that this is the appropriate range going forward? Might current conditions warrant a shift in the range or having different ranges for special circumstances (eg. rural areas, demographic groups that have traditionally been over or under examined in follow up care)?

Also - while additional screening can elicit anxiety, there is also anxiety around uncertainty of diagnosis.

The developer cites a target recall rate of 5% to 12%, depending on the facility. This rate appears arbitrary, albeit inconsistent, and does not explain the US healthcare dynamics (rural vs. urban) or technology. The developers do not describe the actionable quality improvement strategies to develop. Even though CBE #4220e is important, particularly as it focuses on monitoring "rates of recall following screening imaging instead of rates of breast cancer imaging," from a patient perspective, the developers did not describe how patients will be informed about this measure. 

There is strong evidence presented about the benefits of breast cancer screening and follow-up. 

The developer suggests the measure will support the reduction in radiation received, but was unable to identify a clear connection or understanding how they correlate. It is also unclear how tracking this measure would actually improve patient outcomes. Is the benchmark mentioned below take into account different ethnic/racial/rural parameters?

Limitations - The developer does not provide guidance to sites on the actions providers can take to ensure the appropriate recall rates. Also unclear depending on population, what sites should do if their recall rates fall outside of the 5% and 12% range if there is diversity in their population. 

The citations provided regarding the clinical guidelines do not appear appropriate, grading not provided related to recommendations on recall rates. Inconsistent recommendation on recall rates with wide range.

There is not enough information to determine if the patient population finds the process measure meaningful. The developer mentioned hosting a listening session with a multi-stakeholder group of 32 individuals that included one patient. I particularly would have appreciated the feedback of those most impacted especially high-risk patients in underserved areas. 

This is an important measures as Chicago followed the action of NY in terms of identifying the lack of call backs -- and successful call backs.  The variation among black communities was low but the mortality rate was higher than the white population.  There were issues in the testing centers associated with lack of call backs and lack of call backs in a timely manner.   While hospitals performed quite well, some of the outpatient centers and City operated centers performed poorly in terms of call backs.  

If there are variations in mortality among populations, it is helpful for performance improvement to assess the call back outcomes which are really processes of care.

Equal Hope (formerly the Metro Chicago Breast Cancer Task Force) is the organization that has lead the initiative and actually closed the gap by conducting detailed analysis --- resulting in some centers closing and some provided with more support.

If there are disparities in communities and among populations, this is a very important measure.

There are two sides to the coin regarding the importance of this measure. One, unnecessary radiation exposure, which currently, there is no mechanism capturing cumulative radiation exposure for each individual. The other is potential for misdiagnosis an patient harm.

Why is Europe's rate 5% and is there something we can learn from them?

while it is important to identify facilities that over or under recall patients, the measure does not address how the screening recall rate be used to improve performance.    

This is a new measure under PQM. However, it is a respecification measure for the “Mammography Follow Up Rates” under OQR. It is evaluated under the initial/new rather than the maintenance standard. The submission, however, relies significantly on the previous existence of the OQR measure. 

A logic model is provided that describes the pathway to biopsy and surveillance. The clinical patient oriented goal would be accurate identification of mammographic abnormalities. As a initial/new submission, it would be important to have clarity if this is simply a consensus statement/guideline process measure or a patient oriented clinical measure. 

The information provided assumes that there is a correct rate of recall in a population(5-12% based on professional guideline) regardless of the prevalence of breast abnormalities within the population. This promotes precision and homogeneity in high performing entities but does not, prima facia, support clinical accuracy or impact under or over utilization. In low risk populations, recall would be high. In high risk populations, one could conclude that recall is too low. This is problematic because maximizing diagnosis while minimizing injury in breast cancer is critically important.

The developer presents Performance gaps which are only required for maintenance submissions. The developer provides a table with the current distribution  of performance across 3391 facilities. While the developer uses the appropriate level of recall of 5-12%, the gaps are reported in deciles with 4.9% and 13.0% as the closest deciles. This does not allow precise assessment of the gap from the 5-12% suggested. In addition, the high recall rate category (over 13%) has a performance level mean of 13.7% which demonstrates a measuarable but not clearly meaningful performance gap in over utilization based on consensus guidelines. Similarly, the “denominator count” for less than 4.9% seems to be 171/3,307,860 patients or 0.005%. The narrative provides facility counts which do not seem to appear in the data presented. Clarity in performance measures, and maintaining consistent categories and variable definitions would help in interpreting importance.

The developer also provides gap analysis by sex, race, age, and dual eligibility as a proxy for SES. They describe these data, however, as unreliable. In addition, while there are differences by race, all performance is within the recommended range(5-12%) so there would be considered no gap in performance by race because it is a binary yes/no measure of quality. The 5-12% is not a scaled measure of quality.

This was also seen with SES and those eligible for both Medicare and Medicaid.  Younger patients (18-34, 35-44), as a broad category, have a higher rate of recall potentially creating risk based on the importance of the measure, but these patients do not have an indication for screening mammography and likely are receiving diagnostic mammography based on a complaint or an issue. Though patients 40-44 (no subgroup analysis) have the option for screening. Clearly delineating the difference between screening adn diagnostic mammography and follow up is important. Males, and women under 40 could be excluded because they are receiving diagnostic mammography based on a complaint in almost all cases.

The developer does not comment on the adequacy of existing measures.

The information provided sufficiently supports the importance of a measure.

Developer should summarize evidence linking potentially negative consequences if recall rate is either too high or too low (i.e., overuse of imaging/biopsy or less accurate/timely cancer diagnosis), not just state it. This information may have been included in the supplementary materials but if so, it was not obvious. 

Developer should solicit patient input about the meaningfulness of the facility recall rate for patients.

the developer does not provide direct patient input on this measure. However, it does cite evidence of the negative consequences associated with additional screening, which include anxiety and stress to patients, as well as the risk of a delayed cancer diagnosis.

This is 99% met but agree with staff assessment concern about limited patient engagement on importance. Although the developer doesn’t provide input from patients in this section, I’d be curious to hear if the developer got any information on the measures importance from the face validity testing and use survey they did. 

This seems like an important measure for all who get preventative and diagnostic mammograms and another test when a lump is discovered. 

The scores describe a considerable performance gap, but crucially a remedy for underperforming facilities is not apparent.

The developer cites evidence and guidelines from the American College of Radiology, which highlight the potentially negative consequences if the mammography and digital breast tomosynthesis (DBT) recall rate is either too high or too low. The developer posits that this measure will "potentially reduce radiation received from mammography or DBT that may induce more cancers in younger people or those carrying deleterious gene mutations, as well as decreasing unnecessary imaging and biopsies.”

However, the developer states that there are inconsistencies in the target recall rate for breast cancer screening. However, guidelines from the American College of Radiology recommend a target recall rate for mammography screening between 5% and 12%. The committee should consider if the range in recall rates is appropriate and perhaps have the developer further justify the range (benefits vs. harms) associated.

The developer did not provide direct patient input on this measure. However, it does cite evidence of the negative consequences associated with additional screening, which include anxiety and stress to patients, as well as the risk of a delayed cancer diagnosis.

Inconsistencies in the target recall rate for breast cancer screening. However, guidelines from the American College of Radiology recommend a target recall rate for mammography screening between 5% and 12%. In Europe, the International Agency for Research on Cancer sets a target recall rate at 5%. The developer does not describe the actions providers can take to ensure appropriate recall rates.

This is an important measure to have as a balancing measure to tracking rates of screening alone. I do have concerns about the population being measured. USPSTF recommends screening in women aged 40-74. Medicare beneficiaries overlap only slightly with this population, meaning that a sizeable proportion of patients included in this measure are likely to be high-risk or being screened for diagnostic purposes. To me, this raises questions about the import of the results. Men, for example, and women younger than the recommended screening ages are likely to have been referred for suspicion of anomalies. Not surprisingly, these groups, though small, show a high rate of recall. It would also be helpful to know the follow-up of the recalls - how many patients  continue on to treatment and how many turn out to be benign?