Are current mammography quality standards act (MQSA) physician guidelines truly adequate?
Are current mammography quality standards act (MQSA) physician guidelines truly adequate?
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当前的乳房 X 线摄影质量标准法案 (MQSA) 医生指南是否真的足够？
DOI：
10.2214/ajr.07.3883
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发表时间：
2008
期刊：
影响因子：
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通讯作者：
A. R. Melton
中科院分区：
文献类型：
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作者：
A. R. Melton
学杂志2008;191:W79 0361-803X / 08/1912-W79©美国伦线学会现行的乳房x光检查质量标准法案（MQSA）医师指南真的足够吗？在2008年2月的《AJR》上，Smith-Bindman等人撰写了一篇关于乳腺x线摄影资源分配的综合分析文章，并对美国未来的标准提出了建议。这篇文章证实了医学研究所（IOM） 2005年的报告，但又进一步扩展了它。它也将国家标准设定为每位放射科医生每年少于2000例病例，这似乎是为女性提供足够机会的分界线。目前的MQSA标准要求每两年至少解释960个案例。虽然分析系统的目标是不妨碍访问一个优秀的筛选工具，但这篇文章似乎没有考虑到系统目前可能被破坏。在计算数字时，报告指出，如果“体积需求增加（bbb2000），所需的实际工作量将反映出对乳房x光检查更加专业化的需求。”然而，正是由于目前缺乏专业化，这是优质筛查检查的眼中钉，导致筛查性乳房x光检查成为美国医疗事故病例的主要原因。没有建议实施乳房x线摄影专业化的可能性，这目前存在于放射学的其他领域，并存在于几个欧洲国家的乳房x线摄影。文章提到了可能的解决方案，特别是针对农村地区：远程乳房造影、移动数字面包车和集中口译。随着筛查的必要性不断增长，数字乳房x线摄影和远程摄影已经成为现实。远距摄影比远距放射学更复杂，因为它需要传输更多的信息和更大的技术和质量保证要求，但结果是显著的，而且重要的是，不仅适用于农村情况，而且也可以应用于郊区和城市地区。组建集中的远程乳房x光检查中心，配备更少但更专业的乳房x光检查人员，可以潜在地消除或大大减少访问问题，产生更准确的解释，从而可能减少医疗事故，并消除小容量诊所和农村地区的负担。考虑到大多数私人诊所没有专家，私人诊所和医院的另一个潜在好处是，减轻了大多数诊所的筛查负担，因为在这些诊所中，乳房x光检查专家并不总是每天都在办公室。诊所或医院将保留诊断检查、超声检查、核磁共振成像和活组织检查，随后可以更有效地分配资源。这些专门的乳房x光检查医师将像在欧洲一样接受持续的审查，并接受质量和视觉方面的检查，以保持他们的资格。保险公司和医疗事故承运商也可能考虑更好地报销这些乳房x光检查师的专业费用，因为诊断检查、超声检查和漏诊病变的数量将会减少。作为一个恰当的例子，在过去的三年里，我们开始在纽约市的一个主要学术中心使用这个系统。虽然在设施内工作的放射科医生（乳房x线照相术）的分配有所改善，但远程x线照相术仍被用于大多数筛查。在这种关系中，远程乳房x光检查医师（从远程阅读站点操作）可以与其他医院的乳房x光检查医师就特定病例进行沟通，以便在发布最终报告之前获得额外意见。这改变了积极模式下的可访问性。在开始专门的筛查远程摄影之前，该设施的筛查积压超过6个月（在许多实践中，1-6个月并不罕见）[3,4]。积压工作已减少到目前不到3天。随着数字机器市场渗透率的提高，这种情况变得更加可行。例如，我们目前有越来越多的病例由更合格的专家解释，他们在一个不受干扰的环境中工作，每年可以轻松地解释1万2千个病例。这将导致实际的改善（无论地点），减少积压，改善服务不足或职业妇女的机会，因为她们的情况无法在设施预约，减少批次解释系统的召回（已被证明更准确），并可能导致医疗事故病例的减少，而不必立即解决增加当前乳房x光检查奖学金数量的需求。目前有相当数量的优秀的乳房x光检查医生，他们部分退休或刚接受培训，他们可能不想每周工作一个完整的常规工作。这种灵活性也可能改变放射科住院医师对进入乳房x光检查领域的态度。随着远程摄影技术的使用，口译员的工作日程明显更加适应。Alan R. Melton纽约哥伦比亚大学医学中心
AJR 2008; 191:W79 0361–803X/08/1912–W79 © American Roentgen Ray Society Are Current Mammography Quality Standards Act (MQSA) Physician Guidelines Truly Adequate? In the February 2008 issue of the AJR, Smith-Bindman et al. [1] have written a comprehensive and analytic article regarding the allocation of mammographic resources as well as recommendations for future standards in the United States. The article substantiates the Institute of Medicine (IOM) report of 2005 [2], yet extends it further. It, too, draws a line of national standards at < 2,000 cases per year per radiologist, which seems to be the dividing line at providing adequate access for women. The current MQSA standard requires interpreting a minimum of 960 cases every 2 years. Although analyzing a system with a goal of not impeding access to an excellent screening tool, the article does not appear to take into account that the system currently could be broken. In calculating numbers, the report states that if the “volume requirements were increased (> 2,000), the actual work load required would reflect the need for mammography to be more specialized.” How ever, it is precisely this current lack of specialization that is the thorn in the side of the superior screening examination and that has resulted in screening mammography being the primary cause for medical mal practice cases in the United States. There is no suggestion offered for the possibility of implementing mammographic specialization, which is currently present in other areas of radiology and is present in mammography in several European countries. The article mentions possible solutions, speci fically for rural areas: tele mammo graphy, mobile digital vans, and centralization of interpretation. As the necessity for screening continues to grow, digital mammography and telemammo graphy have become realities. Telemammography is much more involved than teleradiology because it requires the transmission of more information and greater technical and quality assurance requirements, but the results are dramatic and, significantly, are not just applicable to rural situations but can be applied to suburban and urban areas as well. The formation of centralized telemammography centers with fewer, yet specialized, mammographers could potentially eliminate or substantially diminish access problems, yield more accurate interpretations resulting in a probable decrease in malpractice, and remove the burden from low-volume practices and rural areas. Another potential benefit to private practices as well as hospital scenarios, given the unavailability of a specialist in most private practices, would be to alleviate the burden of screening from most practices in which a mammography specialist is not always in the office on a daily basis. The practice or hospital would retain the diagnostic workups, sonography examinations, MRIs, and biopsies and could subsequently allocate resources more efficiently. These specialized screening mammographers would undergo continuous review as they do in Europe and be subject to quality and visually oriented examinations to maintain their qualifications. Insurance companies and malpractice carriers might also consider better reimbursement of the professional fee for these mammographers because the number of diagnostic workups, sonography examinations, and missed lesions would be reduced. As a case in point, we began use of this system at a major academic center in New York City over the past 3 years. Although there is improvement of the allocation of radiologists (mammographers) working within the facility, telemammography has been used for the majority of screening. Relationships have developed in which the telemammographer (operating from a remote reading site) can communicate with other hospital-based mammographers on a specific case for an additional opinion before issuing a final report. This has changed accessibility in a positive mode. Before starting dedicated screening telemammography, screening backlogs in the facility were more than 6 months (with 1–6 months not uncommon in a significant number of practices) [3, 4]. The backlog has been reduced to currently < 3 days. As digital machines increase their market penetration, this scenario becomes more feasible. For instance, we currently have an increased volume of cases interpreted by more-qualified specialists who, working in an undisturbed environment, can easily interpret > 12,000 cases per year. This would result in an actual improvement to access (regardless of location), reduce backlogs, improve access to the underserved or working women who because of their situation cannot make an appointment at a facility, diminish recalls in a batch interpretation system (which has been shown to be more accurate), and probably result in a decrease in malpractice cases without having to immediately address the need of increasing the number of current mammography fellowships. There are currently a significant number of excellent mammographers who are partially retired or newly trained who may not want to work a full regular work week. This flexibility may also alter the attitude of radiology residents regarding entering the field of mammography [5]. With the use of telemammography, work schedules are significantly more accommodating to interpreters. Alan R. Melton NYPH-Columbia University Medical Center New York, NY