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  • Measure Summary
  • NQMC:007433
  • Jan 2012

Diagnosis of breast disease: percentage of BI-RADS category 4 or BI-RADS category 5 mammograms that are followed by a biopsy within 7 to 10 days.

Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 45 p. [65 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Jan. 47 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Clinical Quality Measure: Access

Description

This measure is used to assess the percentage of Breast Imaging and Reporting Data System (BI-RADS) category 4 or BI-RADS category 5 mammograms that are followed by a biopsy within 7 to 10 days.

Rationale

The priority aim addressed by this measure is to reduce the length of time between first knowledge of a breast abnormality and diagnostic resolution.

Evidence for Rationale

Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 45 p. [65 references]

Primary Health Components

Breast disease; mammogram abnormality (Breast Imaging and Reporting Data System [BI-RADS] category 4 and 5); biopsy

Denominator Description

Total number of patients with an abnormal mammogram undergoing biopsy

Numerator Description

Total number of patients with less than 10 days between the first documentation of a mammogram abnormality and a completed biopsy for all records reviewed (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

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

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age less than or equal to 74 years

Target Population Gender

Female (only)

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Timeliness

Case Finding Period

Data may be collected semiannually.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Diagnostic Evaluation

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Total number of patients with an abnormal mammogram undergoing biopsy

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Total number of patients with less than 10 days between the first documentation of a mammogram abnormality* and a completed biopsy for all records reviewed

*Breast Imaging and Reporting Data System (BI-RADS) category 4 or BI-RADS category 5.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of BI-RADS category 4 or BI-RADS category 5 mammograms that are followed by a biopsy within 7-10 days.

Measure Collection Name

Diagnosis of Breast Disease

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Security Health Plan of Wisconsin, and UCare. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Composition of the Group that Developed the Measure

Work Group Members: Audrey Park-Skinner, MD (Work Group Leader) (Essentia Health) (Surgery); Deepti Pandita, MD (Park Nicollet Health Services) (Internal Medicine); Mary Lechner, MD (Center for Diagnostic Imaging) (Radiology); Sarah Nielsen, DO (Marshfield Clinic) (Radiology); Judy Boughey, MD (Mayo Clinic) (Surgery); Todd Morris, MD (HealthPartners Medical Group and Regions Hospital) (Surgery); Kari Retzer, RN (Institute for Clinical Systems Improvement) (Facilitator); Cindy Harper (Institute for Clinical Systems Improvement) (Systems Improvement Coordinator)

Financial Disclosures/Other Potential Conflicts of Interest

In the interest of full disclosure, Institute for Clinical Systems Improvement (ICSI) has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this guideline topic. It is not assumed that these financial interests will have an adverse impact on content. They are simply noted here to fully inform users of the guideline.

Mary Lechner, MD, had received speaker's fees from Dilon Technologies in 2009.

No other work group members have potential conflicts of interest to disclose.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 Jan

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Jan. 47 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 45 p. [65 references]

Measure Availability

Source available for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy. Also available to ICSI members for free at the ICSI Web site External Web Site Policy and to Minnesota health care organizations free by request at the ICSI Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 26, 2004.

This NQMC summary was updated by ECRI Institute on December 15, 2005, March 20, 2008, and on May 25, 2010.

This NQMC summary was retrofitted into the new template on July 20, 2011.

This NQMC summary was updated again by ECRI Institute on September 7, 2012.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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