Skip to main content

The AHRQ National Quality Measures Clearinghouse (NQMC, qualitymeasures.ahrq.gov) Web site will not be available after July 16, 2018 because federal funding
through AHRQ will no longer be available to support the NQMC as of that date. For additional information, read our full announcement.
  • Measure Summary
  • NQMC:010224
  • Mar 2015

Diagnostic imaging: fraction of all screening mammograms that are interpreted as positive (abnormal) and have a tissue diagnosis of cancer within 12 months.

American College of Radiology (ACR). National Radiology Data Registry: qualified clinical data registry. Non-PQRS measures. Reston (VA): American College of Radiology (ACR); 2015 Mar. 49 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2017.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the fraction of all screening mammograms that are interpreted as positive (abnormal) and have a tissue diagnosis of cancer within 12 months (expressed per 1000 exams, not as a percentage).

Rationale

Three major goals of screening mammography include:

  1. Find a high percentage of the cancers that exist in a screening population (cancer detection rate)
  2. Find these cancers within an acceptable range of recommendations for recall or biopsy to minimize cost and morbidity (abnormal interpretation, positive predictive value [PPV])
  3. Find a high percentage of small, node-negative cancers, which are more likely to be curable (rate of minimal cancer, node-negative)

There also is evidence of considerable variability in performance parameters among interpreting radiologists. These measures are designed to assess the outcome and effectiveness of the interpretation of screening mammography studies.

Evidence-based guidelines, observational studies, randomized controlled trials, systematic syntheses of research and meta-analyses all provide support for the high impact these mammography measures have on quality healthcare. Mammograms affect large numbers of patients, are frequently performed, relate to a leading cause of morbidity/mortality, in many cases demonstrate a severity of illness, and could impact high resource use.

Cancer detection is the primary goal of screening mammography. A high cancer detection rate is indicative of patient receiving effective screening, where positive findings on imaging are highly likely to be confirmed as malignant disease by pathology results.

Evidence for Rationale

American College of Radiology (ACR). National Radiology Data Registry: qualified clinical data registry. Non-PQRS measures. Reston (VA): American College of Radiology (ACR); 2015 Mar. 49 p.

Burnside ES, Lin Y, Munoz del Rio A, Pickhardt PJ, Wu Y, Strigel RM, Elezaby MA, Kerr EA, Miglioretti DL. Addressing the challenge of assessing physician-level screening performance: mammography as an example. PLoS ONE. 2014;9(2):e89418. PubMed External Web Site Policy

Carney PA, Sickles EA, Monsees BS, Bassett LW, Brenner RJ, Feig SA, Smith RA, Rosenberg RD, Bogart TA, Browning S, Barry JW, Kelly MM, Tran KA, Miglioretti DL. Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 2010 May;255(2):354-61. PubMed External Web Site Policy

D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston (VA): American College of Radiology (ACR); 2013.

Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Sep 3;137(5 Part 1):347-67. [128 references] PubMed External Web Site Policy

Nass S, Ball J, editor(s). Improving breast imaging quality standards. Washington (DC): National Academy of Science; 2005.

Rauscher GH, Murphy AM, Orsi JM, Dupuy DM, Grabler PM, Weldon CB. Beyond the mammography quality standards act: measuring the quality of breast cancer screening programs. AJR Am J Roentgenol. 2014 Jan;202(1):145-51. PubMed External Web Site Policy

Rosenberg RD, Yankaskas BC, Abraham LA, Sickles EA, Lehman CD, Geller BM, Carney PA, Kerlikowske K, Buist DS, Weaver DL, Barlow WE, Ballard-Barbash R. Performance benchmarks for screening mammography. Radiology. 2006 Oct;241(1):55-66. PubMed External Web Site Policy

Schell MJ, Yankaskas BC, Ballard-Barbash R, Qaqish BF, Barlow WE, Rosenberg RD, Smith-Bindman R. Evidence-based target recall rates for screening mammography. Radiology. 2007 Jun;243(3):681-9. PubMed External Web Site Policy

Tabár L, Vitak B, Chen TH, Yen AM, Cohen A, Tot T, Chiu SY, Chen SL, Fann JC, Rosell J, Fohlin H, Smith RA, Duffy SW. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 2011 Sep;260(3):658-63. PubMed External Web Site Policy

Primary Health Components

Cancer; screening mammography; abnormal interpretation; tissue diagnosis

Denominator Description

Number of screening mammograms

Numerator Description

Number of screening mammograms with abnormal interpretation (Breast Imaging Reporting and Data System [BI-RADS] 0, 3, 4 or 5) that have a tissue diagnosis of cancer within 12 months

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

The measures in this set are being made available without any prior formal testing. However, these measures are included in the Centers for Medicare and Medicaid Services (CMS) approved American College of Radiology (ACR) National Radiology Data Registry, a CMS Physician Quality Reporting System (PQRS) Qualified Clinical Data Registry since 2014.

The ACR recognizes the importance of thorough testing all of its measures and encourages ongoing robust testing of the ACR National Radiology Data Registry measurement set for feasibility and reliability by organizations or individuals positioned to do so. The ACR will welcome the opportunity to promote such testing of these measures and to ensure that any results available from testing are used to refine the measures on an ongoing basis. Since these measures are in use for quality improvement and reporting, we can support data analysis of registry data to perform the testing, such as evaluation of gaps for validity testing, and signal-to-noise estimation for reliability testing.

Evidence for Extent of Measure Testing

Blakey A. (Administrator, Quality Management Programs, American College of Radiology, Reston, VA). Personal communication. 2016 Mar 7.  1 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Pay-for-reporting

Professional certification

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Unspecified

Target Population Gender

Female (only)

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Diagnostic Evaluation

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of screening mammograms

Exclusions
None

Exclusions/Exceptions

None

Numerator Inclusions/Exclusions

Inclusions
Number of screening mammograms with abnormal interpretation (Breast Imaging Reporting and Data System [BI-RADS] 0, 3, 4 or 5) that have a tissue diagnosis of cancer within 12 months

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Registry data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Breast Imaging Reporting and Data System (BI-RADS)

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

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

Screening mammography cancer detection rate (CDR).

Measure Collection Name

National Radiology Data Registry Measurement Set

Submitter

American College of Radiology - Medical Specialty Society

Developer

American College of Radiology - Medical Specialty Society

Funding Source(s)

None

Composition of the Group that Developed the Measure

The American College of Radiology (ACR) National Radiology Data Registry (NRDR) helps facilities benchmark outcomes and process-of-care measures and to develop quality improvement programs. The composition of the workgroup is has representation from each of our six data registries:

  1. CT Colonography Registry Committee (CTC)
  2. Dose Index Registry Committee (DIR)
  3. General Radiology Improvement Database Committee (GRID)
  4. National Mammography Database Committee (NMD)
  5. Lung Cancer Screening Registry Committee (LCSR)
  6. IR & INR Registries (Interventional Radiology)

Committee Members

  • Morin Richard, PhD, FACR, Chair of NRDR
  • Kalpana Kanal, PhD, Chair of DIR
  • Zuley Margarita, MD, Chair of NMD
  • Abe Dachman, MD, Chair of CTC Committee
  • Frank Rybicki, MD, Chair of Metrics Committee
  • Siegel Eliot, MD, RSNA Liaison
  • Chad Calendine, MD, Co-Chair of GRID
  • Geoffrey Wiot, Co-Chair of GRID
  • Jeremy Durack, Chair of IR Registry Committee
  • Ella Kazerooni, Co-Chair of Lung-Cancer Screening Committee
  • Deni Aberle, Co-Chair of Lung-Cancer Screening Committee

Committee Staff

  • Judy Burleson, MHSA, American College of Radiology
  • Mythreyi Bhargavan Chatfield, PhD, American College of Radiology

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Mar

Measure Maintenance

This measure is reviewed annually

Date of Next Anticipated Revision

2017 Mar

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2017.

Source(s)

American College of Radiology (ACR). National Radiology Data Registry: qualified clinical data registry. Non-PQRS measures. Reston (VA): American College of Radiology (ACR); 2015 Mar. 49 p.

Measure Availability

Source available from the American College of Radiology (ACR) Web site External Web Site Policy.

For more information, contact ACR at 1891 Preston White Drive, Reston, VA 20191; Phone: 703-648-8900; E-mail: nrdr@acr.org; Web site: www.acr.org External Web Site Policy.

NQMC Status

This NQMC measure summary was completed by ECRI Institute on December 11, 2015. The information was verified by the measure developer on March 7, 2016.

The information was reaffirmed by the measure developer on March 3, 3017.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

©2014 American College of Radiology. All Rights Reserved.

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.

Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact the measure developer.

About NQMC Measure Summaries

NQMC provides structured summaries containing information about measures and their development.

Measure Summary FAQs


Measure Summaries

New This Week

View more and sign up for our Newsletter

Get Adobe Reader