NQMBC Indicators

Measures that can be provided using Mammologix's services:

• Imaging 1 | Imaging Timeliness of Care | Time Between Screening Mammogram and Diagnostic Mammogram. ©
• Imaging 2 | Mammography Recall Rate © | Percent of screening mammogram patients recommended for additional imaging.
• Imaging 3 | Imaging Timeliness of Care | Time Between First Diagnostic Imaging Study and First Needle/Core Biopsy.
• Imaging 4 | Surgical Timeliness of Care | Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery.
• Imaging 5 | Needle/Core Biopsy Rate © | Percent of patients having biopsy who received a needle or core biopsy rather than open biopsy.
• Imaging 6 | Cancer Detection Rate | The number of breast cancer patients found per one thousand screening (asymptomatic) examinations.
• Imaging 7 | Positive Biopsy Rate (PPV2) | Percent of screening patients who were recommended for biopsy or surgical consultation that result in a diagnosis of breast cancer within 1 year.
• Imaging 8 | Percent Use of Screening Tomosynthesis | Percentage of all screening cases that use tomosynthesis.

Imaging 1 | Imaging Timeliness of Care

Time Between Screening Mammogram and Diagnostic Imaging Procedure.©

Parameters Used by Mammologix in Reporting Imaging 1 Indicator:

• Selection of All Examinees whose Breast Imaging Procedure is like a Screening Mammogram     - AND -
• Examinee's Screening Mammogram Exam Date is Between the Specified Start/Stop period 1      - AND -
• Examinee's Screening Mammogram assessed by an Interpreting Physician as; Incomplete: Needs Additional Imaging (Bi-Rads© 0), Probably Benign (Bi-Rads© 3), Suspicious Finding (Bi-Rads© 4), or Highly Suggestive for Malignancy (Bi-Rads© 5) 2  - OR -  Examinee's Screening Mammogram was Converted to a Diagnostic Study Status with Additional Breast Imaging Procedure(s) Performed at Time of Screening 3      - AND -
• Examinee Obtaining Additional Breast Imaging Procedure(s) after Returning to the Breast Imaging Center 4 , as a Diagnostic Study within the Specified Throttle 5 of a Screening Mammogram 6

Imaging Indicator 1 Reports Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Throttle (# of Days Permitted in Follow-Up Window)
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Timeliness of Care (Calendar Days)
• Timeliness of Care (Business Days)
• Maximum # of Calendar Days Reported
• Minimum # of Calendar Days Reported
• Total Count of All Screening Mammograms
• Total Count of Screening Mammograms Used in Deriving Imaging Timeliness of Care (Time between Screening Mammogram and Diagnostic Breast Imaging Study)

Imaging 2 | Mammography Recall Rate ©

Percent of screening mammogram patients recommended for additional imaging.

Parameters Used by Mammologix in Reporting Imaging 2 Indicator:

• Selection of All Examinees whose Breast Imaging Procedure is like a Screening Mammogram     - AND -
• Examinee's Screening Mammogram Exam Date is Between the Specified Start/Stop period 1      - AND -
• Examinee's Screening Mammogram assessed by an Interpreting Physician as; Incomplete: Needs Additional Imaging (Bi-Rads© 0), Probably Benign (Bi-Rads© 3), Suspicious Finding (Bi-Rads© 4), or Highly Suggestive for Malignancy (Bi-Rads© 5) 2  - OR -  Examinee's Screening Mammogram was Converted to a Diagnostic Status with Additional Breast Imaging Procedure(s) Performed at Time of Screening 3

Imaging Indicator 2 Reports Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Percent of Examinees having Screening Mammogram with Positive Findings as Compared to All Screening Mammograms
• Total Count of All Screening Mammograms
• Total Count of Screening Mammograms Assessed with Positive Finding

Imaging 3 | Imaging Timeliness of Care

Time Between First Diagnostic Imaging Study and First Needle/Core Biopsy.

Parameters Used by Mammologix in Reporting Imaging 3 Indicator:

• Selection of Unique Examinees whose Breast Imaging Procedure is an Initial Diagnostic Study - OR -  is the First Diagnostic Breast Imaing Study Following a Screening Mammogram 6   - OR -  Examinee's Screening Mammogram was Converted to a Diagnostic Study Status with Additional Breast Imaging Procedure(s) Performed at Time of Screening 3    - AND -
• Examinee's First Diagnostic Study Exam Date is Between the Specified Start/Stop period 1   - AND -
• Examinee has a Confirmed Needle/Core Biopsy 7 obtained at the Breast Imaging Center 4 

Imaging Indicator Reports 3 Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Throttle (# of Days Permitted in Follow-Up Window)
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Timeliness of Care (Calendar Days)
• Timeliness of Care (Business Days)
• Maximum # of Calendar Days Reported
• Minimum # of Calendar Days Reported
• Total Count of Unique Examinees whose Breast Imaging Procedure is an Initial Diagnostic Study - OR -  is the First Diagnostic Follow-Up of a Screening Mammogram
• Total Count of Unique Examinees whose Breast Imaging Procedure is an Initial Diagnostic Study - OR -  is the First Diagnostic Follow-Up of a Screening Mammogram with Confirmed Needle/Core Biopsy obtained at the Breast Imaging Center

Imaging 4 | Surgical Timeliness of Care

Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery.

Parameters Used by Mammologix in Reporting Imaging 4 Indicator:

• Selection of Unique Examinees Undergoing Confirmed Needle/Core Biopsy 7 with a Reported Malignant Outcome Resulting a Tissue Sample Collected at the Time of the Needle/Core Biopsy obtained at the Breast Imaging Center 4 - AND -
• Examinee Subsequently Undergoing an Excisional Biopsy as a Part of the Examinee's Initial Breast Cancer Surgery obtained at the Breast Imaging Center 4  - AND -
• Examinee's Needle Biopsy Exam Date with a Reported Malignant Outcome is Between the Specified Start/Stop period 1  - AND -
• Exam Date for Examinee's Subsequent Initial Excisional Breast Cancer Surgery Confirmed Needle/Core Biopsy 7 obtained at the Breast Imaging Center 4 Following Needle Needle/Core Biopsy 7 with a Reported Malignant Outcome 

Imaging Indicator Reports 4 Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Throttle (# of Days Permitted in Follow-Up Window)
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Timeliness of Care (Calendar Days)
• Timeliness of Care (Business Days)
• Maximum # of Calendar Days Reported
• Minimum # of Calendar Days Reported
• Total Count of Unique Examinees undergoing Confirmed Needle/Core Biopsy 7 with a Reported Malignant Outcome Resulting a Tissue Sample Collected at the Time of the Needle/Core Biopsy obtained at the Breast Imaging Center 4
• Total Count of Unique Examinees undergoing Confirmed Needle/Core Biopsy 7 with a Reported Malignant Outcome Resulting a Tissue Sample Collected at the Time of the Needle/Core Biopsy - AND - Subsequent Initial Breast Cancer Surgery Confirmed Needle/Core Biopsy 7 obtained at the Breast Imaging Center 4

Imaging 5 | Needle/Core Biopsy Rate ©

Percent of patients having biopsy who received a needle or core biopsy rather than open biopsy.

Parameters Used by Mammologix in Reporting Imaging 5 Indicator:

• Selection of Unique Examinees Undergoing Confirmed Needle/Core Biopsy 7 as the Initial Interventional Study at the Breast Imaging Center 4 - AND -
• Selection of Unique Examinees Undergoing Confirmed Excisional Biopsy as the Initial Interventional Study at the Breast Imaging Center 4 - AND -
• Examinee's Initial Biopsy Exam Date is Between the Specified Start/Stop period 1 

Imaging Indicator Reports 5 Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Percent of Unique Examinees Undergoing Confirmed Needle/Core Biopsy 7 as the Initial Interventional Study at the Breast Imaging Center 4 as Measured Against All Initial Interventional Studies Between the Specified Start/Stop period 1 
• Percent of Unique Examinees Undergoing Confirmed Excisional Biopsy as the Initial Interventional Study at the Breast Imaging Center 4 as Measured Against All Initial Interventional Studies Between the Specified Start/Stop period 1 
• Total Count of Unique Examinees Undergoing Confirmed Needle/Core Biopsy 7 as the Initial Interventional Study at the Breast Imaging Center 4
• Total Count of Unique Examinees Undergoing Confirmed Excisional Biopsy as the Initial Interventional Study at the Breast Imaging Center 4

Imaging 6 | Cancer Detection Rate

The number of breast cancer patients found per one thousand screening (asymptomatic) examinations.

Parameters Used by Mammologix in Reporting Imaging 6 Indicator:

• Selection of All Examinees whose Breast Imaging Procedure is like a Screening Mammogram     - AND -
• Examinee's Screening Mammogram Exam Date is Between the Specified Start/Stop period 1      - AND -
• Examinee's Resulting in a Tissue Diagnosis of Breast Cancer Within 1 Year Performed by the Breast Imaging Center 4
• Cancer Detection Rate (CDR) = (Total Count of Breast Cancer via Tissue Sampling in All Unique Examinees Having a Screening Mammogram * 1000) / Total Count of Screening Mammograms 8

Imaging Indicator 6 Reports Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Grouping of Output Data Yearly
• Cancer Detection Rate (CDR) Reported per 1000 Screened
• Total Count of Screening Mammograms
• Total Count of Breast Cancer via Tissue Sampling in All Unique Examinees Having a Screening Mammogram

Imaging 7 | Positive Biopsy Rate (PPV2)

Percent of screening patients who were recommended for biopsy or surgical consultation that result in a diagnosis of breast cancer within 1 year.

Parameters Used by Mammologix in Reporting Imaging 7 Indicator:

• Selection of All Examinees whose Breast Imaging Procedure is like a Screening Mammogram     - AND -
• Examinee's Screening Mammogram Exam Date is Between the Specified Start/Stop period 1      - AND -
• Examinee's Screening Mammogram Initally assessed by an Interpreting Physician as; Suspicious Finding (Bi-Rads© 4), or Highly Suggestive for Malignancy (Bi-Rads© 5)   - OR -  Examinee's Screening Mammogram Initally assessed by an Interpreting Physician as; Incomplete: Needs Additional Imaging (Bi-Rads© 0) with a Subsequent Diagnostic Breast Imaging Study performed at the Breast Imaging Center 4  with a Final Imaging Assessment of; Suspicious Finding (Bi-Rads© 4), or Highly Suggestive for Malignancy (Bi-Rads© 5)     - AND -
• Examinee's Resulting in  a Tissue Diagnosis of Breast Cancer Within 1 Year
• Screening PPV2 = True Positive [TP] / (True Positive  [TP] + False Positive2 [FP2]) 9, 10

Imaging Indicator 7 Reports Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Grouping of Output Data Yearly
• Screening PPV2
• True Positive [TP]
• False Positive2 [FP2]

Imaging 8 | Percent Use of Screening Tomosynthesis

Percentage of all screening cases that use tomosynthesis.

Parameters Used by Mammologix in Reporting Imaging 8 Indicator:

• Selection of All Examinees whose Breast Imaging Procedure is like a Screening Mammogram     - AND -
• Examinee's Screening Mammogram Exam Date is Between the Specified Start/Stop period 1      - AND -
• Examinee's Screening Mammogram Reported to be Performed using Digital Breast Tomosynthesis (DBT)

Imaging Indicator 8 Reports Includes:

• Facility Location (including Aggregate Data for Multi-Facility Locations)
• Start Date/Stop Date
• Grouping of Output Data (Daily, Weekly, Monthly, Quarterly, Semi-Annually, Yearly)
• Percent of Examinees having Screening Mammogram using DBT as compared to All Screening Mammograms
• Total Count of All Screening Mammograms
• Total Count of Screening Mammograms using DBT

Footnotes

- Need to define screening mammogram as the initial procedure.

- Need to define who qualifies for an initial excisional bx = no core within 6 months prior (breast laterality considered)

1 NQMBC measures are typically reported on a semi-annual basis. Mammologix reports measures using the following timeframe to allow for reporting of follow-up breast imaging, interventional procedures, and a diagnosis of breast cancer within 1 year (PPV2).

2  D'Orsi, MD, C., Sickels, MD, E., Mendelson, MD, E., Morris, MD, E., Creech, W., Butler, P., Wiegmann, P., Chatfield, PhD, M., Meyer, MS, L. and Wilcox, MBA, P., 2013.  ACR BI-RADS Atlas Breast Imaging Reporting And Data System. 5th ed. American College of Radiology,  Follow-Up and Outcome Monitoring, p 18.

3 Imaging Timeliness of Care reported as 0 days when an examinee's screening mammogram is converted to a diagnostic status with additional breast imaging procedure(s) performed at the time of screening.

4  Breast Imaging Center is the specific location for the Screening Breast Center, Diagnostic Breast Center, Clinical Breast Center, Treatment Breast Center, or Comprehensive Breast Center as certified by the NQMBC™ or undergoing the process of certification. In the case of a Breast Imaging Center that is part of a healthcare enterprise incorporating multiple breast imaging sites serving its examinees within the same geographical region, Mammologix utilizes the aggregate follow-up and/or outcome results from all affiliated locations when reporting, unless otherwise requested by the client.

5 The throttle default for the number of follow-up days is equal to 365 days unless otherwise specified.

6 Includes additional imaging accompanying an interventional breast performed on the same day as the first diagnostic follow-up to a screening mammogram.

7 Needle/Core Biopsy includes; Stereotactic Guided Breast/Axillary Biopsy, Tomographically Guided Breast/Axillary Biopsy, Tomgraphicaly Guided Stereotactic Breast/Axillary Biopsy, Ultrasound-Guided Breast/Axillary Biopsy, MR Guided Breast/Axillary Biopsy, Core Type NOS Breast/Axillary Biopsy, and Fine Needle Aspiration.

8 Cancer Detection Rate - The number of cancers detected at imaging per 1000 examinees having screening mammography. Reported as X per 1000 Screened.

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