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.
9 True Positive - Tissue diagnosis of cancer within 1 year after a positive imaging assessment defined as;
Suspicious Finding (Bi-Rads© 4), Highly Suggestive for Malignancy (Bi-Rads© 5) at Screening - OR - 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). Note:All reference information available from NQMBC indicates the imaging assessment
Probably Benign (Bi-Rads© 3), utilized in recommending an interval diagnostic breast imaging study is excluded from its definition of Screening PPV2 and as such, is not included in reporting by Mammologix.
10 False Positive2 - No known diagnosis of breast cancer within 1 year of a positive imaging assessment defined as;
Suspicious Finding (Bi-Rads© 4), Highly Suggestive for Malignancy (Bi-Rads© 5) at Screening - OR - 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).