About Outcomes and Interpreting Physicians
QUESTION:
Based on what we understand, the practice must make every reasonable attempt to obtain an actual follow-up" outcome" on the disposition of all positive exams. That includes correlating pathology results with the physician's report made at their site. Then, we use the information to calculate the quality indicators you identified in your email.
Also, on another note, can an audit IP be different from the leading IP? See the statement below.
From the previous email:
As of September 10, 2024, a facility must have designated an audit interpreting physician (or "audit IP") and must have established the required audit procedures, including the procedures for calculating the three required metrics (i.e., PPV, CDR, and recall rate).
ANSWER:
- Based on what we understand, the practice must make every reasonable attempt to obtain an actual follow-up "outcome" on the disposition of all positive exams. That includes correlating pathology results with the physician's report made at their site. Then, use the information to calculate the quality indicators you identified in your email.
This is the correct procedure.
- Can an audit IP be different from the leading IP?
That is also correct. This IP must be clearly identified for the MQSA Inspector.
As of September 10, 2024, a facility must have designated an audit interpreting physician (or "audit IP") and must have established the required audit procedures, including the procedures for calculating the three required metrics (i.e., PPV, CDR, and recall rate) For an audit that includes some mammograms performed before the effective date, the facility may choose to perform the calculations if the necessary outcomes data are available or, the facility may report one or more of the three metrics as "Not Applicable." For an audit that covers only mammograms performed on or after September 10, 2024, all three metrics must be calculated as applicable (e.g., screening-only facilities or facilities with no positive exams may report some metrics as "Not Applicable").
All information in this answer and all others are sourced from the MQSA Hotline at +1 (800) 838-7715. For other questions, contact Mammologix or the MQSA Program directly!