Reducing number of patient visits and time to biopsy after suspicious breast MRI

From the 2019 HVPAA National Conference

Dr. Sarah Moorman (University of Michigan), Dr. Colleen Neal (University of Michigan), Ms. Rebecca Hall (University of Michigan), Ms. Heather Cheasick (University of Michigan), Mr. Damon Arnold (University of Michigan), Dr. Akshat Pujara (University of Michigan)

Background

As breast MRI volume at an NCI-Designated Cancer Center has increased, so has the number of suspicious breast MRI findings necessitating tissue sampling. Historically, most cases proceeded to MRI-directed ultrasound, followed by core biopsy at a separate appointment. If necessary, two breast MRI biopsy slots were available per week. Thus, patients often made three hospital visits for 1) initial MRI, 2) MRI-directed ultrasound, and 3) core biopsy. The time to biopsy after suspicious breast MRI averaged nearly three weeks.

Objective

To reduce number of patient visits and time to biopsy after identification of suspicious breast MRI findings, without adding MRI biopsy slots.

Methods

This QI initiative was HIPAA-compliant and IRB approval was waived. MRI-directed ultrasound utilization and biopsy scheduling grids were analyzed. Following identification of root causes leading to multiple patient visits and long wait times, countermeasures were developed and proposed to MRI leadership, ten breast MRI readers, and schedulers. These efforts culminated in an algorithm for recommending MRI-directed ultrasound, with highest priority placed on discrete masses over dominant foci and nonmass enhancement. Opportunities for providing MRI-directed ultrasound with same day biopsy by MRI or ultrasound were also identified and implemented. Two-tailed t tests were performed to assess the impact of these countermeasures.

Results

Between 8/1/2017 and 5/31/2018 (10 months prior to the QI initiative), 56 suspicious breast MRI findings in 55 patients were biopsied by MRI or ultrasound. Of the 56 findings, 16/56 (29%) went directly to MRI-guided biopsy and 40/56 (71%) underwent MRI-directed ultrasound, with a sonographic correlate identified in 18/40 (45%). Same day MRI-directed ultrasound and ultrasound-guided biopsy was facilitated for 1 finding. The other 39 findings that underwent MRI-directed ultrasound required a third visit for biopsy – 22 by MRI and 17 by ultrasound.

Between 6/1/2018 and 3/31/2019 (10 months into the QI initiative), 80 suspicious breast MRI findings in 78 patients were biopsied by MRI or ultrasound. Of the 80 findings, 31/80 (39%) went directly to MRI-guided biopsy and 49/80 (61%) underwent MRI-directed ultrasound, with a sonographic correlate identified in 29/49 (59%). Same day biopsy after MRI-directed ultrasound was facilitated for 20 findings – 3 by MRI and 17 by ultrasound. The other 29 findings that underwent MRI-directed ultrasound required a third visit for biopsy – 17 by MRI and 12 by ultrasound.

Mean number of patient visits (2.4 + 0.5 vs 2.7 + 0.5; p<0.0001) and mean time to biopsy (14.0 + 9.9 vs 19.7 + 9.2 days; p=0.0009) following suspicious breast MRI were significantly reduced after initiation of the QI initiative.

Conclusions

Focused use of MRI-directed ultrasound and coupling of MRI-directed ultrasound to image-guided biopsy reduced number of patient visits and time to biopsy after suspicious breast MRI.

Clinical Implications

Patients undergoing breast MRI are often at high risk for breast cancer. Reducing number of visits and time to biopsy after suspicious breast MRI may help ease patient anxiety and improve overall patient experience.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog