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DOI: 10.1148/radiol.2341040125
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(Radiology 2005;234:79-85.)
© RSNA, 2005

Breast Imaging

Screening Mammography: Costs and Use of Screening-related Services1

Steven P. Poplack, MD, Patricia A. Carney, PhD, Julia E. Weiss, MS, Linda Titus-Ernstoff, PhD, Martha E. Goodrich, BS and Anna N. A. Tosteson, ScD

1 From the Departments of Radiology (S.P.P.), Community and Family Medicine (P.A.C., J.E.W., L.T.E., M.E.G., A.N.A.T.), and Medicine (A.N.A.T.), Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, HB 7999, Lebanon, NH 03756. Received January 22, 2004; revision requested March 31; revision received June 10; accepted July 20. Supported in part by grants from the U.S. Department of Defense (DASD17–94-J-4109) and National Cancer Institute (U01 CA86082–01 and R01-CA080888–01A1). Address correspondence to S.P.P. (e-mail: steven.p.poplack@hitchcock.org).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
PURPOSE: To determine the costs and screening-related services in women undergoing screening mammography.

MATERIALS AND METHODS: Study procedures were approved by the institutional committee for the protection of human subjects, and participants gave prior written consent. Data from a statewide mammography registry were used to identify imaging examinations, clinical consultations, interventional procedures, and pathology reports associated with screening mammography. The analysis included 99 064 women in the New Hampshire Mammography Network who underwent screening mammography between November 1, 1996, and March 31, 2000. Use of screening-related services in each case was tracked over an 18-month period, and procedure-specific national Medicare reimbursement rates from 2002 were applied for estimation of costs. Descriptive statistics (means, medians, standard deviations, 95% confidence intervals, frequencies, and percentages of resources and of costs) were calculated.

RESULTS: The majority of subjects (85 809, or 87%) underwent screening mammography only. Of the 13 255 (13%) who underwent diagnostic imaging, additional mammographic views were obtained in most at the time of screening, within days or weeks of screening, or at short-interval follow-up. The total cost was $12 287 739. Approximately 80% ($9 777 670) of the total cost was related to imaging, and 68% ($8 410 313), specifically to screening mammography. Twenty percent ($2 510 069) of the total cost was associated with consultation and interventional procedures in only 2942 (3%) of the women, primarily those who underwent biopsy. Procedures resulted in benign findings in 2247 (76%) of the 2942. Mean total direct medical costs per capita were low ($99) in women who underwent screening mammography only, moderate ($286) in women who also underwent diagnostic imaging, and substantially greater in women who underwent biopsy ($993).

CONCLUSION: While the largest component cost of screening mammography is that incurred in obtaining screening views alone, the highest costs per capita are associated with interventional procedures.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Mammographic screening for breast cancer can be a complicated process. While the majority of women undergo a single examination that involves bilateral mammographic views, an important subgroup of women in whom results are abnormal or ambiguous undergo supplemental imaging, clinical evaluation, and/or biopsy (1,2). This additional testing has potentially far-reaching implications for the well-being of patients (3–5), healthcare access (6,7), and the overall costs of the screening process (1,8–11).

The viability of screening mammography may depend on the economics of breast imaging service provision. Increasing demand for mammography may outpace current levels of technical and professional staffing and result in access problems (12–14). Recent cost analyses of the mammographic screening process have been performed in U.S. health maintenance organizations (6) and in population-based screening programs outside the United States (7,8), and costs have been estimated by using statistical models (10). Studies of resource utilization and costs associated with the provision of screening mammography to the community, the predominant model for the delivery of mammographic screening in the United States, are limited (1), and the literature is outdated (9,15). Thus, the purpose of our study was to determine the costs and screening-related services in women undergoing screening mammography.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Study Population
The New Hampshire Mammography Network (NHMN) is a statewide registry of data collected from women undergoing mammography, from interpreting radiologists, and from pathologists (16). Approximately 90% of women examined at participating mammographic facilities provide written consent for the use of their information for research purposes. The procedures used in our study were approved by the Committee for the Protection of Human Subjects at our institution. We (M.E.G., J.E.W.) identified 107 718 consenting women who had undergone screening mammography between November 1, 1996, and March 31, 2000, and for whom pathology reports were available. From this group we (J.E.W.) excluded 900 women with breast implants and 6709 women with a personal history of breast cancer. Women who presented for diagnostic mammography because of a specific breast symptom were not eligible for this study. To further ensure that the study was limited to a screening population, we also omitted 1045 women who had undergone mammography within 270 days of their first screening examination recorded in the registry. After these exclusions, 99 064 participants were available for analysis.

Data Collection Procedures
Consenting NHMN participants completed a patient intake form that indicated informed consent and demographic and selected risk information. Additional clinical information of relevance to the assessment of risk and the mammographic interpretation (eg, family history, use of hormones, menopausal status, and current clinical concerns) was collected during a face-to-face interview conducted by the mammographic technologist. Data about image interpretation, including the purpose of examination (screening vs diagnostic), radiographic depiction of tissue density, Breast Imaging Reporting and Data System assessment (17), and management recommendations, were reported directly by the interpreting radiologist. These data primarily involved imaging examinations associated with mammography, as the NHMN does not routinely capture data from ultrasonography (US) performed as the sole examination. Reports of benign and malignant findings from participating pathology laboratories were abstracted and entered into a breast pathology database and later were matched to women in the mammography data file.

Definitions and Screening-related Services
A mammographic examination was classified as screening if the interpreting radiologist indicated it was such and if the woman did not report symptoms of possible breast disease (eg, lump, nipple discharge, or skin change). A mammographic examination was considered diagnostic if signs or symptoms of breast disease were noted by either the women or the technologist or if the examination was intended to evaluate a mammographic abnormality or was coded as diagnostic by the radiologist. Each woman’s first screening mammographic examination during the study period was considered the index examination. The follow-up period for resource and cost assessment extended 18 months from the date of the index examination.

To capture all data about screening-related services, including immediate and short-interval follow-up imaging and biopsy, we (S.P.P., P.A.C., J.E.W., A.N.A.T.) analyzed the diagnostic examinations and breast interventional procedures that women underwent after the index screening through the 18-month follow-up period. We (J.E.W.) excluded additional rounds of routine screening. We estimated the frequency of clinical consultation on the basis of the interpreting radiologist’s recommendation for clinical breast examination or surgical consultation. We assumed that an excisional biopsy was preceded by a surgical consultation. Interventional procedures were classified according to mode of biopsy. Core biopsies for which the type of imaging guidance was not specified were classified as either stereotactically guided or US-guided core biopsies on the basis of the percentage of biopsies of each type that were reported to the NHMN.

Diagnostic imaging that occurred during the 18-month follow-up period was defined as imaging used to evaluate either a clinical problem or a mammographic abnormality identified at interpretation of screening views. Specific diagnostic examinations included immediate additional mammography (on the same day as screening mammography), subsequent additional mammography (within days to weeks of initial screening mammography), short-interval follow-up mammography (usually 3–9 months after screening mammography), US, and imaging of a clinical problem. We (S.P.P.) distinguished between immediate and subsequent additional mammography because the billing of these examinations differed during the study period, in that facilities typically billed screening with immediate additional mammography as a bilateral diagnostic examination, whereas subsequent additional mammography was billed as a separate diagnostic examination (18). Imaging of a clinical problem identified during the interpretation of mammographic screening views was included in the analysis because clinical problems often become evident in the screening process. Women engaged in screening may utilize imaging services differently from women in a nonscreening population. For example, a woman who presents for routine screening may inform the technologist that she or her provider just noticed a lump, or a technologist may discover a palpable abnormality while positioning the breast for screening views. Cancer was defined as either invasive breast cancer or ductal carcinoma in situ identified at pathologic analysis. Lobular carcinoma in situ and other high-risk breast lesions were considered negative findings and were classified with benign results.

Cost Analysis
Total and component costs of imaging, consultation, and biopsy were estimated according to 2002 national Medicare reimbursement rates. Medicare fee schedules are based on the resource-based relative value scale, which is used to assess healthcare service costs according to the resources used in providing the service (19–21). We (J.E.W., A.N.A.T.) applied Current Procedural Terminology (CPT) codes to categorize each specific imaging examination, consultation visit, and interventional procedure (Table 1). Reimbursement rates from 2002 were used to estimate the most current costs (22). For most imaging examinations and interventional procedures, CPT coding was straightforward (eg, bilateral screening mammography was coded as bilateral screening examination). The following assumptions, however, were applied to more complex diagnostic services: Immediate additional mammography (on the same day as screening mammography) was coded as bilateral diagnostic mammography (CPT 76091). Subsequent additional mammography and short-interval follow-up mammography were coded as unilateral diagnostic mammography (CPT 76090), since a single breast is usually evaluated in examinations of these types. A recommendation for a clinical breast examination was assumed to represent a brief medical consultation with the patient’s primary care provider (eg, established patient evaluation and management 10-minute visit, CPT 99212). A recommendation for surgical consultation was assumed to require a more lengthy new patient evaluation (eg, established patient evaluation and management 30-minute visit, CPT 9242). A combination of CPT codes (Table 1) was used for calculating the costs of biopsy procedures (23). We (S.P.P.) assumed that stereotactic biopsy was performed with a vacuum-assisted needle or rotating biopsy device (CPT 19103) and that US-guided biopsy was conducted with a cutting needle and was not vacuum assisted (CPT 19102). Stereotactic biopsy performed with the minimally invasive breast biopsy technique or the advanced breast biopsy instrument was classified as stereotactic biopsy.


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  		TABLE 1. CPT Service Codes and Corresponding National Medicare Global Allowable Reimbursement Amounts for 2002

 
Statistical Analysis
For each woman, the frequencies of various combinations of imaging examinations, clinical recommendations, and interventions were totaled over the 18-month follow-up period. Descriptive statistics (mean, median, standard deviation, and 95% confidence interval) were used to characterize type, frequency, and costs of imaging examinations, clinical consultations, and interventional procedures associated with screening mammography. No statistical tests were performed. Statistical software (SAS, version 8; SAS Institute, Cary, NC) was used to generate descriptive statistics. Global Medicare reimbursement rates were assigned to all service events that occurred within the 18-month follow-up period. Thus, the estimated costs reflect the total combined services used by each woman.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Study Population
Most of the 99 064 women were older than 40 years, had no family history of breast cancer, were postmenopausal, and had a breast composition characterized by scattered fibroglandular densities or heterogeneous density (Table 2). In addition, 95% (n = 94 001) had some form of health insurance, and 80% (n = 78 823) had some college education or were college graduates. Sixty-one percent (n = 59 929) were married, 6% (n = 5597) were single, 12% (n = 12 145) were separated or divorced, and 8% (n = 7 395) were widowed; information about marital status was missing for 14% (n = 13 998). Of the 53 880 women included in the analysis for whom race was known, 98% (n = 52 535) were white; the ethnic composition of our study group thus mirrored that of the general population in the state of New Hampshire.


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  		TABLE 2. Characteristics of Women Included in the Analysis

 
Service Utilization
The majority in the study group, 85 809 (87%) of 99 064, underwent screening mammography as the only form of imaging. Of the 13 255 (13%) who underwent diagnostic imaging, most underwent additional mammography immediately (n = 5832; 44%), subsequently (n = 3313; 25%), or at short-interval follow-up (n = 3976; 30%) (Fig 1). Consultations were infrequent, except in the subgroup of women who underwent breast biopsy.



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  		Figure 1. Bar graph shows distribution of screening-related services for all women in the study (gray bars, n = 99 064), for those who underwent diagnostic imaging (black bars, n = 13 255), and for those who underwent interventional procedures (white bars, n = 2942).

 
A total of 2942 women underwent an interventional procedure that resulted in the diagnosis of benign or malignant breast disease. Of these women, 695 (24%) had invasive breast cancer and/or ductal carcinoma in situ. (Data regarding the frequency of different biopsy types have not been included in any of the tables in the article but are detailed next.) Excisional biopsy was the single most common interventional procedure and was performed in 1277 (43%) of the 2942 women. In most women who underwent biopsy, however, a percutaneous method was used; 1127 (38%) of 2942 women underwent stereotactically guided core-needle biopsy, 265 (9%) underwent fine-needle aspiration, 212 (7%) underwent biopsy with the advanced breast biopsy instrument, 114 (4%) underwent US-guided core-needle biopsy, and 38 (1%) underwent minimally invasive breast biopsy. More than one procedure (of the same type or different types) was performed in 175 (6%) of the women who underwent biopsy.

Costs of Services
Of the approximately $12.3 million total cost of the screening mammography program, roughly $9.8 million, or 80% ($9 777 670 [$8 410 313 + $1 367 357] of $12 287 739), was incurred in imaging, and 20% ($2 510 069 [$1 194 555 + $1 315 514] of $12 287 739), in breast interventional procedures or clinical consultations (Fig 2). Screening mammography alone accounted for 68% ($8 410 313) of the total cost. Immediate additional mammography, which included screening views, accounted for 39% of the diagnostic imaging cost ($535 851 of $1 367 357) and was the largest component cost for women who underwent diagnostic imaging (Fig 2).



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  		Figure 2. Pie charts show component costs associated with screening mammography (left) and detailed cost stratification of subsequent diagnostic imaging according to modality and time interval after screening (right).

 
Consultations and interventional procedures that resulted in diagnosis of benign or malignant breast disease accounted for 20% of the total cost associated with screening ($2 480 098 of $12 287 739) but affected only 3% of the study group (2942 of 99 064; Fig 3). About two-thirds, or 65% ($1 615 991 of $2 480 098), of the nonimaging cost was incurred through excisional biopsy. Consultations accounted for 4% ($90 404 of $2 480 098) of the nonimaging cost.



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  		Figure 3. Pie chart shows component costs of screening-related interventional procedures and consultations (total cost, $2 480 098).

 
Eighty-five percent ($2 480 098 of $2 920 434) of the total cost of screening in women with a diagnosis based on biopsy was unrelated to imaging and was primarily associated with interventional procedures (Fig 4). Women with benign breast disease accounted for 18% of the total screening cost ($2 230 532 of $12 287 739), and women with cancer contributed 6% to overall cost ($689 902 of $12 287 739). Seventy-six percent ($9 337 334 of $12 287 739) of the total cost was incurred in imaging that did not lead to biopsy.



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  		Figure 4. Pie chart shows screening-related costs for women with benign or malignant findings at pathologic analysis after biopsy and for women without biopsy.

 
The mean total cost per woman was $124, of which $99 was attributable to imaging, and $25, to consultation and/or intervention (Table 3). The median total cost was $82, or approximately the cost of a single bilateral screening mammographic examination. The mean total cost per woman who underwent diagnostic imaging ($286) was more than double that for the entire study group ($124), because of the higher mean cost of imaging ($196) and consultation and/or intervention ($90). The mean total cost per woman with any type of pathologic finding was markedly higher ($993), driven upward by a high mean cost of interventional procedures ($843). As expected, the lowest cost per capita was found in the group of women who underwent screening mammography only (ie, as the only imaging examination): The mean total cost of $99 per woman reflected the mean cost of screening mammography ($84) and a small component cost ($15) of consultations and interventional procedures.


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  		TABLE 3. Median and Mean per Capita Costs Based on Services Received

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Although previous reports have addressed costs associated with screening mammography (1,9), breast imaging and diagnosis have changed considerably in the ensuing years. Supplementary diagnostic US, short-interval follow-up mammography, and imaging-guided core-needle biopsy have become commonplace, and mammography has come to be federally regulated through the Mammography Quality Standards Act (24). In this article, we report the results of a recent analysis of services and costs associated with screening mammography in diverse practice settings in New Hampshire.

Consistent with the results of prior studies (1,2,25), our study results show that the vast majority of women who underwent screening mammography received screening views only (87%, 85 809 of 99 064), and a distinct minority (13%, 13 255 of 99 064) underwent diagnostic imaging. In contrast with results reported a decade and a half ago (9), however, we found that the costs associated with standard screening outweighed the "induced costs" of diagnostic imaging, clinical evaluation, and interventional procedures that result from screening. In our study, the costs of procedures and consultations, while modest overall, accounted for a substantial share of the total cost, despite the small proportion of women receiving these services. Only 2942 (3%) of 99 064 women underwent a breast interventional procedure, but 20% of the financial resources ($2 510 069 of $12 287 739) were consumed by them. Furthermore, most of this expense was incurred in the diagnosis of benign breast disease, which was found in 2247 (76%) of the 2942 women who underwent biopsy.

We found that additional mammography following the acquisition of screening mammograms accounted for the majority of diagnostic imaging examinations, which we defined as including US, short-interval follow-up, and imaging of a clinical problem, as well as supplemental mammography of screening abnormalities. A specific analysis of the processes and costs associated with the performance of diagnostic mammography only (in women who manifest specific breast symptoms) would require a separate study. Our results are remarkably similar to those of Brown and colleagues (1), who showed a comparable stratification of diagnostic examination types by using data collected from 50 community mammography facilities for screening mammograms with abnormal findings obtained in 1991. In our analysis, supplemental mammography accounted for the majority of diagnostic imaging costs. These costs could be reduced with a decrease in the recall rate.

We were surprised that the utilization of US had not changed more dramatically in the previous decade, despite an increase in the indications for US examination (26–28). Although some of these newer indications may not have found general application in the community, it is important to note that the NHMN registry does not routinely collect information about US when it is conducted alone (eg, not in conjunction with mammographic imaging). Therefore, it is likely that we have underestimated the frequency of breast US examinations relative to mammographic examinations.

The distribution of interventional services was notable for a relatively balanced mix of percutaneous (57%, 1665 of 2942) and excisional biopsy (43%, 1277 of 2942) procedures. The high frequency of excisional biopsy likely reflects differences in resource utilization in practice type (eg, academic vs community practice), regional differences in technology diffusion across the country, and need for excisional biopsy subsequent to nondiagnostic, atypical, or high-risk pathologic findings at fine-needle aspiration or core biopsy. The modest number of fine-needle aspiration cytology procedures (9%, 265 of 2942) is probably related to symptomatic abnormalities in women who presented for the evaluation of a clinical problem, which was the examination indication in 9% of women who underwent an interventional procedure.

Excisional biopsy accounted for nearly two-thirds of the costs of nonimaging services because of the higher procedural cost of open biopsy compared with percutaneous procedures. Consistent with those in other reports (23,29,30), our findings show that significant cost savings could be achieved by performing a larger percentage of percutaneous biopsy procedures, especially US-guided core biopsy.

Eleven percent of the total cost ($1 315 514 of $12 287 739) was generated by women who did not undergo diagnostic imaging but went straight to consultation or intervention based on results of screening mammography alone. Although it may appear that cost savings could result from more limited use of diagnostic imaging prior to biopsy, it is possible that additional imaging might obviate tissue sampling in those with definitely benign or probably benign findings (31).

To estimate direct medical costs of screening mammography, we used the standard Medicare reimbursement amounts, because Medicare is an important insurance provider in most breast imaging practices and these amounts are generalizable to facilities across the country. Medicare reimbursement rates tend to be at the low end of the reimbursement spectrum and, for certain examination types, are roughly equivalent to the direct medical costs (32,33). Medicare reimbursement rates thus serve as a reasonable and convenient surrogate for direct medical cost estimates. We did not address treatment-related direct medical costs because, as noted by Moskowitz and Fox, "the cost of initial treatment will occur with or without screening" (34). The financial effect of screening on treatment, including likely cost savings associated with finding breast cancer at an earlier stage, is important. Unfortunately, it was beyond the scope of this analysis. We did not evaluate the direct nonmedical (eg, cost of transportation) or indirect costs (eg, time lost from work) associated with screening. We used an 18-month follow-up period of resource and cost assessment, which is shorter than the 24–36-month time frame used to confirm benignity of a probably benign finding. Thus, we have likely underestimated the total costs associated with screening mammography, although we believe this underestimation is very slight.

Several additional limitations deserve comment. First, our estimates are based on our use of the NHMN registry to identify or estimate the costs of diagnostic services associated with screening mammography. Although NHMN has a high participation rate among women, mammography facilities, and pathology labs and performs rigorous quality assurance measures to capture key data variables that are not reported (16), it does not provide complete coverage for the state of New Hampshire. Second, during the time period studied, data about the utilization of breast magnetic resonance imaging, computer-aided diagnostic devices, and breast scintigraphy were not recorded, and digital mammography was not distinguished from screen-film mammography, by the NHMN. Third, our estimates of the frequency of clinical consultation were based on the number of recommendations for clinical breast examination (eg, medical consultation) and/or surgical consultation in the mammography interpretive report. We assumed a simple one-to-one correspondence between the number of procedures recommended and the number actually performed, a correspondence that does not always exist (1). Fourth, we chose to include in our analysis diagnostic imaging examinations used to evaluate a clinical problem, because clinical problems often come to light as part of the screening process. While the inclusion of this type of examination may have resulted in overestimation of the frequency and cost of diagnostic imaging in a screening population, it involved only 1.3% of the screening mammography population. Finally, although we have attempted to present these data in a form that is generalizable, we cannot be certain that practices in New Hampshire are comparable to those in other regions. Also, the population of our state is predominantly white, and our findings may not apply to other demographic groups. Despite these limitations, our data are valuable because they are based on actual clinical encounters in a geographic sample of the population and reflect a broad range of mammography facilities, radiology practice types, and pathology laboratories.

In conclusion, screening mammography is a complex process that may involve a variety of imaging examinations, consultations, and interventional procedures. While the largest component cost of screening mammography services is incurred by the acquisition of screening views alone, a moderate amount is spent on diagnostic imaging, and a disproportionate sum is spent on breast biopsy, especially wire-localized excision. An understanding of the direct medical costs of providing screening mammography and associated services is important in the context of the current financial pressures faced by the breast imaging community and the medical community at large.


   ACKNOWLEDGMENTS
 
The authors greatly thank Bernard F. Cole, PhD, and Qing-Lin Zhu, MS, for data development, and Robyn E. Mosher, MS, for editorial assistance.


   FOOTNOTES
 
Abbreviations: CPT = Current Procedural Terminology, NHMN = New Hampshire Mammography Network

Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, S.P.P., P.A.C.; study concepts and design, S.P.P., P.A.C., L.T.E., A.N.A.T.; literature research, S.P.P., P.A.C.; clinical studies, S.P.P.; data acquisition, S.P.P., P.A.C., M.E.G.; data analysis/interpretation, all authors; statistical analysis, J.E.W., A.N.A.T.; manuscript preparation, S.P.P., P.A.C., L.T.E., M.E.G.; manuscript definition of intellectual content, S.P.P., J.E.W., L.T.E., A.N.A.T.; manuscript editing, S.P.P., P.A.C., J.E.W., L.T.E.; manuscript revision/review and final version approval, all authors


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 

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