Leveling the Workload for Radiologists in Diagnostic Mammography: Application of Lean Principles and Heijunka

To facilitate the delivery of accurate and timely care to patients in complex environments, process improvement methodologies such as Lean can be very effective. Lean is a quality improvement methodology that seeks to add value for patients and employees by continuously improving processes and eliminating waste. At our institution, Lean principles were applied to improve efficiency and minimize waste in the diagnostic breast imaging reading room. This paper describes how we applied Lean principles, including plan-do-study-act testing, level-loading (heijunka), and visual management, to level the workload of the diagnostic radiologists in our practice. Implementation of these principles to improve the diagnostic workflow in breast imaging is described along with examples from our practice, including challenges and future opportunities.

The age-specific differences in histopathological tumor characteristics and TNM classification of breast carcinomas in Quality assured mamma diagnostic (QuaMaDi) program in the state of Schleswig–Holstein in Germany

Background We explored the hypothesis that high-quality standards in diagnostic mammography can lead to an early diagnosis of breast cancers and identifies at risk populations outside screening programs. The histopathological features and distribution of the TNM classification were examined in relation to patient age in a large group of women with breast cancers participating in the Quality Assured Mamma Diagnostic (QuaMaDi) program of the state of Schleswig–Holstein. Patients and methods Surgical pathological reports were studied for clinicopathological characteristics, receptor status, molecular subtype and tumor stage. The analysis was conducted by dividing the study population into three age groups: women under 50 years (pre-screening), 50–69 years (peri-screening) and over 70 years (post-screening). Results 7.111 biopsies and 2.887 resection specimens were included. Breast cancer was diagnosed in 4.241 (59.7%) cases, one fourth of them in women < 50 years. Elderly women (> 70 years) had more well-differentiated, estrogen receptor (ER)-positive and HER2-negative carcinomas, whereas younger women (< 50 years) tended to have more poorly differentiated, ER negative, and HER2-positive carcinomas. 47% of breast carcinoma were luminal B tumors and were most common regardless of age. 70.4% of resected specimen had pT1 stage. Nodal negative were 71.2%. Conclusion In QuaMaDi breast cancer was diagnosed at an early and potentially curable stage of the disease due to high-quality standards in diagnostic mammography. In addition, regardless of age, an increased number of prognostically unfavorable molecular subtypes were detected. Thus, QuaMaDi helps to identify at risk populations. QuaMaDi significantly improves diagnostic mammography and complements mammography screening programs.

Shorter delay to treatment by integrated diagnostic services and NGO- provided support among breast cancer patients in two Brazilian referral centres

Background: The diagnosis of breast cancer requires a complicated series of diagnostic exams. The present study addressed the delay of patients who used publicly and privately financed diagnostic services. Non-governmental organizations (NGOs) donated diagnostic mammograms and biopsies.Design and Methods: Data from 304 patients were obtained from two Brazilian referral centres. In one referral centre (FAP), diagnostic mammography, clinic-histopathological exam and immunohistochemistry were outsourced, whereas in the other centre (HNL), these services were integrated. Cox regression, Kaplan-Meier analysis and non-parametric tests were used to compare variables and time intervals.Results: If diagnostic mammography was financed privately and covered by private health insurance, the likelihood of a delay of >90 days between the first medical visit and the initiation of treatment decreased 2.15-fold (95%CI: 1.06- 4.36; p=0.033) and 4.44-fold (95%CI: 1.58-12.46; p=0.004), respectively. If the clinic-histopathological exam was outsourced (FAP) and publicly or privately financed, the median time between diagnostic mammography and the diagnostic result was 53 and 65 days in the integrated (HNL) and outsourced public system, compared to 29 days in the outsourced private system (p<0.050). The median time between the first medical visit and the diagnostic results of patients who were supported by NGOs, who financed their diagnostic services privately, and who used exclusively public diagnostic services was, respectively, 28.0, 48.5 and 77.5 days (p<0.050).Conclusion: Patients who used privately financed health services had shorter delays. Compared to outsourcing, the integration of the publicly financed clinic-histopathological exam diminished the delay. The support of patients by NGOs accelerated patient flow.

Application of the Health Action Process Approach Model in Predicting Mammography among Iranian Women

Background: This aim of this study was examining the application of the Health Action Process Approach Model (HAPA) in predicting diagnostic mammography among women over 40 years old in Iran.Methods: This was a cross-sectional study that was performed on four hundred women over 40 years old in health centers in Tehran between May to September 2017. The multi-stage cluster sampling were selected for sample research. The instrument was designed on based literature review about Health Action Process Approach (HAPA). Data were collected by self-report questionnaires and analyzed using statistical tests, t-test, correlation regression analysis. The predictors of diagnostic mammography were determined by the structures of the HAPA model.Results: The result regression analysis showed the diagnostic mammography behavior prediction rate, using the structures of the HAPA model was generally 60%.Conclusions: This study showed the effectiveness of the HAPA to predict diagnostic mammography in women over 40 years old. So, it seems examining mammography behavior and individuals' beliefs about breast cancer based on HAPA model is important in order to development of training programs and effectiveness interventions for breast cancer prevention.

Charged with Discharge: A Case-based Review of Nipple Discharge Using the American College of Radiology’s Appropriateness Guidelines

Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions. Men can also present with nipple discharge, and when they do, they have a higher likelihood of malignancy than women. Radiologists vary in their evaluation of patients with nipple discharge, although the American College of Radiology practice guidelines for nipple discharge provides data-driven appropriate algorithms. In patients with physiologic discharge, imaging is not typically indicated. For those with pathologic nipple discharge, imaging typically starts with diagnostic mammography and retroareolar ultrasound for women over 40 years of age, diagnostic mammogram or ultrasound for women aged 30–39 years, and ultrasound for women younger than 30 years. Finally, contrast-enhanced breast MRI or galactography are usually reserved for identifying the cause of discharge when initial imaging with mammography and ultrasound is unrevealing.