Background: The widespread use of mammography, and its lack of specificity in younger women with denser breasts, increases the potential for a large number of biopsies and surgeries performed in women without breast cancer. Once a suspicious breast lesion is identified with mammography, the use of minimally-invasive breast biopsy (MIBB) as the initial tissue acquisition method for diagnosis is widely supported and advocated as best practice. This research focused on the utilization of MIBB techniques and surgical breast procedures to diagnose image-detected suspicious breast lesions, particularly those lesions ultimately diagnosed as benign, in an effort to better understand the quality and cost implications unnecessary surgical care. Methods: This retrospective cohort study evaluated the practice patterns of a variety of physicians in multiple facilities and physician offices across the country for MIBB and open surgical procedures to diagnose image-detected suspicious breast lesions among a cohort of well-insured women younger than 65 years old and eligible for TRICARE (the U.S. military's health benefit). Additionally, mean total costs were calculated to estimate the cost advantages of one initial tissue acquisition procedure versus another and how these costs were impacted by final diagnosis. Results: In total, 80 percent of the episodes began with the less-invasive MIBB, and 20 percent began with an open surgical procedure. Approximately 77 percent of the episodes using MIBB as the initial diagnostic technique were ultimately diagnosed as benign, as compared to a benign diagnosis in 82 percent of episodes initially utilizing open surgical biopsy and in 20 percent of episodes where other definitive surgery was the initial procedure. In total, potentially unnecessary surgery accounted for 15 percent of all cases requiring follow-up biopsy after abnormal mammography. The strongest predictors for the initial use of an open surgical procedure to diagnose a suspicious breast lesion that was ultimately diagnosed as benign were a lesion indicating benign atypia after diagnosis, patient age younger than 40 years old, a military physician performing the initial procedure, and a physician in the Midwest performing the initial procedure. On average, the excess cost associated with the use of surgical biopsy over MIBB as the initial procedure was 3 percent (ranging from 3 to 30 percent), but increased to 70 percent (ranging from 70 to 235 percent) for episodes ultimately diagnosed as benign. Conclusions: The use of surgical procedures to diagnose suspicious breast lesions is declining as the appropriate use of less-invasive MIBB techniques is growing. However, the variation in the utilization of these diagnostic techniques, particularly among younger women and among certain groups of physicians, results in a large number of women undergoing inappropriate surgical diagnosis of suspicious lesions that are ultimately diagnosed as benign. Policies are needed that promote the dissemination of comparative information to physicians about practice patterns, the use and monitoring of physician-level measures of compliance with care standards, payment policies that incentivize physician-level decision-making for high-value care, and balanced information sharing between physicians and patients about the harms and benefits of mammography screening.
|Advisor:||Wood, Susan F.|
|Commitee:||Haugen, Olaf G., Lantz, Paula M., Steiner, Claudia A., Zuckerman, Diana M.|
|School:||The George Washington University|
|School Location:||United States -- District of Columbia|
|Source:||DAI-B 75/06(E), Dissertation Abstracts International|
|Subjects:||Medicine, Public health, Public policy|
|Keywords:||Benign breast lesions, Breast cancer screening, Core-needle biopsy, Mammogram, Mibb|
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