received annual mammograms during the entire 10 years. Similarly, data from the New Mexico Mammography Project revealed that between 1994 and 1997, 30 percent or fewer women had adhered to the Project’s established annual screening recommendations (Gilliland et al., 2000). On the other hand, researchers who examined one of the few examples of organized breast cancer screening in the United States—a not-for-profit managed health care plan serving more than 350,000 people in the state of Washington—found that women who were enrolled in the plan’s screening program had a 61 percent lower risk of late-stage breast cancer, compared with women who were not enrolled in the program, using primarily a 2-year interval of screening (Taplin et al., 2004).

Unlike organized breast cancer screening programs in European countries, the United States has not established centralized registers or reminder systems to alert women when they are due for a mammogram. While there are many obstacles to the development of European-style systematized screening in the United States, a variety of reminder systems (see Box 5-1) that have been implemented in both opportunistic and organized screening programs could be further expanded. However, as the findings in Box 5-1 indicate, no single type of mammography reminder system has been found to be superior to others in all populations and situations.

It would also seem that a reminder system that monitors multiple diseases and health risks would be better—from the point of view of both patient and health care provider—than the sort of single-disease intervention typified by mammogram reminders. Related needs such as screening for breast and cervical cancers may be more effectively addressed in combination than through approaches that target single interventions (Valanis et al., 2003). Because many health organizations are committed to increasing rates of preventive care, there is significant potential for developing reminder systems to coordinate multiple prevention activities. For example, an evolving collaboration among the American Cancer Society, the American Heart Association, and the American Diabetes Association could lead to the development of systems that integrate preventive care and testing for each of these diseases (Eyre et al., 2004).

The Committee concluded that patient reminder systems are an important and effective tool to encourage women to undergo breast cancer screening at recommended intervals, and that broader use should be encouraged. However, the variability of practice settings in the United States makes it difficult to recommend any one particular type of reminder system, or to mandate their use under MQSA.

MEDICOLEGAL LIABILITY AND THE QUALITY OF CARE

As noted in Chapter 4, concerns about the likelihood and consequences of malpractice liability may discourage radiologists from interpreting mammograms. Malpractice lawsuits (described in Box 5-2) have become increasingly common, costly, and time-consuming. Malpractice liability insurance rates have also risen. Physicians interpreting mammograms are particularly concerned about the high frequency of malpractice lawsuits involving delayed diagnosis of breast cancer and the expense of paid claims for such suits.

The escalation of medicolegal costs could perhaps be contained through medical liability reform. However, this is a complex topic of considerable controversy. Many approaches to reform have been proposed, but there is widespread disagreement in the



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