• Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jan. 47 p. [63 references]

Does not apply to this measure

This measure is used to assess the percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7 to 10 days.

The priority aim addressed by this measure is to reduce the length of time between first knowledge of a breast abnormality and diagnostic resolution.

Breast disease; mammogram abnormality; biopsy; timing

Total number of patients with an abnormal mammogram undergoing biopsy

Total number of patients within 7 to 10 days between the first documentation of a mammogram abnormality and a completed biopsy for all records reviewed

• A clinical practice guideline or other peer-reviewed synthesis of the clinical evidence

Unspecified

Current routine use

Internal quality improvement

Physician Group Practices/Clinics

Physicians

Group Clinical Practices

Age less than or equal to 74 years

Female (only)

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Getting Better

Effectiveness
Patient-centeredness
Timeliness

Users of care only

Women through age 74 with biopsy for possible diagnosis of breast cancer

A list of all patients with breast biopsies for mammogram abnormalities during the previous target period. The medical records can be reviewed to determine the number of days between first documentation of an abnormal mammogram and completion of a biopsy.

Data may be collected semiannually.

Patients associated with provider

Inclusions
Total number of patients with an abnormal mammogram undergoing biopsy

Exclusions
Unspecified

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Diagnostic Evaluation

Time window is a single point in time

Inclusions
Total number of patients within 7 to 10 days between the first documentation of a mammogram abnormality and a completed biopsy for all records reviewed

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Fixed time period

Medical record

Individual Case

Unspecified

Rate

Better quality is associated with a higher score

Unspecified

Internal time comparison

Unspecified

Percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7-10 days.

Institute for Clinical Systems Improvement

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Work Group Members: Michael Nelson, MD (Work Group Leader) (University of MN Physicians) (Radiology); Charles McCoy, MD (Park Nicollet Health Services) (Family Practice); Jay Gutenkauf, MD (HealthPartners Medical Group) (Family Practice); Ruth Johnson, MD (Mayo Clinic) (Internal Medicine); Joseph Tashjian, MD (St. Paul Radiology) (Radiology); Clive Grant, MD (Mayo Clinic) (Surgery); Omer Sanan, MD (Aspen Medical Group) (Surgery); Barbara Maclin, RN, OC (HealthPartners Medical Group) (Nursing); Sylvia Robinson, BSN, MBA (Institute for Clinical Systems Improvement) (Measurement and Implementation Advisor); Brent Metfessel, MD, MPH (Institute for Clinical Systems Improvement) (Evidence Analyst); Linda Setterlund, MA (Institute for Clinical Systems Improvement) (Facilitator)

Measure was not adapted from another source.

2003 Nov

2008 Jan

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2005 Nov. 51 p.

• Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jan. 47 p. [63 references]

This NQMC summary was completed by ECRI on May 26, 2004. This NQMC summary was updated by ECRI Institute on December 15, 2005 and again on March 20, 2008.

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.