Workforce Shortages in Breast Imaging: Impact on Mammography Utilization
Workforce Shortages in Breast Imaging: Impact on Mammography Utilization
Objective: The objective of this study was to develop reliable forecasts of the future supply of radiologists and radiologic technologists practicing mammography under different assumptions about future introduction of new practitioners. In addition, this article includes basic mammography workforce statistics to provide a context for the forecasts.
Materials and Methods: The forecasts were developed using an age cohort flow model based on data provided by the American College of Radiology (ACR) on the numbers and age distribution of radiologists and on data provided by the American Society of Radiologic Technologists (ASRT) on radiologic technologists providing mammography services.
Results: The forecasts show that the current rates of production of new mammography professionals will result in dramatic reductions in mammography professionals per woman age 40 years old and older over the next 15-20 years.
Conclusion: Unless the number of new mammography professionals entering practice every year increases beyond the current levels, there will be a growing gap between the supply of and demand for mammography professionals over the next two decades.
Since recommended screening guidelines were developed in the early 1980s, a decrease in the risk of mortality from breast cancer and ultimately more favorable health outcomes have been linked to the shift to early-stage detection -- that is, detection of localized rather than regionalized disease -- through increased rates of mammography screening. Although the actual impact of mammography on mortality from breast cancer has been widely debated and although discussions about its specificity and sensitivity continue, there was a 23.5% decrease in the mortality rate from breast malignancies between 1990 and 2000 for women 30-79 years old. The mortality rate from breast cancer in the United States decreased approximately 2% per year over the 1990s.
Although some of this decrease in mortality rate can be attributed to improvements in breast cancer therapy, data from Sweden and The Netherlands and strong evidence from the United States show that the primary factor responsible for the decrease in deaths from breast cancer has been early detection through mammography screening. This benefit has accrued to greater numbers of women as the rate of screening has increased, but these gains are currently in jeopardy because of a potential decrease in access to screening mammography because of workforce staffing shortages.
In recent years, concerns about the availability and adequacy of mammography services have been prominently featured in both the popular and the scientific literature. The review and reauthorization of the Mammography Quality Standards Act (MQSA) legislation in 2004 placed mammography in the forefront of discussion among imaging professionals, government regulators and policy makers, health care providers, and patients. Access to breast imaging services in certain geographic areas, limited availability or utilization of mammography by high-risk populations, the adequacy of the supply of the professional and technical breast imaging workforce, the accuracy and variability of interpretation, low insurance reimbursement rates, and the high number of malpractice claims and high cost of professional liability insurance have dominated the discussion.
A U.S. Government Accountability Office (GAO) study published in 2002 found the number of facilities providing mammography services nationwide had decreased from 9,884 in 1998 to 9,393 in 2001. A 2006 update to that report revealed further attrition: Between October 1, 2001, and October 1, 2004, the number of mammography facilities in the United States dropped to 8,768, reflecting the closure of 1,290 facilities and the opening of 752 new facilities over that time period, a net closing of 538 sites. To operate lawfully under federal guidelines, mammography facilities, except those operated by the Department of Veterans Affairs, must be certified by a U.S. Food and Drug Administration (FDA)-approved accrediting body. The FDA has approved the American College of Radiology (ACR) and has identified four qualified states (Iowa, Illinois, South Carolina, and Texas) to accredit facilities. Although there was an 11% decline in the number of facilities providing mammography services between 2000 and 2007, there was a 4.6% increase in the number of accredited mammography devices in the United States from 12,956 devices in 2000 to 13,546 devices in 2007.
At the same time, experts agreed that the number of new professionals entering the breast imaging field was insufficient to continue to meet the needs of the growing population of women who required or would require breast imaging services. Each year approximately 1.2 million women enter the age group suggested for screening mammography. Approximately 61% of currently practicing radiologists, about 16,000 doctors, provided interpretation of at least some mammography studies in the practices where they worked. Only 28% of radiologists interpreted 2,000 or more mammography studies per year and just 7.2% interpreted 5,000 or more annually. A 2006 GAO analysis of the FDA mammography reporting database revealed a 5% decrease in the number of physicians who interpreted mammograms between 2001 and 2004 and a 3% decrease in the number of radiologic technologists performing mammography.
In a study conducted at 196 facilities providing 4.2 million mammograms in 2004, the overall mean number of mammograms interpreted by a radiologist was 1,777. However, 31% of all radiologists included in the study interpreted fewer than 1,000 mammograms annually. At the other end of the spectrum, 10% of radiologists in the study group interpreted more than 3,000 mammograms annually, accounting for 32% of all studies read.
The reluctance of recently trained radiologists to enter breast imaging as a full-time profession has been documented. Radiology residents in mammography rotations in 211 accredited radiology residences in the United States and Canada were surveyed to ascertain their interests and attitudes toward mammography. Among those canvassed:
The reasons for the radiology residents' reluctance to consider a fellowship or work in mammography included a lack of interest in the field, fear of lawsuits, and stress of interpretation. A similar study of radiology residents in Massachusetts found that only 3% would like to spend substantial time interpreting mammograms in clinical practice.
In a survey conducted by the Society of Breast Imaging in 2003 and 2004, 29% of breast imaging practices reported a vacancy for one or more radiologists to interpret mammography studies. A higher proportion of facilities reporting vacancies also reported longer wait times for screening mammography than facilities without vacancies. Almost one third (30%) of practices responding to the survey also reported unfilled positions for radiologic technologists certified in mammography.
There is also evidence that the growth of the technical workforce in mammography is not keeping up with demand. The American Registry of Radiologic Technologists (ARRT) listed 48,665 radiologic technologists as certified in mammography in 2007, an increase from 45,730 radiologic technologists certified in mammography in 2004. However, among radiologic technologists certified in mammography, only about half work in mammography as a primary discipline. The number of radiologic technologists seeking certification in mammography remained essentially flat from 2000 until 2003 when there was a 6% annual increase in first-time examinees in mammography. One reason for the lack of radiologic technologists' interest in mammography might be that salaries in mammography are among the lowest of any imaging technique.
The national mammography workforce projections cited in this article were originally prepared as background for an Institute of Medicine study on mammography to inform the reauthorization of MQSA conducted in 2004. The Division of Research of the ACR provided 2003 survey data and the American Society of Radiologic Technologists (ASRT) provided data from a 2004 radiologic technologist wage and salary survey for the construction of the projection models.
Abstract and Introduction
Abstract
Objective: The objective of this study was to develop reliable forecasts of the future supply of radiologists and radiologic technologists practicing mammography under different assumptions about future introduction of new practitioners. In addition, this article includes basic mammography workforce statistics to provide a context for the forecasts.
Materials and Methods: The forecasts were developed using an age cohort flow model based on data provided by the American College of Radiology (ACR) on the numbers and age distribution of radiologists and on data provided by the American Society of Radiologic Technologists (ASRT) on radiologic technologists providing mammography services.
Results: The forecasts show that the current rates of production of new mammography professionals will result in dramatic reductions in mammography professionals per woman age 40 years old and older over the next 15-20 years.
Conclusion: Unless the number of new mammography professionals entering practice every year increases beyond the current levels, there will be a growing gap between the supply of and demand for mammography professionals over the next two decades.
Introduction
Since recommended screening guidelines were developed in the early 1980s, a decrease in the risk of mortality from breast cancer and ultimately more favorable health outcomes have been linked to the shift to early-stage detection -- that is, detection of localized rather than regionalized disease -- through increased rates of mammography screening. Although the actual impact of mammography on mortality from breast cancer has been widely debated and although discussions about its specificity and sensitivity continue, there was a 23.5% decrease in the mortality rate from breast malignancies between 1990 and 2000 for women 30-79 years old. The mortality rate from breast cancer in the United States decreased approximately 2% per year over the 1990s.
Although some of this decrease in mortality rate can be attributed to improvements in breast cancer therapy, data from Sweden and The Netherlands and strong evidence from the United States show that the primary factor responsible for the decrease in deaths from breast cancer has been early detection through mammography screening. This benefit has accrued to greater numbers of women as the rate of screening has increased, but these gains are currently in jeopardy because of a potential decrease in access to screening mammography because of workforce staffing shortages.
In recent years, concerns about the availability and adequacy of mammography services have been prominently featured in both the popular and the scientific literature. The review and reauthorization of the Mammography Quality Standards Act (MQSA) legislation in 2004 placed mammography in the forefront of discussion among imaging professionals, government regulators and policy makers, health care providers, and patients. Access to breast imaging services in certain geographic areas, limited availability or utilization of mammography by high-risk populations, the adequacy of the supply of the professional and technical breast imaging workforce, the accuracy and variability of interpretation, low insurance reimbursement rates, and the high number of malpractice claims and high cost of professional liability insurance have dominated the discussion.
A U.S. Government Accountability Office (GAO) study published in 2002 found the number of facilities providing mammography services nationwide had decreased from 9,884 in 1998 to 9,393 in 2001. A 2006 update to that report revealed further attrition: Between October 1, 2001, and October 1, 2004, the number of mammography facilities in the United States dropped to 8,768, reflecting the closure of 1,290 facilities and the opening of 752 new facilities over that time period, a net closing of 538 sites. To operate lawfully under federal guidelines, mammography facilities, except those operated by the Department of Veterans Affairs, must be certified by a U.S. Food and Drug Administration (FDA)-approved accrediting body. The FDA has approved the American College of Radiology (ACR) and has identified four qualified states (Iowa, Illinois, South Carolina, and Texas) to accredit facilities. Although there was an 11% decline in the number of facilities providing mammography services between 2000 and 2007, there was a 4.6% increase in the number of accredited mammography devices in the United States from 12,956 devices in 2000 to 13,546 devices in 2007.
At the same time, experts agreed that the number of new professionals entering the breast imaging field was insufficient to continue to meet the needs of the growing population of women who required or would require breast imaging services. Each year approximately 1.2 million women enter the age group suggested for screening mammography. Approximately 61% of currently practicing radiologists, about 16,000 doctors, provided interpretation of at least some mammography studies in the practices where they worked. Only 28% of radiologists interpreted 2,000 or more mammography studies per year and just 7.2% interpreted 5,000 or more annually. A 2006 GAO analysis of the FDA mammography reporting database revealed a 5% decrease in the number of physicians who interpreted mammograms between 2001 and 2004 and a 3% decrease in the number of radiologic technologists performing mammography.
In a study conducted at 196 facilities providing 4.2 million mammograms in 2004, the overall mean number of mammograms interpreted by a radiologist was 1,777. However, 31% of all radiologists included in the study interpreted fewer than 1,000 mammograms annually. At the other end of the spectrum, 10% of radiologists in the study group interpreted more than 3,000 mammograms annually, accounting for 32% of all studies read.
The reluctance of recently trained radiologists to enter breast imaging as a full-time profession has been documented. Radiology residents in mammography rotations in 211 accredited radiology residences in the United States and Canada were surveyed to ascertain their interests and attitudes toward mammography. Among those canvassed:
87% of residents rated interpretation of breast images as more stressful than other imaging techniques;
70% of radiology residents expressed greater concern about missing a finding in mammography than in other imaging techniques;
93% of residents were "somewhat" or "much" more concerned about the potential malpractice liability in mammography than in other imaging techniques;
65% believed that mammograms should be interpreted by a subspecialist in breast imaging;
64% would not consider a fellowship in breast imaging if offered to them; and
63% did not want to spend more than 25% of their time in clinical practice interpreting mammograms.
The reasons for the radiology residents' reluctance to consider a fellowship or work in mammography included a lack of interest in the field, fear of lawsuits, and stress of interpretation. A similar study of radiology residents in Massachusetts found that only 3% would like to spend substantial time interpreting mammograms in clinical practice.
In a survey conducted by the Society of Breast Imaging in 2003 and 2004, 29% of breast imaging practices reported a vacancy for one or more radiologists to interpret mammography studies. A higher proportion of facilities reporting vacancies also reported longer wait times for screening mammography than facilities without vacancies. Almost one third (30%) of practices responding to the survey also reported unfilled positions for radiologic technologists certified in mammography.
There is also evidence that the growth of the technical workforce in mammography is not keeping up with demand. The American Registry of Radiologic Technologists (ARRT) listed 48,665 radiologic technologists as certified in mammography in 2007, an increase from 45,730 radiologic technologists certified in mammography in 2004. However, among radiologic technologists certified in mammography, only about half work in mammography as a primary discipline. The number of radiologic technologists seeking certification in mammography remained essentially flat from 2000 until 2003 when there was a 6% annual increase in first-time examinees in mammography. One reason for the lack of radiologic technologists' interest in mammography might be that salaries in mammography are among the lowest of any imaging technique.
The national mammography workforce projections cited in this article were originally prepared as background for an Institute of Medicine study on mammography to inform the reauthorization of MQSA conducted in 2004. The Division of Research of the ACR provided 2003 survey data and the American Society of Radiologic Technologists (ASRT) provided data from a 2004 radiologic technologist wage and salary survey for the construction of the projection models.
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