John D. Keen MD, MBA, Presenter: Nothing to Disclose

James Edward Keen DVM, Abstract Co-Author: Nothing to Disclose

In order to promote unbiased professional recommendations, we analyzed the marginal cost and marginal benefit of digital screening mammography performed at a hypothetical "expert" center rather than a random film screening facility.

We assumed "expert" mammography centers are represented by the Digital Mammographic Screening Trial (DMIST) participants. We used a previously developed decision model of subsequent screening mammography, and assumed a 50 year old woman would face the cash price of a screening mammogram. We assumed that hypothetical "expert" breast imaging specialists work at the DMIST facilities, and would read at about one "great" or two "stellar" positive standard deviations above the mean. This gives a sensitivity of 85% or 95%, and specificity of 95% or 98%, instead of 78%/92% national averages for radiologists. We calculated the fair price to justify the "expert" skill assuming a value of $100K per year of life saved at 3% discount. We compared this price to the previously obtained national average digital and film price and the "expert" digital price.

The median DMIST cash price was $337 (95% CI 271-383, n=27). This compares to $241 (95% CI 216-276,n=24) for digital and $173 (95% CI 156-188,n=137) for film from a random survey of mammogram facilities. Increased specificity results in lower false recall costs, while increased sensitivity improves the cancer detection rate. The "fair" price would be $203 per digital mammogram for "great" readers and $246 for "stellar" readers. Applying the national cash price of $241 to "great" readers cost $500K/life year, while "stellar" readers cost $80K/life year. Only 3 of 27 DMIST facilities have fair prices.

Using society guidelines, "expert" digital breast imaging specialists can only charge at most a premium of $30 to $68 to justify the marginal benefit of their skill, not $164. Most "expert" centers would have to lower their prices to be a "good deal" to educated consumers in a competitive market.

The claim that women should go to a digital breast imaging specialist instead of a general radiologist ignores costs and requires a means to identify expert performance, and is therefore problematic.

Keen, J, Keen, J, Should I, My Wife, or My Mother Go to an "Expert" Mammography Center with Digital Screening Technology?.  Radiological Society of North America 2007 Scientific Assembly and Annual Meeting, November 25 - November 30, 2007 ,Chicago IL. http://archive.rsna.org/2007/5000836.html