To Standardize or Not to Standardize?

Applying the main principles of MQSA to other areas of radiology may prove valuable.standardize or not to standardize

Standardizing the way medical imaging is performed and how its subsequent reads are classified and communicated can help ensure patient safety, proper training for technologists, image quality, and even appropriate equipment calibration.

The Mammography Quality Standards Act (MQSA) of 1992 sought to bring these benefits to mammography, a distinctive section of women's imaging.

"In mammography, you're taking an X-ray image of a single organ and predominantly looking for breast cancer, although you sometimes see other diseases or benign findings," explains James V. Rawson, MD, FACR, chair of the Department of Radiology at the Medical College of Georgia at Georgia Health Sciences University in Augusta, Ga., who led the creation of a poster for the 2011 RSNA conference titled Standardizing Imaging Technique and Interpretation: MQSA Case Study. "When you look at other imaging and disease processes, there are often more variables and complexities — in a head CT or brain MRI, for example, you may be looking for a tumor, a stroke, multiple sclerosis, or a whole host of other things," he adds.

The ACR initially conceived mammography accreditation as a voluntary program to demonstrate a practice's commitment to quality. When Congress passed MQSA, however, all mammography facilities had to be accredited by Oct. 1, 1994.1 "MQSA created requirements for personnel, the reading radiologist, the technologist performing the study, as well as the medical physicist who evaluates the mammography equipment," explains Chaltsy M. Carlton, DO, radiology resident at the Georgia Health Sciences University, who assisted with the case study poster.

Also significant is the MQSA regulation related to communicating mammography results to the referring physician and patient. It requires that written reports to clinicians include certain information, such as assessment categories based on the Breast Imaging Reporting and Data System® (BI-RADS®) and recommendations to the health-care provider. (The FDA does not mandate the identical BI-RADS language.) Additionally, results must be provided to patients in lay terms within 60 days of the screening exam. "We send letters to all patients written in lay terms, which is not routinely done in other modalities," says Carlton.

Evaluating the Effects

How do these specific MQSA regulations contribute to quality? Karen C. Panzitta, MD, associate professor of breast imaging at Georgia Health Sciences University, and ACR clinical reviewer for mammography accreditation, explains, "MQSA has ensured that facilities performing mammograms provide radiologists with high-quality images that enable the best chance to detect breast cancer early."

And with the BI-RADS classification system and reporting standards, "There's no ambiguity," says Panzitta. "With the lexicon, it's a lot easier to communicate image findings between facilities or even between radiologists and referring physicians."

Furthermore, "The standardization of radiology vocabulary in our reports will enable us to do comparative effectiveness research and data mining," says Rawson. The ACR National Mammography Database™ also uses the same BI-RADS terminology and yields other information about mammography practice and trends, says Panzitta. "It's helpful in evaluating quality assurance," she says.

MQSA certification, a prerequisite to legally perform mammography in the United States, may be exemplary in its successful regulation of mammography quality, says Rawson. But could the act — or at least aspects of it — be mimicked in other areas of imaging?

Expanding the Application

Despite MQSA's positive impact on mammography, applying similar regulations to all modalities or disease sites might be difficult. As Rawson explains, "It would be hard to make the jump from mammography to all other imaging [due to variability]." However progress is being made in standardization of other modalities as well.

For example, the success of the BI-RADS Atlas supports the viability of a standardized lexicon in other areas of radiology. The ACR is currently developing the Liver Imaging Reporting and Data System, which proposes standardized language to clarify liver findings. In addition, a new joint effort of the ACR, European Society of Urogenital Radiology, and the AdMeTech Foundation is underway to develop a reporting system for prostate MRI called the Prostate Imaging Reporting and Data System. Many individual physicians, as well as health-care organizations and societies, are hard at work on other forms of structured radiology reporting systems that include more standardized vocabularies. Read "Sketching a New Reality" in the April 2012 ACR Bulletin to learn more.

Accrediting imaging equipment beyond mammography is another potential opportunity to employ MQSA-type standards, whether through legislation like the MIPPA or even voluntary accreditation. The ACR is one of several accrediting bodies verifying these standards are met for equipment and image quality through MIPPA, as well as other areas of imaging. (

Nonetheless, MQSA is a unique program, and challenges exist in implementing similar initiatives in radiology. "We recognize that standardizing vocabulary, report format, or even imaging protocols and techniques isn't easy," Rawson admits. "It's a lot of work; it requires a change in clinical practice and habits that have been in place a long time. But it can make a huge impact on the ultimate outcome for our patients."

1. Butler P., et al. “The ACR’s Mammography Accreditation Program: Ten Years of Experience Since MQSA.” JACR 2005:5;585–594.

By Alyssa Martino

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