This paper is a very interesting economic analysis of workplace mammography screening programs. Especially important is the discussion of the effect of disease prevalence on the cost-effectiveness of workplace screening programs.
Workplace screening programs would be most beneficial for populations with a low rate of screening among employees through existing programs and for locations where there are a sufficient number of women old enough to require annual screening. In workplaces where screening rates are already adequate, workplace screening may provide little incremental benefit to the employed population. Similarly, workplace screening will provide little benefit in workplaces that have a high proportion of female employees who are unlikely to require mammographic screening. These issues should be addressed directly in the evaluation of breast cancer screening programs by each employer.
Some aspects of the analysis of workplace screening programs are not fully developed by the authors and require further elaboration. These include: (1) the quality of the screening mammograms, (2) the quality of the follow-up for abnormal mammograms, and (3) the continuity between the program and the employees' primary-care providers. Each of these additional topics will be discussed in turn.
Quality of Screening Mammograms
The authors discuss the quality of mammography examinations as a variable to be considered in an assessment of a workplace screening program. Obviously, one should be interested in whether the program meets the quality guidelines established by the American College of Radiology and the federal Mammography Quality Standards Act. However, these are not the only issues related to the quality of the mammography readings that need to be addressed.
Diagnostic quality of the examinations becomes a critical variable in assessing these programs. This includes not only the technical quality of the images, but the characteristics of the radiologist reading the images. For example, radiologists in a worksite screening program are not involved in the usual care of the patient and may be concerned about the potential for malpractice suits from employees. Would radiologists be more likely to overread images in such a program, increasing the rate of false-positive results for female employees? This potential for overreading mammograms may be increased by the fact that these programs suffer from a lack of access to prior examinations, which can help in the interpretation of mammograms with questionable findings. These issues need to be tested empirically.
Follow-up of Abnormal and Suspicious Mammograms
Mammography is not a simple screening test, but rather, is part of a diagnostic evaluation that requires careful follow-up of abnormal and suspicious examinations. These follow-up issues need to be carefully considered in establishing a worksite screening program. Is there a mechanism for follow-up of abnormal or suspicious mammograms? What are the costs of implementing the follow-up program?
An additional concern in developing a program is whether privacy concerns are addressed. For example, are employees to be contacted through their employer to notify them of abnormal results or to report for follow-up examinations for these screening programs? Given the employer's knowledge of results of the test, are employees then at risk for losing their position or insurance benefits?
Finally, are employers liable for poor follow-up provided by physicians participating in these programs?
A last issue to consider is how the program will support the efforts of the primary-care physicians who see these employees on a regular basis. Mammography is often part of annual physical examinations. Thus, women may receive several services simultaneously during primary-care visits, decreasing the lost productivity incurred when receiving the isolated mammograms reported by Griffiths et al.
Employers must pay for worksite screening programs after they have already provided employees with a mammography benefit through their insurance programs. Thus, even though worksite programs may have a lower cost per screening examination, employers may actually be paying twice for these services under certain insurance programs. If the worksite program is not integrated into primary-care practice, primary-care physicians may not have records of the results of these mammograms, either for patient-care purposes or for reporting purposes within managed-care organizations (ie, HMO report cards).
Finally, women whose mammograms are abnormal may prefer to receive counseling from a primary-care physician they trust rather than from a physician in a worksite program.
Mammography screening rates in the United States are far below optimal levels. Thoughtful worksite mammography screening programs may help increase the current rate of mammography screening. Careful study of new means of providing this service to patients, such as worksite screening programs, can help improve these efforts. Economic analysis of these programs must address the issues raised by Dr. Griffiths and colleagues, as well as those included in this commentary.