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.
This paper is a very interesting economic analysis of workplacemammography screening programs. Especially important is the discussionof the effect of disease prevalence on the cost-effectivenessof workplace screening programs.
Workplace screening programs would be most beneficial for populationswith a low rate of screening among employees through existingprograms and for locations where there are a sufficient numberof women old enough to require annual screening. In workplaceswhere screening rates are already adequate, workplace screeningmay provide little incremental benefit to the employed population.Similarly, workplace screening will provide little benefit inworkplaces that have a high proportion of female employees whoare unlikely to require mammographic screening. These issues shouldbe addressed directly in the evaluation of breast cancer screeningprograms by each employer.
Some aspects of the analysis of workplace screening programs arenot 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-careproviders. Each of these additional topics will be discussed inturn.
Quality of Screening Mammograms
The authors discuss the quality of mammography examinations asa variable to be considered in an assessment of a workplace screeningprogram. Obviously, one should be interested in whether the programmeets the quality guidelines established by the American Collegeof Radiology and the federal Mammography Quality Standards Act.However, these are not the only issues related to the qualityof the mammography readings that need to be addressed.
Diagnostic quality of the examinations becomes a critical variablein assessing these programs. This includes not only the technicalquality of the images, but the characteristics of the radiologistreading the images. For example, radiologists in a worksite screeningprogram are not involved in the usual care of the patient andmay be concerned about the potential for malpractice suits fromemployees. Would radiologists be more likely to overread imagesin such a program, increasing the rate of false-positive resultsfor female employees? This potential for overreading mammogramsmay be increased by the fact that these programs suffer from alack of access to prior examinations, which can help in the interpretationof mammograms with questionable findings. These issues need tobe tested empirically.
Follow-up of Abnormal and Suspicious Mammograms
Mammography is not a simple screening test, but rather, is partof a diagnostic evaluation that requires careful follow-up ofabnormal and suspicious examinations. These follow-up issues needto be carefully considered in establishing a worksite screeningprogram. Is there a mechanism for follow-up of abnormal or suspiciousmammograms? What are the costs of implementing the follow-up program?
An additional concern in developing a program is whether privacyconcerns are addressed. For example, are employees to be contactedthrough their employer to notify them of abnormal results or toreport for follow-up examinations for these screening programs?Given the employer's knowledge of results of the test, are employeesthen at risk for losing their position or insurance benefits?
Finally, are employers liable for poor follow-up provided by physiciansparticipating in these programs?
A last issue to consider is how the program will support the effortsof the primary-care physicians who see these employees on a regularbasis. Mammography is often part of annual physical examinations.Thus, women may receive several services simultaneously duringprimary-care visits, decreasing the lost productivity incurredwhen receiving the isolated mammograms reported by Griffiths etal.
Employers must pay for worksite screening programs after theyhave already provided employees with a mammography benefit throughtheir insurance programs. Thus, even though worksite programsmay have a lower cost per screening examination, employers mayactually be paying twice for these services under certain insuranceprograms. If the worksite program is not integrated into primary-carepractice, primary-care physicians may not have records of theresults of these mammograms, either for patient-care purposesor for reporting purposes within managed-care organizations (ie,HMO report cards).
Finally, women whose mammograms are abnormal may prefer to receivecounseling from a primary-care physician they trust rather thanfrom a physician in a worksite program.
Mammography screening rates in the United States are far belowoptimal levels. Thoughtful worksite mammography screening programsmay help increase the current rate of mammography screening. Carefulstudy of new means of providing this service to patients, suchas worksite screening programs, can help improve these efforts.Economic analysis of these programs must address the issues raisedby Dr. Griffiths and colleagues, as well as those included inthis commentary.