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Getting breast cancer diagnoses right: help from an insurer

Copyright 2003 by the American College of Physicians.

While mammography has been credited with helping to reduce breast cancer deaths, one medical liability insurer in Massachusetts has worked to improve its physicians' breast care management—and has seen related malpractice claims against its physicians reduced by more than 50%.

The Risk Management Foundation (RMF) in Cambridge, Mass., owned by Harvard medical institutions, handles malpractice claims for all 9,000 Harvard-affiliated physicians. As breast cancer screening became more prevalent in the 1990s, the insurer noticed its number of failure to diagnose malpractice claims was also on the rise. After receiving eight failure-to-diagnose breast cancer suits in 1999, the Harvard institutions and RMF set out to lower their physicians' risk of being sued.

RMF collected and analyzed its claims data, then presented findings to its physicians in focus groups, said Robert B. Hanscom, RMF's director of loss prevention and patient safety. The result was an algorithm distributed to all its primary care physicians that prompts them to ask patients certain questions and to order certain tests, and contains guidance on when to refer patients to a surgical specialist.

The algorithm targets the three major risk areas physicians encounter in diagnosing breast complaints, Mr. Hanscom said. First, primary care physicians need to pay close attention to risk factors, such as the incidence of breast cancer in a patient's family. They then need to guard against what Mr. Hanscom called "a low index of suspicion."

"Many of our claims were from patients who didn't fit the high-risk age category," he said. (A woman's average age at diagnosis is 64.) "We found that even if there was an irregular finding on the mammogram, the physician decided to not pursue it further because the patient didn't fit the category."

Third, physicians need to avoid the opposite problem: over-relying on negative mammogram results. "Mammograms have limitations, so many times clinicians have to move beyond mammography," he said. When mammograms were normal, physicians too often had a tendency to not follow up on other subtle indications such as a lump, mass or thickening.

The combination of developing the algorithm and educating its physicians has dramatically cut down on the numbers of breast cancer claims in the Harvard system-although it is still too early to tell, Mr. Hanscom said, what the algorithm's long-term impact will be. (The algorithm is available online.) Having created other algorithms for obstetrics, anesthesia and emergency medicine, RMF is now considering one for colon cancer, which is getting more frequent claims with higher associated dollar amounts.

As for breast cancer, "Our doctors are now much more aware of what they need to do with a particular patient, instead of relying on preconceived notions," Mr. Hanscom said. "They're really trying to cover all the bases."

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