36C24419R0074-020.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 11-37 March 27, 2014

SCREENING FOR BREAST DISEASE

I. PURPOSE: To establish policy, responsibility and outline procedures for breast disease screening.

II. POLICY: It is the policy of the Veterans Affairs (VA) and this medical center to provide breast disease screening to include diagnostic and routine screening mammography and/or breast ultrasound for eligible Veterans.

III. RESPONSIBILITY:

A. The facility Director is responsible for ensuring policies and procedures related to quality, patient education, effective and clear communication with patients and clear communication of mammography results.

B. Chief of Staff is responsible for providing guidance, education and logistical support for this program.

C. Chief of Clinical Operations is responsible for maintaining the contract between the Medical Center and the contract agency. The contract agency will be in compliance with the American College of Radiology Performance Guidelines.

The contract mammography facility must have a current and valid Mammography Quality Standards Act (MQSA) certificate, issued by either FDA or an FDA-approved state.

D. Women’s Health (WH) Providers/Primary Care staff/ PACT teamlets will ensure performance of clinical breast exams when appropriate, and referral of patients for mammography and/or breast ultrasound per American Cancer Society and per VHA/Network/Facility Guidelines. It remains the responsibility of the ordering VHA practitioner to discuss any positive results discovered on studies they have ordered and to discuss the meaning of the findings and the alternatives for further study, treatment, or referral with the patient.

E. Women Veterans Program Manager (WVPM) and WH Case Manager are responsible for tracking mammography and are available as a resource to both staff and patients regarding all aspects of this program

Attachment R

MCM 11-37, Screening for Breast Disease

F. Nursing staff is responsible for providing patient teaching on breast cancer detection as appropriate

IV. PROCEDURES:

A. Clinical breast exams will only be done and documented when the provider deems this to be clinically appropriate.

B. Patients with indications of breast disease will be referred for mammography within 10 days.

C. A biennial mammogram will be offered for women age 50-74 years, based on previous mammography findings and personal history. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Screening decisions in women over age 74 should be individualized by considering the potential benefits and risk of mammography in the context of current health status and estimated life expectancy. As long as a woman is in reasonably good health and would be a candidate for treatment, she should continue to be screened with mammography.

Women at increased risk of breast cancer might benefit from additional screening intervals, or the addition of screening modalities other than mammography and physical examination, such as ultrasound or magnetic resonance imaging.

D. The radiologist report from the contract or non-VA care facility will be scanned into VISTA Imaging, The off-site non-VA mammography facility has the same legal obligation to communicate the results of the exam to the patient and to the ordering practitioner that VHA Mammography Programs have, which includes the following:

1. To Patients: there must be a written lay summary within 30 days for normal results. A communication of results is required within 5 working days if the final assessment is “Suspicious” or “Highly Suggestive of Malignancy.” This can be done through direct verbal communication but this does not obviate the need to also provide a written lay communication to the patient.

2. To Ordering VHA Practitioner: there must be a written report within 30 days of the procedure, if the final assessment is “Suspicious.” If the final assessment is “Highly Suggestive of Malignancy,” communication of the report must be within 3 working days.

3. All patients will be notified within thirty (30) working days of the results.

4. All patients whose mammogram results are normal should receive a mailed communication stating that their mammogram was normal and stressing the importance of continued regular mammography screening.

5. The value of abnormal or incomplete results will be assessed by the referring provider, who will then take proper and appropriate action to assure medical follow-up.

6. Patients with abnormal or incomplete results requiring any service that the

Medical Center does not provide will be referred through non-VA Care for the appropriate service. Their care will be subjected to monitoring and evaluation.

E. A process will be in place that will track the results of mammography screening.

F. An electronic clinical reminder will be used to assure completion.

G. Materials on breast health will be available through CPRS to all patients.

V. REFERENCES:

A. U.S. Preventive Services Task Force (USPSTF), Agency for Health Care Research and Quality, at: http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm

B. FDA website for MQSA policy guidance:

http://www.fda.gov/CDRH/MAMMOGRAPHY/robohelp/START.HTM

C. ACR Mammography web site:

http://www.acr.org/accreditation/mammography.aspx

D. American College of Radiology Mammography Guidelines

E. VHA Handbook 1330.1, Health Care Services for Women Veterans, dated May

21, 2010

F. VHA Handbook 1105.03, Mammography Program Procedures and Standards, dated April 28, 2011

G. VHA National Center for Health Promotion and Disease Prevention (NCP)

Screening for Breast Cancer, accessed on 1/2/14, http://vaww.prevention.va.gov/Screening_for_Breast_Cancer.asp

VI. FOLLOW UP RESPONSIBILITY: Women Veterans Program Manager

VII. REPORTING REQUIREMENTS: Women Veterans Program Manager reports status of the program quarterly to Medical Executive Council

VIII. RESCISSION: MCM 111-15, Screening for Breast Disease, dated July 14, 2009.

(Original Signed 3/27/14)

MICHAEL D. ADELMAN, M.D.

Medical Center Director