Session 2: The Role of Specialist Radiology Technologists

Session 2: The Role of Specialist Radiology Technologists Louise M. Henderson, MSPH PhD Assistant Professor, Department of Radiology The University of North Carolina, Chapel Hill

Overview Role of the technologist American Registry of Radiologic Technologists Mammography technologist training, education, certification Technologist impact on mammography performance Pre- or second- readers Impact on radiologists Summary / Next Steps 2

Background / Role of Technologists Over 38 million mammograms performed annually at MQSA accredited facilities Interpreted by radiologists Performed by mammography technologists Responsible for quality of image Correct positioning Sufficient compression Image sharpness Often the technologist is the sole point of contact for the patient during her breast screening experience Radiologic technologists are the 3 rd largest category of healthcare professionals in the U.S. 3

American Registry of Radiologic Technologists (ARRT) Test, certify, and register >250K radiologic technologists to promote high standards of patient care Award the Registered Technologist (RT) designation Ensure continuing education Require annual registration of ARRT certificate Certification is voluntary Employers, state licensing agencies and federal regulators view ARRT credentials as a plus Source: https://www.arrt.org/ 4

ARRT Mammography Certification Education requirements Complete 25 supervised mammography exams Perform another 75 mammography exams focusing on patient preparation/education, mammographic procedure Participate in the performance, evaluation and recording of all quality control tests Review >10 mammography exams with a MQSA qualified interpreting physician to evaluate radiographic technique, positioning, breast anatomy & pathology Observe, assist with or participate in >4 of the following: needle localization, breast MRI, breast US (imaging, biopsy or FNA), stereotactic procedure, breast implant imaging, ductography, or diagnostic work-up Ethics requirements "be a person of good moral character and must not have engaged in conduct that is inconsistent with the ARRT Rules of Ethics" Pass examination 5

Technologist Certification vs. Licensing Certification by ARRT indicates technologist has met initial eligibility requirements and maintains credentials by renewing annually and reporting CE credits every 2 years Licensing refers to state laws Each state is the authority that administers the license and grants an individual permission to practice radiologic technology within that state 35 states use ARRT exam scores in licensing decisions 6

FDA/MQSA - Radiologic Technologist Mammography Specific Training Hold state licensure and/or certification from FDA approved certifying agency Completed >40 contact hours of documented training specific to mammography under the supervision of a qualified instructor Training in breast anatomy and physiology, positioning and compression, quality assurance/quality control techniques, imaging of patients with breast implants Perform > 25 examinations under direct supervision Have > 8 hours of training in each mammography modality to be used Minimum volume of 200 mammograms performed in 24 months prior to facility s annual MQSA inspection 7

How could technologists impact mammography performance? 8

Technologists Impact on Mammography Performance: Conceptual Framework Patient Characteristics - Age, density, screening history, menopausal status Practice & Facility Characteristics - Academic affiliation, use of CAD, # radiologists Radiologist Characteristics - Years of experience, training, specialty, annual volume Performance Measures - Recall rate - Sensitivity - Specificity - Positive Predictive Value - Cancer Detection Rate 9

Technologists Impact on Mammography Performance: Conceptual Framework Patient Characteristics - Age, density, screening history, menopausal status Practice & Facility Characteristics - Academic affiliation, use of CAD, # radiologists Radiologist Characteristics - Years of experience, training, specialty, annual volume Performance Measures - Recall rate - Sensitivity - Specificity - Positive Predictive Value - Cancer Detection Rate Technologist Characteristics - Years of experience, training, annual volume, communication patterns 10

Mammography Technologists as Pre- or Double- Readers Majority of studies conducted in Europe where recall rates are lower than in the US Technologists as pre- or double- readers for screening mammograms led to increased cancer detection rates without significantly increased recall or false positive rates 11

Impact of mammography technologist on radiologists interpretative performance Possible that radiologists ability to interpret mammograms is affected by technologists Interface between the radiologist and technologist Ability of technologist to obtain high quality image positioning, compression, sharpness Two studies assessed if mammographic technologists influenced radiologists' performance Film versus digital Screening and diagnostic mammography Henderson LM et al. AJR 2015 Apr;204(4):903-8. Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 12

Results: Technologists impact on radiologist performance Utilized data from North Carolina from 1994-2009 1,003,276 screening mammograms 394 technologists 372 radiologists 4,892 cancers 162,755 diagnostic mammograms 303 technologists 286 radiologists 5,554 cancers Henderson LM et al. AJR 2015 Apr;204(4):903-8. Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 13

Screening Mammography: Sensitivity FILM DIGITAL 70 70 60 60 50 50 Percent of Technologists 40 30 Percent of Technologists 40 30 20 20 10 10 0 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86 0.88 0.90 0.92 0.94 0.96 0.98 1.00 Sensitivity 0 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86 0.88 0.90 0.92 0.94 0.96 0.98 1.00 Sensitivity Model-based smoothed histograms of screening mammography sensitivity for the 356 technologists by modality with solid vertical lines at 25 th, 50 th, and 75 th quartiles Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 14

Screening Mammography: Specificity FILM DIGITAL 80 80 70 70 60 60 Percent of Technologists 50 40 30 Percent of Technologists 50 40 30 20 20 10 10 0 0.850 0.860 0.870 0.880 0.890 0.900 0.910 0.920 0.930 0.940 0.950 0.960 0.970 Specificity 0 0.850 0.860 0.870 0.880 0.890 0.900 0.910 0.920 0.930 0.940 0.950 0.960 0.970 Specificity Model-based smoothed histograms of screening mammography specificity for the 356 technologists by modality with solid vertical lines at 25 th, 50 th, and 75 th quartiles Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 15

Screening Mammography: PPV FILM DIGITAL 100 100 90 90 80 80 70 70 Percent of Technologists 60 50 40 Percent of Technologists 60 50 40 30 30 20 20 10 10 0 0.028 0.038 0.048 0.058 0.068 0.078 0.088 0.098 Positive Predictive Value 0 0.028 0.038 0.048 0.058 0.068 0.078 0.088 0.098 Positive Predictive Value Model-based smoothed histograms of screening mammography PPV for the 356 technologists by modality with solid vertical lines at 25 th, 50 th, and 75 th quartiles Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 16

Screening Mammography: Recall Rate FILM DIGITAL 80 80 70 70 60 60 Percent of Technologists 50 40 30 Percent of Technologists 50 40 30 20 20 10 10 0 0.027 0.037 0.047 0.057 0.067 0.077 0.087 0.097 0.107 0.117 0.127 0.137 0.147 Recall Rate 0 0.027 0.037 0.047 0.057 0.067 0.077 0.087 0.097 0.107 0.117 0.127 0.137 0.147 Recall Rate Model-based smoothed histograms of screening mammography recall rate for the 356 technologists by modality with solid vertical lines at 25 th, 50 th, and 75 th quartiles Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 17

Screening Mammography: Cancer Detection Rate FILM DIGITAL 80 80 70 70 60 60 Percent of Technologists 50 40 30 Percent of Technologists 50 40 30 20 20 10 10 0 3 4 5 6 7 8 9 Cancer Detection Rate 0 3 4 5 6 7 8 9 Cancer Detection Rate Model-based smoothed histograms of screening mammography CDR for the 356 technologists by modality with solid vertical lines at 25 th, 50 th, and 75 th quartiles Henderson LM et al. Acad Radiol 2015 Mar;22(3):278-89. 18

Summary: Technologists impact on radiologist performance Screening mammography Interpretative performance of radiologists varies by the technologist performing the exam Diagnostic mammography Technologist has an impact on radiologists' interpretive performance for film but not digital mammography 19

Summary: Technologists impact on radiologist performance Screening mammography Interpretative performance of radiologists varies by the technologist performing the exam Diagnostic mammography Technologist has an impact on radiologists' interpretive performance for film but not digital mammography Are there specific technologist characteristics that impact the observed variability? 20

Technologist characteristics that may impact observed variability Education Training Experience Years Volume Imaging modalities Interactions with radiologists and peers Job satisfaction 21

Summary / Next Steps Importance of technologists in mammography screening Use of technologists as pre-/second- readers Impact of technologists on radiologists performance Future work aimed at identifying technologist characteristics that may explain variation in radiologists performance 22

Thank you 23