Applied Radiology

In the last two decades, women's health concerns have begun to be addressed more specifically through several avenues. Largely as a result of a tremendous outcry from the public, Congress has designated Department of Defense funds to be earmarked for breast cancer research. Congress also passed the Mammography Quality Standards Act (MQSA) in 1992, which went into effect in 1994. The MQSA required all facilities performing mammography to function at a basic or standard level of quality that is rigorously enforced through annual reviews and inspections.1

Since the 1970s, centers devoted to the specific health care needs of women have emerged; such centers became the most rapidly growing area of health care services between 1985 and 1988.2 As the general population's life expectancy and the need for providing comprehensive health care to women beyond their obstetrical years increases, the growth of these centers is expected to continue.

Women's health centers offer comprehensive care in an outpatient, often free-standing setting. The development of such centers also has been recognized by health care facilities as an important service to offer. National statistics suggest that in almost 70% of households, the health care decisions, such as selection of a center for care, are made for the family members by women.2 Women's health care centers can offer comprehensive education, prevention, diagnosis, and sometimes treatment, all within one location. In such centers, multiple interactions with various health care providers (including primary care physicians, nurse practitioners, and specialists) and various diagnostic evaluations all can occur in one visit. The obvious advantage for the patient is a more efficient and complete coordination of her basic health care needs. Such patient-focused delivery of care which crosses departmental organization is expeditious, well planned, and allows for rapid communication of findings to all concerned.

Within the women's health center stands a critical component in the diagnostic compendium, namely radiology. In this paper we will discuss our experience with a comprehensive women's health center in an academic setting.

Overview of the women's health center

Conceptual objectives in planning a women's center should include providing comprehensive services by experts in a convenient setting and a patient-focused atmosphere. In our center we seek to offer integrated clinical and educational services in a comfortable, caring, and user-friendly environment. Providers from many disciplines come to the center to share their expertise and offer their services. This setting provides an excellent opportunity for linking the main campus academic medical center with the women's center, to share resources.

The establishment of a consumer-based health care advisory council is most helpful in planning and implementation of such a center.2 The women who sit on the council can provide first-hand information about women's personal health care needs in the community. As programs are planned and developed, the council can provide advice as to what services would be of interest to consumers.

Conceptually, each component and area of the center is patient focused; all staff members clearly understand and support that goal. The success of the women's health center is dependent on many factors, including the integration of services, dedication and expertise of the staff, sound marketing and outreach to the community, accessibility of location and hours, and assessment of patient feedback.2,3

With the larger number of women who work outside the home, an important planning issue to consider is the advantages of offering non-traditional clinical hours in the evenings and/or on Saturdays. Safety and accessibility to the site also are key issues, as educational programs are often planned for evenings. Central to the concept of the women's center is the emphasis on health maintenance, disease prevention, and changing health risk behaviors. More specifically, increasing the utilization of screening mammography is one of the fundamental components of the program.

Physician referral for screening mammograms is an important incentive to increasing utilization of this procedure.4 Having the mammography area within or contiguous with a women's health center readily increases the volume of women who undergo screening on a regular basis.

A women's center model

Among the clinical services offered in our medical center are obstetrical care, infertility treatment, perimenopausal care, breast health and care, adolescent care, internal medicine, and a range of psychiatric and counseling services. Radiology services include general radiology, breast imaging, and general ultrasound. These radiology services are provided to all patients in the outpatient center, many of whom are seen at the women's health center, as well as patients referred from private physicians in the community.

MCV Women's HealthCare, the women's health center at our institution, is located within a larger, free-standing outpatient center (figure 1). Portions of the clinical space are shared, maximizing the efficient use of space and staff. Within the women's center itself the services include health/clinical, psychosocial, nutritional, and educational. The departments of Obstetrics and Gynecology, Internal Medicine, Surgery, Plastic Surgery, Psychiatry, Genetics, and Radiology from the main medical center are all represented at the women's center: A primary presence is maintained daily by faculty from OB/GYN, Internal Medicine and Radiology, with other services providing scheduled coverage. Nurse practitioners, a dietician, clinical social workers, and counselors provide extensive support to the clinical aspects of the center.

The design of MCV Women's HealthCare is such that the clinical space flows freely from one area to the next. One advantage of this is that patients scheduled for a routine gynecologic examination can be scheduled for annual mammography at the same time. The hallways of the center are contiguous, allowing easy access of the gowned patient from one area to the next without the need for re-dressing, re-registering, etc. For example, a patient with a palpable finding on her breast exam can be seen immediately in the radiology area for breast imaging, with a minimum of discomfort or embarrassment.

The marketing of breast imaging services to the community has enhanced the growth of the radiology practice and has served as an additional referral source to the women's center. Patients who are self requesting or self-referred for screening mammography often receive their introduction to the array of services offered by the outpatient center through their mammography appointment. Those patients with a positive experience in this setting may seek referral to a primary care physician or gynecologist in the center.

The radiology services offered at women's centers are far more comprehensive than just screening mammography. Full-time staffing by a breast imager ensures that diagnostic mammography (figure 2) can be directed and performed at any time, providing a more comprehensive approach to patient care. Breast ultrasound, if needed, can be performed at the same time as mammography, and the patient is able to leave the radiology area knowing the results of her study.

Within the radiology area, instruction in breast self examination (figure 3) is given by the mammography technologists to those patients requesting it. The technologists also are key in the area of patient education during the scheduling of procedures. With patient-focused care in mind, these technologists provide the patient with explanations of the procedures and approximate length of testing time, and allow her to ask any questions she may have. Patients are given the name and direct phone number of the interventional technologist, and many do call with questions before their procedure.

A full range of breast interventional procedures are offered in the typical women's center, including stereotactic breast biopsy, cyst aspiration, fine needle aspiration biopsy, ultrasound-guided core biopsy, galactography, and needle localization. Patients who are found to have an abnormality on mammography requiring percutaneous biopsy are informed of the findings and are scheduled for the procedure. The referring physician is consulted regarding the recommendation at the same time. Patients who require a surgical consultation are scheduled with a surgical oncologist, who can see patients right there in the center, if desired. This rapid response to the patient with an abnormality greatly expedites her care and alleviates much of the anxiety associated with waiting for the various steps in the process, such as results of mammography, results of sonography, a call from the referring physician, a scheduled appointment for biopsy, etc.

When tests on patients from the women's health center demonstrate an abnormality, referring physicians or nurse practitioners are available for consultation, often before the patients are ready to leave the building.

In cases of imaging an abnormality, the results of the biopsy can be conveyed directly to the patient, as well as to her physician, by the radiologist. Patients with malignant diagnoses are told in person, and need not be called with the results by phone. The radiologist can then spend time explaining the next step, and may even set up the appointment with the surgical oncologist so that care is complete and the patient is not left to sort out the information and schedules for herself.

The Breast Health component of MCV Women's HealthCare is staffed by surgical oncology and is a satellite of the much larger Breast Health Center in the Cancer Center at the main campus. The Breast Health Center is a multidisciplinary center in which surgical staff, radiation and medical oncologists, pathologists, radiologists, and nurses come together to discuss findings and plan care for the patient. Those patients seen at the satellite breast center have already had their radiographs and data evaluated at the multidisciplinary Breast Center in advance, and are afforded the expertise of a comprehensive, multidisciplinary opinion within the quiet, private framework of the women's health center.

Other imaging services provided in radiology include general ultrasound and radiography. Male and female patients of all ages are seen for these procedures, yet the design of the department, with separate areas for patient dressing booths and waiting, maintains the private women's health focus of the breast imaging area.

Although rather small in terms of number of staff and pieces of equipment, the area is highly efficient and productive. The technologists, clerical staff, and physicians operate as a team, with the patient as the focal point. Technologists oversee clerical and file room staff, ensuring that patients are moving quickly from reception into the clinical area and verifying that reports are completed, signed, and sent. This crossing over of the duties enhances the quality of the entire operation and improves the utilization of staff. Yet within this productive framework each patient is meant to feel that she is not being rushed through, that her questions are being answered, and that she was provided with the quality of services that she deserved and sought.

A computerized database is utilized for reporting mammography and for the medial audit required by the MQSA. In our center, the computerized patient reporting and tracking database for mammography patients also is utilized to generate recall letters to patients. The use of such reminders is advantageous in improving the regular utilization of screening by women.5

Conclusion:

As the population of women in midlife grows, there is increasing need for high quality women's health care services that provide comprehensive efficient care in a single location. This concept requires rethinking the traditional departmental organization, remaining patient focused, and bringing various specialists together. Radiology is a key component to these centers; in particular, the comprehensive breast imaging services can enhance the mission of improving the health of women. AR

Acknowledgement

The authors gratefully acknowledge the excellent assistance of Ms. Susan Ross in the preparation of the manuscript.

References

1. 21 CFR Part 900: Mammography Facility- Requirements for Accrediting Bodies and Quality Standards and Certification Requirements; Interim Rules: Federal Register, Washington, DC 12/21/1993 58: (243) 67558-67572.

2. Hardigan EO: The development of a women's health center is an academic health center. College Review A C MGA: 10(2):5-20, 1993.

3. Knight D: Hospital women's centers that work. Health Care Strategic Management 1214, 1988.

4. Rimer BK: Mammography use in the US: Trends and the impact of interventions: Ann Behav Med 16:317-326, 1994.

5. Taplin SH, Anderman C, Grothaus L, et al: Using physician correspondence and postcard reminders to provide mammography use. Am J Publ Health 84:571-574, 1994.

Dr. deParedes is Professor of Radiology and Director of Breast Imaging at the Medical College of Virginia of Virginia Commonwealth University in Richmond. She is also a member of the editorial advisory board of this journal. Dr. Klein is Assistant Professor of Internal Medicine, and Ms. Collins is Associate

Professor Emeritus in the Department of Ob/Gyn and Director of MCV Women's HealthCare, also at the Medical College of Virginia of Virginia Commonwealth University.