College, society drop out of surgeon-sponsored breast ultrasound accreditation program

July 12, 2007

The American College of Radiology and the Society of Breast Imaging have walked away from the National Accreditation Program for Breast Centers, an ambitious effort to certify breast ultrasound and ultrasound-guided interventions backed by the American College of Surgeons. They disagree with the program’s accreditation standards, especially minimal physician qualifications for interpreting breast ultrasound and performing ultrasound-guided breast interventions.

The American College of Radiology and the Society of Breast Imaging have walked away from the National Accreditation Program for Breast Centers, an ambitious effort to certify breast ultrasound and ultrasound-guided interventions backed by the American College of Surgeons. They disagree with the program's accreditation standards, especially minimal physician qualifications for interpreting breast ultrasound and performing ultrasound-guided breast interventions.

After nearly two years of discussion, the ACR and SBI withdrew from deliberations after failing to persuade the NAPBC board to adopt the ACR's long-established standards, practice guidelines, and accreditation programs related to breast imaging and image-guided interventions, according to a statement issued by the college.

"This decision is not something that we came to quickly. But after a lot of discussions, the breast imaging community did not see any benefit to the way we deliver care to our patients by participating in this initiative," said Dr. Carol H. Lee, a professor of diagnostic radiology at Yale University and chair of the ACR Breast Imaging Commission.

Rather than accept ACR standards, the NAPBC planning group adopted alternative standards from the American Society of Breast Surgeons, said Dr. Richard L. Ellis, codirector of the Norma J. Vinger Center for Breast Care at Gundersen Lutheran Medical Center in La Crosse, WI.

In a written statement, NAPBC president Dr. David P. Winchester, chair of surgery at Evanston Northwestern Healthcare in Illinois, praised the radiology groups' past contributions and expressed regret about their departure. But he questioned their ability to recognize breast care as a multidisciplinary endeavor.

"In the final analysis, the ACR took the position that radiologists or other qualified physicians could only be accredited through the ACR ultrasound program. It did not accept accreditation through the American Society of Breast Surgeons-established program for ultrasound, despite the comparability of the two," Winchester said.

The American College of Surgeons created the NAPBC in 2005 after its board of regents called for a program focused on specialized breast care centers in the U.S. Eighteen professional associations, including the ACR and SBI, worked with the surgeon's group to develop an accreditation program covering diagnostic breast ultrasound and ultrasound-guided biopsy. These two aspects of breast imaging services are not covered by the Mammography Quality Standards Act, the federally mandated breast imaging center accreditation program.

Among other requirements adopted from the breast surgeons' society, the NAPBC will demand at least one year of experience involving the interpretation and performance of breast ultrasound. Physicians must document at least 100 breast ultrasound exams, 100 mammography exams, and 80 diagnostic and 20 interventional procedures annually. They must also complete 15 American Medical Association category 1 continuing medical education credits in breast ultrasound and at least seven CME credits in breast ultrasound in the 12 months prior to application.

The ACR's breast ultrasound accreditation program demands the completion of more training than these standards, Ellis said. To qualify to perform or interpret diagnostic ultrasound at an ACR-accredited breast ultrasound facility, physicians must first complete 200 hours of category 1 CME in breast-related courses and perform and read 500 supervised breast cases in the previous three years. To maintain certification, a physician must then perform at least 100 exams annually or undergo an evaluation that indicates proficiency and fulfillment of the ACR practice guideline for CME. Separate certification requirements apply to ultrasound-guided biopsy.

The NAPBC incorporated other ACR/SBI practice guidelines and features of the ACR's accreditation programs related to breast imaging and image-guided biopsies into its standards and survey process, Winchester said. Program organizers did not seek to duplicate ACR's effort, and the NAPBC program itself will not accredit a breast imaging service that fails to meet the ACR's or mandatory MQSA requirements.

The proposed NAPBC support of the ASBS standards are not physician inclusive (as are the established ACR standards), but surgeon specific (a physician must be a surgeon to apply), according to Ellis, who turned down an invitation to undergo an NAPBC-sponsored pilot site visit. Accepting the NAPBC/ASBC proposed standards would result in creating a double practice standard in the U.S.

Ellis told Diagnostic Imaging that he could not support the current language and standards offered by the NAPBC as this will result in a lower of accreditation standards for diagnostic breast ultrasound.

"I am not advocating radiologists. I am advocating the patient. So it doesn't make any difference whether you are a radiologist, psychologist, surgeon, or pathologist," he said. "There has to be a common standard that all physicians must meet before they are allowed to do a procedure, whether it's breast ultrasound, colonoscopy, or a surgical procedure like appendectomy."

Another option will be introduced this fall when the ACR launches its voluntary Breast Imaging Centers of Excellence initiative. A facility accredited by NAPBC can also become a center of excellence, though the NAPBC program will not replace any of the ACR's voluntary breast imaging accreditation programs, Lee said.

For more information from the Diagnostic Imaging archives:

ACR facilities accreditation rules add M.D. peer review

Quality issue must move beyond mammography

Ultrasound's future in play: Will radiologists remain in the picture?

MQSA historic success becomes regulatory threat