1. FAVOR F actors A ssociated with V ariability O f R adiologists (2000 to present) Supported by grants from the National Cancer Institute (R01 CA-107623; K05 CA-104699) and the Agency for Healthcare Research and Quality

2. Development of FAVOR My interest in mammography My frustration over data from academic centers and experts, not community setting Invitation from Steve Taplin to attend the 1998 BCSC meeting

3. FAVOR I (2000 to 2005) Specific Aims 1. Radiologists’ characteristics (new survey data collected) 2. Facility level characteristics (new survey data collected) 3. Statistical modeling Multi-site project: BCSC sites (GHC, CO, NH), the Univ of WA and Duke

4. Computer-Aided Detection (CAD) Marks on Screening Mammogram

5. Impact of CAD on Performance Recall rate Biopsies completed per 1,000 screens increased 10% to 13% (p<0.001) 15 to 18 (p<0.001) Sensitivity (% of women with cancer that have positive tests) 80% to 84% J Fenton et al., NEJM 2007

6. CAD Use and Overall Accuracy AUCs for facilities without vs. with CAD are 0.919 vs. 0.871 (p=0.005). Adjusted for patient, radiologist, and facility characteristics, registry, and facility-level random effects.

7. Impact of CAD on Performance % of cancers that are DCIS increased with CAD 25% to 34% (p<0.04) J Fenton et al., NEJM 2007

8. FAVOR I Medical Malpractice Malpractice experience (N=127 MD’s) –52% reported prior claim –15% reported prior mammography related claim Malpractice effect on clinical practice –76% expressed concern about the impact on their practice –59% concerned that malpractice increased their recommendations for biopsy Elmore et al. Radiology 2005.

10. Radiologists’ Estimates of the 5-year risk of a breast cancer diagnosis. “A 41-year old white woman...” Calculated risk Egger et al. Med Dec Mak 2005.

11. FAVOR II (2006 to present) Specific Aims 1. Statistical methods 2. Radiologists’ characteristics (new survey collection) 3. Continuing Medical Education (CME) 4 BCSC sites initially Expanded to all 7 BCSC sites to gather survey data on interpretive volume and practice locations for the AIM study (Funding from the American Cancer Society/NCI)

12. FAVOR Involvement of Junior Investigators Medical Students –HeYon Sohng Residents –John Dick –Laurel Desnick PhD students –Gavino Puggioni –Prashni Paliwal –Carolyn Prouty –Dawn Woodard MPH students –Connie Nakano Junior Faculty Members –Amy Baernstein –John Choe –Joshua Fenton –Tom Gallagher –Sara Jackson –Hillary Liss –Shin Ping Tu

13. FAVOR Supplement Disclosure of Medical Errors Vignette added to FAVOR II survey on the topic of medical errors in mammography (T. Gallagher et al., Radiology 2009) Supplement funding to support qualitative research project.

14. Beyond FAVOR New R01 on Breast Pathology “BPATH” – A study of variability in interpretation of breast pathology, the impact of digital images and double reading 5-year multicenter study (R01 CA- 140560) Using pathology cases from BCSC sites in NH, VT Random stratified sampling, with emphasis on atypia and DCIS Development of test sets and future CME

15. Beyond FAVOR Other Areas to Investigate Comparative effectiveness of new technology in the real community setting Medicare linkage data elements Diagnostic evaluation of breast abnormalities

16. FAVOR Summary Synergistic impact of collaborations with BCSC Collaboration with BCSC has allowed multiple cost effective R01’s with unique linkage to performance data FAVOR provided augmented data on individual radiologists and facilities and infrastructure to expand and support the AIM study Supportive of junior investigators Development of long term collaborations