Leading the way in technology

It should come as no surprise that the largest city in the Southern Hemisphere is also home to one of the area's most forward-thinking imaging clinics. Unidade Radiológica Paulista (URP) Diagnósticos Médicos and its medical director, Dr. Aron Belfer of São Paulo, Brazil have been leading the charge for technological advancement in the region, using Hologic mammography and osteoporosis assessment equipment as part of their pioneering efforts.

Early in Dr. Belfer's association with URP he brought the first bone densitometry system to Brazil. URP was already using several of the day's most effective imaging modalities, including CT, xerommamography and nuclear medicine. After seeing Hologic's Discovery bone densitometry system in use at Barnes-Jewish Hospital in Saint Louis, MO, Dr. Belfer and URP added DXA technology to their capabilities with the purchase of a Discovery.

Discovery offers the highest precision, accuracy rate, system speed and imaging resolution. And, with two powerful screening tools, high definition instant vertebral assessment and bone mineral density measurements his patients have the best bone assessment tools available.

The 52-year old imaging clinic has a long history of investing in cutting-edge technologies whose impact extends far beyond medicine. In January of 1980, Dr. Belfer and his team developed the first Local Area Network (LAN) in Brazil, partnering with a local computer firm to bypass import restrictions that limited the introduction of cost-effective computer components and equipment into the country. At the same time, they created a Radiology Information System (RIS). Today, URP's RIS houses 26 years' worth of clinical information, 14 of which are online.

Digital mammography and improved image quality

The first automatic film processor in Latin America was installed at URP, as was Brazil's first whole-body CT system installed at a local hospital where URP was responsible for running it. With the advent of the revolutionary Lorad HTC-grid technology from Hologic, URP began using both Affinity and M-IV screen- film mammography equipment. Most recently, URP is one of the first sites in the region to offer Hologic's Selenia full-field digital mammography. Having seen the Hologic direct capture detector technology before the first machines were actually built, Dr. Belfer, along with mammography specialists from the breast imaging department, watched its development closely.

"When we saw the physics behind it and the idea of direct imaging we thought that this would be much better than any other detector," he explained. Rather than investing immediately in the technology, he waited until he felt it had matured enough to surpass others on the market.

"There is a huge difference between what I refer to as first generation digital and second generation digital," Dr. Belfer added. "Other digital breast images are not as impressive as what you get with the Hologic system."

"We want to differentiate the kind of images we do from the kind that others are doing. So, instead of trying to explain direct versus indirect imaging to gynecologists, it's much easier to understand first versus second generation," says Belfer. "Other digital breast images are not as impressive as what you get with the Hologic system."

After the first Selenia was installed, the URP team temporarily kept one of the screen-film machines as backup, but, as Dr. Belfer pointed out, the technological savvy of patients in the area created an immediate demand for the full-field digital equipment. "It took about six days," he said. "Everyone, including the technologists and the patients wanted to use the Selenia. They wanted to be sure they were getting the latest technology." The site soon found that just one Selenia digital mammography system wasn't enough for the patient load. They now have two systems installed and an order for a third system is underway.

Dr. Belfer and his colleagues at URP use the term 'second generation digital' to communicate the growth potential advantages of the Selenia system to referring physicians. "We want to differentiate the kind of images we do from the kind that others are doing. So, instead of trying to explain direct versus indirect imaging to gynecologists, it's much easier to understand first versus second generation."

The difference in image quality and increased speed of a screening exam is readily apparent to URP's patients, as well. Unlike in the in the U.S. medical system, the Brazilian medical system requires patients to keep their radiology films. Many patients compare films from exam to exam, and the approach is proving to be helpful in explaining the difference in image quality.

According to Dr. Belfer, "Not only are we getting comments about the difference between conventional film and digital, but also between first and second generation digital. So patients are looking at other digital mammograms. They say the other one was blurred - that's a word used very often." Patients have also mentioned that the Selenia mammogram seems more comfortable in terms of compression. "I need to tell them, there's no less compression, I swear, it's the exact same compression, the right amount of compression, but the shorter compression time may give the impression that they feel less discomfort," he noted. The Selenia FAST paddle may also be a contributing factor. The FAST paddle tilts to the natural contour of the breast, applying the compression uniformly. This not only brings the patient more comfort, but also improves the quality of the image.

Digital mammography and reduced callback

The protocols for image reading in Brazil differ from those in the U.S. and some other countries because there is no official screening program. At URP, immediately after images are taken, a physician reads them, consults the patient's history and will often talk to the patient or perform any additional physical exam that's needed all in the same visit. In a city the size of São Paulo, which covers 588 square miles and is home to over 11 million paulistas (as the city's residents are known), callbacks for second readings can be extremely inconvenient. Fortunately, Selenia has helped URP lower their mammogram callback rate to less than two percent.

With a combined workload of over 20.000 annual mammograms at two clinical imaging sites, the presence of a dedicated, highly-skilled team is a must. URPs 36-person clinical team is one of the best. "When a patient calls to make an appointment, very often she asks not for a doctor, but for a specific technologist," Dr. Belfer said. "This is the most fantastic thing because that's the ideal. Our technologists need to feel that they're as important as anybody else on the team."

Exceptional patient care

"Our physicians do what we call clinical radiology," Dr. Belfer says, "That means every patient that comes for an exam is put in contact with a physician. The physician sees why he's doing each exam and customizes the exam if necessary and orients the technologist on how to do it." The patient-physician relationship is augmented by 14 years of onsite previous exam reports and a brief clinical history. This way, physicians have an overall imaging portrait of their patients, which helps to keep patients connected to the practice. "Sometimes you'll get to talk to a patient who is there for her annual breast exam and be able to ask about other issues. This may lead to a bone density examination or other radiology services. You build a relationship with the patient; it's very close."

"With an unflagging commitment to innovative practice management, advanced imaging technology, and exceptional patient care, Dr. Belfer and his colleagues at URP see their practice as the women's imaging leader in Sao Paulo and they are working hard to stay that way.

Dr. Belfer continues to leverage the PACS system he developed in 1994 as a practice builder. In addition to scanning previous screen-film images, digital records will also be kept in the PACS. While the patients still must keep their own films, URP will offer an added convenience. "We tell our patients that they don't have to worry about bringing their films," Dr. Belfer said. "We have everything here. So that means the patient will come back to the same clinic."

The DMIST strategy

Faced with less-than-impressive reimbursement rates for breast cancer screening, the team's pioneering attitude is extending to the development of new strategies there, too. Dr. Belfer wanted to use established, widely-accepted criteria on which to base this approach, so he chose the results of the Digital Mammography Imaging Screening Trial (DMIST) recommendations. While DMIST screening criteria could be used to justify reimbursement for digital exams for a certain portion of URP's patients - most notably women under 50, women with dense breasts and premenopausal or perimenopausal women -- accurately categorizing the needs of URP's entire 40,000 patient population was extremely complicated and untenable on a day-to-day basis. "We checked our database to see how many of those patients would benefit from a digital exam according to DMIST criteria. I proposed to have one price for the insurance payers: a combination of the price between digital and analog multiplied by the incidence of the patients who will benefit." This creative solution will lower the cost for the payers and raise the reimbursement rate for URP. Even before applying this idea, some of the payers called asking how much we would charge to perform digital on all of their patients. That means that some of the payers are capable of foreseeing the digital advantage in a mammography center.