Patient Utilization of Weekend and Evening Appointments for Screening Mammography: An 8-Year Observational Cohort Study.

OBJECTIVE: To characterize the patient population using weekend and evening appointments for screening mammography versus standard appointment times across four outpatient facilities in our academic health system. METHODS: In this institutional review board-approved retrospective cohort study, there were 203,101 screening mammograms from 67,323 patients who had a screening mammogram performed at outpatient centers at a multisite academic institution from January 1, 2015, to December 31, 2022. Screening appointments were defined as "standard appointment time" (between 8 am and 5 pm on Monday through Friday) or "weekend or evening appointment time" (scheduled after 5 pm on Monday through Friday or at any time on a Saturday or Sunday). Associations between appointment group and patient characteristics were analyzed using univariate and multivariate logistic regression. RESULTS: Most screening mammograms (n = 185,436, 91.3%) were performed at standard times. The remainder (n = 17,665, 8.7%) were performed during weekends or evenings. As we created additional weekend and evening appointments after the coronavirus disease 2019 pandemic, the annual percentage of all screening mammograms performed on evenings and weekends increased. On multivariate analysis, when compared with standard appointment times, we found that patients who were younger than age 50 (P < .001), a race other than non-Hispanic White (P < .001), non-English speakers (P < .001), and from less advantaged zip codes (P < .03) were more likely to use weekend and evening appointment times compared with those aged 70 and above, non-Hispanic White patients, English speakers, and those from the most advantaged zip codes. CONCLUSIONS: Weekend and evening appointment availability for screening mammograms might improve screening access for all patients, particularly for those younger than age 50, those of races other than non-Hispanic White, and those from less advantaged zip codes.

Evaluating the Use of ChatGPT to Accurately Simplify Patient-centered Information about Breast Cancer Prevention and Screening.

Purpose To evaluate the use of ChatGPT as a tool to simplify answers to common questions about breast cancer prevention and screening. Materials and Methods In this retrospective, exploratory study, ChatGPT was requested to simplify responses to 25 questions about breast cancer to a sixth-grade reading level in March and August 2023. Simplified responses were evaluated for clinical appropriateness. All original and simplified responses were assessed for reading ease on the Flesch Reading Ease Index and for readability on five scales: Flesch-Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Automated Readability Index, and the Simple Measure of Gobbledygook (ie, SMOG) Index. Mean reading ease, readability, and word count were compared between original and simplified responses using paired t tests. McNemar test was used to compare the proportion of responses with adequate reading ease (score of 60 or greater) and readability (sixth-grade level). Results ChatGPT improved mean reading ease (original responses, 46 vs simplified responses, 70; P < .001) and readability (original, grade 13 vs simplified, grade 8.9; P < .001) and decreased word count (original, 193 vs simplified, 173; P < .001). Ninety-two percent (23 of 25) of simplified responses were considered clinically appropriate. All 25 (100%) simplified responses met criteria for adequate reading ease, compared with only two of 25 original responses (P < .001). Two of the 25 simplified responses (8%) met criteria for adequate readability. Conclusion ChatGPT simplified answers to common breast cancer screening and prevention questions by improving the readability by four grade levels, though the potential to produce incorrect information necessitates physician oversight when using this tool. Keywords: Mammography, Screening, Informatics, Breast, Education, Health Policy and Practice, Oncology, Technology Assessment Supplemental material is available for this article. © RSNA, 2023.

Appropriateness of Information Provided by ChatGPT Regarding Breast Pathologic Diagnoses.

A multidisciplinary physician team rated information provided by ChatGPT regarding breast pathologic diagnoses. ChatGPT responses were mostly appropriate regarding accuracy, consistency, definitions provided, and clinical significance conveyed. Responses were scored lower in terms of management recommendations provided, primarily related to low agreement with recommendations for high-risk lesions.

Spatial Coherence Approaches to Distinguish Suspicious Mass Contents in Fundamental and Harmonic Breast Ultrasound Images.

When compared to fundamental B-mode imaging, coherence-based beamforming, and harmonic imaging are independently known to reduce acoustic clutter, distinguish solid from fluid content in indeterminate breast masses, and thereby reduce unnecessary biopsies during a breast cancer diagnosis. However, a systematic investigation of independent and combined coherence beamforming and harmonic imaging approaches is necessary for the clinical deployment of the most optimal approach. Therefore, we compare the performance of fundamental and harmonic images created with short-lag spatial coherence (SLSC), M-weighted SLSC (M-SLSC), SLSC combined with robust principal component analysis with no M-weighting (r-SLSC), and r-SLSC with M-weighting (R-SLSC), relative to traditional fundamental and harmonic B-mode images, when distinguishing solid from fluid breast masses. Raw channel data acquired from 40 total breast masses (28 solid, 7 fluid, 5 mixed) were beamformed and analyzed. The contrast of fluid masses was better with fundamental rather than harmonic coherence imaging, due to the lower spatial coherence within the fluid masses in the fundamental coherence images. Relative to SLSC imaging, M-SLSC, r-SLSC, and R-SLSC imaging provided similar contrast across multiple masses (with the exception of clinically challenging complicated cysts) and minimized the range of generalized contrast-to-noise ratios (gCNRs) of fluid masses, yet required additional computational resources. Among the eight coherence imaging modes compared, fundamental SLSC imaging best identified fluid versus solid breast mass contents, outperforming fundamental and harmonic B-mode imaging. With fundamental SLSC images, the specificity and sensitivity to identify fluid masses using the reader-independent metrics of contrast difference, mean lag one coherence (LOC), and gCNR were 0.86 and 1, 1 and 0.89, and 1 and 1, respectively. Results demonstrate that fundamental SLSC imaging and gCNR (or LOC if no coherence image or background region of interest is introduced) have the greatest potential to impact clinical decisions and improve the diagnostic certainty of breast mass contents. These observations are additionally anticipated to extend to masses in other organs.

Clinical and Imaging Features of MRI Screen-Detected Breast Cancer.

BACKGROUND: Supplemental screening with breast MRI is recommended annually for patients who have greater than 20% lifetime risk for breast cancer. While there is robust data regarding features of mammographic screen-detected breast cancers, there is limited data regarding MRI-screen-detected cancers. PATIENTS AND METHODS: Screening breast MRIs performed between August 1, 2016 and July 30, 2022 identified 50 screen-detected breast cancers in 47 patients. Clinical and imaging features of all eligible cancers were recorded. RESULTS: During the study period, 50 MRI-screen detected cancers were identified in 47 patients. The majority of MRI-screen detected cancers (32/50, 64%) were invasive. Pathology revealed ductal carcinoma in situ (DCIS) in 36% (18/50), invasive ductal carcinoma (IDC) in 52% (26/50), invasive lobular carcinoma in 10% (5/50), and angiosarcoma in 2% (1/50). The majority of patients (43/47, 91%) were stage 0 or 1 at diagnosis and there were no breast cancer-related deaths during the follow-up periods. Cancers presented as masses in 50% (25/50), nonmass enhancement in 48% (25/50), and a focus in 2% (1/50). DCIS was more likely to present as nonmass enhancement (94.4%, 17/18), whereas invasive cancers were more likely to present as masses (75%, 24/32) (P < .001). All cancers that were stage 2 at diagnosis were detected either on a baseline exam or more than 4 years since the prior MRI exam. CONCLUSION: MRI screen-detected breast cancers were most often invasive cancers. Cancers detected by MRI screening had an excellent prognosis in our study population. Invasive cancers most commonly presented as a mass.

Self-scheduling of Screening Mammograms Using an Online Patient Portal: Initial 8-year Experience at a Multisite Academic Institution.

OBJECTIVE: The goal of this study was to determine patient factors associated with the use of self-scheduling of screening mammograms (SMs) using an online portal. METHODS: All SMs scheduled at our multisite academic institution from January 1, 2015, to December 31, 2022, were included. The frequency of self-scheduling via an online portal was calculated per year. Univariate and multivariate logistic regression models with generalized estimating equation were used to estimate associations between patient characteristics and scheduling format after accounting for correlations between mammograms performed on the same woman. RESULTS: During the study period, 250,369 SMs were performed in 74,860 unique patients (mean age 59 ± 12 years). Of these, 36,200 (14.5%) were self-scheduled via the online portal. Self-scheduling increased each year, from 3.7% in 2015 to 36.9% in 2022. Younger age, non-Black race, being an English speaker, and being from a nondisadvantaged zip code were significant predictors of self-scheduling on univariate and multivariate logistic regression. Age <50 years versus age ≥70 years was the patient characteristic that most strongly predicted the likelihood of self-scheduling (adjusted odds ratio 5.4, 95% confidence interval 5.2-5.6). CONCLUSIONS: Over 8 years (2015-2022), utilization of self-scheduling for screening mammography using an online patient portal increased from 3.7% to 36.9%. Age < 50 years was the patient characteristic that most strongly predicted likelihood of self-scheduling.

Rate and Timeliness of Diagnostic Evaluation and Biopsy After Recall From Screening Mammography in the National Mammography Database.

OBJECTIVE: To describe the rate and timeliness of diagnostic resolution after an abnormal screening mammogram in the ACR's National Mammography Database. METHODS: Abnormal screening mammograms (BI-RADS 0 assessment) in the National Mammography Database from January 1, 2008, to December 31, 2021, were retrospectively identified. The rates and timeliness of follow-up with diagnostic evaluation and biopsy were assessed and compared across patient and facility demographics. RESULTS: Among the 2,874,310 screening mammograms reported as abnormal, follow-up was documented in 66.4% (n = 1,909,326). Lower follow-up rates were observed in younger women (59.4% in women < 30 years, 63.2% in women 30-39 years), Black (57.4%) and American Indian (59.5%) women, and women with no breast cancer family history (63.0%). The overall median time to diagnostic evaluation was 9 days. Longer median diagnostic evaluation time was noted in Black (14 days), other or mixed race (14 days), and Hispanic women (13 days). Of the 318,977 recalled screening mammograms recommended for biopsy, 238,556 (74.8%) biopsies were documented. Lower biopsy rates were noted in older women (71.5% in women aged ≥80) and Black (71.5%) and American Indian (52.2%) women. The overall median time from diagnostic evaluation to biopsy was 21 days. Longer median biopsy time was noted in older (23 days aged ≥80), Black (25 days), mixed or other race (26 days), and Hispanic women (23 days), and rural (24 days) or community hospital affiliated facilities (22 days). DISCUSSION: There is variability in the rates and timeliness of diagnostic evaluation and biopsy in women with abnormal screening mammogram. Subsets of women and facilities could benefit from targeted interventions to promote timely diagnostic resolution and biopsy after an abnormal screening mammogram.

Can breast MRI predict pathologic response following neoadjuvant chemotherapy for breast cancer? A retrospective cohort study.

PURPOSE: For patients treated with neoadjuvant chemotherapy (NAC) for breast cancer, it is standard of care to perform pre- and post-NAC imaging to evaluate response to therapy prior to surgery. In this study we assess outcome metrics of magnetic resonance imaging (MRI) following NAC. METHODS: We conducted a retrospective analysis of patients with invasive breast cancer who underwent a breast MRI before and after NAC between 2016 and 2021 at a single, multisite academic institution. All breast MRI studies were characterized as either radiologic complete response (rCR) or non-rCR. Corresponding surgical pathology reports were reviewed and categorized as pathologic complete response (pCR) or non-pCR. We defined a positive test as having residual enhancement on MRI (non-rCR) and a positive outcome as having residual disease on final surgical pathology (non-pCR). RESULTS: There were 225 patients included in the study (mean age 52 ± 12 years). Breast cancer receptor distribution was HR+/HER2- (n = 71, 32%), HR+/HER2+ (n = 51, 23%), HR-/HER2- (n = 72, 32%), and HR-/HER2+ (n = 31, 14%). In total, 78 (35%) had rCR and 77 (34%) had pCR; 43 (19%) had both rCR and pCR. The overall accuracy rate was 69% (156/225), sensitivity 76% (113/148), specificity 56% (43/77), positive predictive value 77% (113/147), and negative predictive value 55% (43/78). The PPV was significantly associated with receptor status (p = 0.004). No patient or imaging characteristics were associated with sensitivity. CONCLUSION: Breast MRI only moderately predicts pathologic response for invasive breast cancer treated with NAC (overall accuracy 69%). PPV is significantly associated with receptor status.

Axillary adenopathy detected on breast MRI following COVID-19 vaccination: outcomes and follow-up recommendations.

This retrospective study presents 110 patients with suspected COVID-19 vaccine-related axillary adenopathy on breast MRI. Our study aimed to assess the outcomes of axillary adenopathy detected on breast MRI performed within one year after COVID-19 vaccination. The median time between the COVID-19 vaccine and breast MRI was shorter in patients with detected adenopathy compared to patients without detected adenopathy (6 weeks [2-17] versus 15 [7-24] weeks, p < 0.001). Unilateral axillary adenopathy detected on breast MRI had a low malignancy rate (3.3%), and no cases of malignant axillary adenopathy were diagnosed without a known breast cancer in the ipsilateral breast. Our findings suggest that unilateral axillary adenopathy identified on breast MRI ipsilateral to a recent COVID-19 vaccination can be considered benign in the absence of a suspicious breast finding or known breast cancer. Regardless of vaccine status and timing, unilateral axillary adenopathy detected on MRI evaluation with a known malignancy or suspicious breast finding should be considered suspicious. This will avoid unnecessary scheduling constraints, patient anxiety, and cost, without delaying diagnosis of metastatic breast cancer.

Comparison of Diagnostic Mammography-Guided Biopsy and Digital Breast Tomosynthesis-Guided Biopsy of Suspicious Breast Calcifications: Results in 1354 Biopsies.

BACKGROUND. Studies have shown improved targeting and sampling of noncalcified lesions (asymmetries, masses, and architectural distortion) with digital breast tomosynthesis (DBT)-guided biopsy in comparison with digital mammography (DM)-guided stereotactic biopsy. Literature that compares the two techniques specifically for sampling calcifications has been scarce. OBJECTIVE. The purpose of this study was to compare the performance and outcomes of DM- and DBT-guided biopsy of suspicious calcifications. METHODS. This retrospective study included 1310 patients (mean age, 58 ± 12 [SD] years) who underwent a total of 1354 9-gauge vacuum-assisted core biopsies of suspicious calcifications performed at a single institution from May 22, 2017, to December 31, 2021. The decision to use a DM-guided or DBT-guided technique was made at the discretion of the radiologist performing the biopsy. Procedure time, the number of exposures during the procedure, and the histopathologic outcomes were recorded. The two techniques were compared using a two-sample t test for continuous variables and a chi-square test for categoric variables. Additional tests were performed using generalized estimating equations to control for the effect of the individual radiologist performing the biopsy. RESULTS. A total of 348 (26%) biopsies used DM guidance, and 1006 (74%) used DBT guidance. The mean procedure time was significantly lower for DBT-guided biopsy (14.9 ± 8.0 [SD] minutes) than for DM-guided biopsy (24.7 ± 14.3 minutes) (p < .001). The mean number of exposures was significantly lower for DBT-guided biopsy (4.1 ± 1.0 [SD] exposures) than for DM-guided biopsy (9.1 ± 3.3 exposures) (p < .001). The differences in procedure time and number of exposures remained significant (both p < .001) when controlling for the effect of the radiologist performing the biopsy. There were no significant differences (all p > .05) between DM-guided and DBT-guided biopsy in terms of the malignancy rate on initial biopsy (20% vs 19%), the rate of high-risk lesion upgrading (14% vs 22%), or the final malignancy rate (23% vs 22%). CONCLUSION. DBT-guided biopsy of suspicious calcifications can be performed with shorter procedure time and fewer exposures compared with DM-guided biopsy, without a significant difference in rates of malignancy or high-risk lesion upgrading. CLINICAL IMPACT. The use of a DBT-guided, rather than a DM-guided, biopsy technique for suspicious calcifications can potentially reduce patient discomfort and radiation exposure without affecting clinical outcomes.

Coherence Metrics for Reader-Independent Differentiation of Cystic From Solid Breast Masses in Ultrasound Images.

Traditional breast ultrasound imaging is a low-cost, real-time and portable method to assist with breast cancer screening and diagnosis, with particular benefits for patients with dense breast tissue. We previously demonstrated that incorporating coherence-based beamforming additionally improves the distinction of fluid-filled from solid breast masses, based on qualitative image interpretation by board-certified radiologists. However, variable sensitivity (range: 0.71-1.00 when detecting fluid-filled masses) was achieved by the individual radiologist readers. Therefore, we propose two objective coherence metrics, lag-one coherence (LOC) and coherence length (CL), to quantitatively determine the content of breast masses without requiring reader assessment. Data acquired from 31 breast masses were analyzed. Ideal separation (i.e., 1.00 sensitivity and specificity) was achieved between fluid-filled and solid breast masses based on the mean or median LOC value within each mass. When separated based on mean and median CL values, the sensitivity/specificity decreased to 1.00/0.95 and 0.92/0.89, respectively. The greatest sensitivity and specificity were achieved in dense, rather than non-dense, breast tissue. These results support the introduction of an objective, reader-independent method for automated diagnoses of cystic breast masses.

Solitary Dilated Ducts Revisited: Malignancy Rate and Implications for Management.

RATIONALE AND OBJECTIVES: A solitary dilated duct (SDD) is a single asymmetrically dilated breast duct with diameter more than 2 mm. The Breast Imaging Reporting and Data System (BI-RADS) fifth edition recommends additional imaging and biopsy for SDDs without demonstrated benign etiology, however management of this rare entity remains controversial. This study describes practice patterns, malignancy rate, and features associated with high-risk/malignant SDDs to better stratify patients requiring biopsy versus follow-up. MATERIALS AND METHODS: This IRB-approved retrospective study identified mammographic, sonographic and MRI exams utilizing the term "solitary dilated duct" at a multisite academic institution between 1/1/2010 and 12/31/2020. Clinical and imaging features, BI-RADS assessments, and outcomes were analyzed. Univariate and multivariate analyses identified predictors of high-risk/malignant histology. RESULTS: SDDs identified in 49 women (mean age 56.1 years) were assessed as BI-RADS 4/5 (31/49, 63%), BI-RADS 3 (9/49, 18%), or BI-RADS 2 (9/49, 18%). Most sampled lesions were benign (16/31, 52%) and the remaining were high-risk (15/31, 48%, all papillary lesions). The only papilloma with atypia on core biopsy upgraded to grade 2 DCIS on excision (malignancy rate 1/49, 2%). All anechoic SDDs were benign (n=13), and all benign SDDs lacked internal vascularity. SDDs with associated masses were associated with malignant/high-risk outcomes on multivariate analysis (p < .001). CONCLUSION: The BI-RADS fifth edition recommends biopsy for SDDs without demonstrated benign etiology. In our 11-year study period, practice patterns were variable with a low malignancy rate of 2%. Our findings suggest that anechoic SDDs may be followed, and SDDs with associated masses or internal vascularity require biopsy.

Impact of Patient Navigation on Reducing Breast Imaging Disparities and Applications in the COVID-19 Era.

The coronavirus (COVID-19) pandemic has impacted breast cancer screening with concerns that this may lead to increased overall breast cancer mortality and worsened racial and ethnic disparities in breast cancer survival. As pandemic recovery efforts are underway, we must be prepared to address barriers to timely access of breast imaging services, including those that existed prior to the pandemic, as well as any new barriers that may arise as a result of the pandemic. Patient navigation is an important tool that has been shown to address barriers to timely breast imaging access and help reduce disparities. Patient navigation programs can serve as a key part of the strategy to mitigate the impact of the COVID-19 pandemic on timely breast cancer diagnosis. These programs have been shown to be successful in promoting adherence to breast cancer screening guidelines as well as encouraging timely diagnostic follow-up, particularly in underserved communities. Further research is needed to explore the role of using a telehealth platform for patient navigation and evaluate the cost-effectiveness of patient navigator programs as well as more randomized controlled trials to further explore the impact of patient navigation programs.

Circumscribed Masses on Breast MRI: Can MRI Features Guide Management?

OBJECTIVE: Management of circumscribed breast masses seen on MRI is largely extrapolated from mammography and US data with limited MRI-specific data available. This study aimed to assess clinical and MRI imaging features of malignant circumscribed breast masses. METHODS: In this IRB-approved retrospective study, breast MRIs performed between April 1, 2008, and August 30, 2020, containing circumscribed masses, excluding multiple bilateral circumscribed masses, were reviewed. Clinical and imaging features of all eligible masses were recorded, and associations with malignant outcomes were assessed using Fisher's exact test and Wilcoxon rank sum test, with P < 0.05 considered significant. RESULTS: For the 165 masses that met study criteria in 158 women, the mean age was 48 years (SD 12.0 years). Nine of 165 masses were malignant (5.5%). Round masses were significantly more likely to be malignant (7/37, 18.9%) compared to oval masses (2/128, 1.7%) (P < 0.001). Among masses with available dynamic contrast kinetics data, the malignancy rate was 0/84 (0%) for persistent kinetics, 2/23 (8.7%) for plateau kinetics, and 4/24 (16.7%) for washout kinetics (P = 0.002). The malignancy rate for oval masses without washout kinetics was 0% (0/92). T2 hyperintense masses had a malignancy rate of 7/104 (6.7%), and homogeneously enhancing masses had a malignancy rate of 5/91 (5.5%). CONCLUSION: These data support the use of mass shape and dynamic contrast enhancement kinetics to guide management of circumscribed breast masses seen by MRI, with oval masses without washout kinetics and any circumscribed mass with persistent kinetics showing no malignancies in this study.

High-risk lesions in the breast diagnosed by MRI-guided core biopsy: upgrade rates and features associated with malignancy.

PURPOSE: This study assessed the upgrade rates of high-risk lesions (HRLs) in the breast diagnosed by MRI-guided core biopsy and evaluated imaging and clinical features associated with upgrade to malignancy. METHODS: This IRB-approved, retrospective study included MRI-guided breast biopsy exams yielding HRLs from August 1, 2011, to August 31, 2020. HRLs included atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, and papilloma. Only lesions that underwent excision or at least 2 years of MRI imaging follow-up were included. For each HRL, patient history, imaging features, and outcomes were recorded. RESULTS: Seventy-two lesions in 65 patients were included in the study, with 8/72 (11.1%) of the lesions upgraded to malignancy. Upgrade rates were 16.7% (2/12) for ADH, 100% (1/1) for pleomorphic LCIS, 40% (2/5) for other LCIS, 0% (0/19) for ALH, 0% (0/18) for papilloma, and 0% (0/7) for radial scar/complex sclerosing lesion. Additionally, two cases of marked ADH bordering on DCIS and one case of marked ALH bordering on LCIS, were upgraded. Lesions were more likely to be upgraded if they presented as T2 hypointense (versus isotense, OR 6.46, 95% CI 1.27-32.92) or as linear or segmental non-mass enhancement (NME, versus focal or regional, p = 0.008). CONCLUSION: Our data support the recommendation that ADH and LCIS on MRI-guided biopsy warrant surgical excision due to high upgrade rates. HRLs that present as T2 hypointense, or as linear or segmental NME, should be viewed with suspicion as these were associated with higher upgrade rates to malignancy.

Disparities Associated With Patient Adherence to BI-RADS 3 Assessment Follow-up Recommendations for Mammography and Ultrasound.

OBJECTIVE: To assess the relationship between sociodemographic factors and adherence rates in patients with a BI-RADS 3 assessment. METHODS: This retrospective cohort study reviewed data from all patients with a BI-RADS 3 assessment on mammography and ultrasound examinations at a single, multisite academic institution, which serves a diverse urban-suburban population, from January 1, 2015, to December 13, 2017. Appropriate follow-up was defined as returning for the first follow-up examination 3 to 9 months after the index examination. Associations between BI-RADS 3 adherence rates and patient sociodemographic characteristics were evaluated using logistic regression. RESULTS: There were 4,038 patients in our study period; 2,437 patients (60%) had appropriate follow-up, 765 (19%) patients had delayed follow-up, and 836 patients (21%) were lost to follow-up. The overall malignancy rate was 1.4% (46 of 3,202). Older age, retired employment status, and Medicare insurance status were associated with increased adherence to BI-RADS 3 follow-up recommendations. Black race, single relationship status, Medicaid and self-pay insurance status, and living in a top 15% disadvantaged zip code were associated with decreased adherence. On multivariate analysis, older age remained associated with increased adherence and Medicaid insurance status with decreased adherence. Time between index examination and cancer diagnosis was shorter in patients who had timely follow-up (202 days [interquartile range 183-358] versus 392 days [interquartile range 365-563], P ≤ .001), although there was not a significant difference in stage at diagnosis (P = .46). DISCUSSION: Multiple sociodemographic factors are associated with low adherence to BI-RADS 3 follow-up recommendations suggesting that more frequent and targeted interventions are needed to close disparity gaps.