Rebecca Smith-Bindman

Potomac Institute for Policy Studies, Arlington, Virginia, United States

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Publications (114)998.58 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: The objective of our study was to develop an automated calculation method to provide organ dose assessment for a large cohort of pediatric and adult patients undergoing CT examinations. Materials and methods: We adopted two dose libraries that were previously published: the volume CT dose index-normalized organ dose library and the tube current-exposure time product (100 mAs)-normalized weighted CT dose index library. We developed an algorithm to calculate organ doses using the two dose libraries and the CT parameters available from DICOM data. We calculated organ doses for pediatric (n = 2499) and adult (n = 2043) CT examinations randomly selected from four health care systems in the United States and compared the adult organ doses with the values calculated from the ImPACT calculator. Results: The median brain dose was 20 mGy (pediatric) and 24 mGy (adult), and the brain dose was greater than 40 mGy for 11% (pediatric) and 18% (adult) of the head CT studies. Both the National Cancer Institute (NCI) and ImPACT methods provided similar organ doses (median discrepancy < 20%) for all organs except the organs located close to the scanning boundaries. The visual comparisons of scanning coverage and phantom anatomies revealed that the NCI method, which is based on realistic computational phantoms, provides more accurate organ doses than the ImPACT method. Conclusion: The automated organ dose calculation method developed in this study reduces the time needed to calculate doses for a large number of patients. We have successfully used this method for a variety of CT-related studies including retrospective epidemiologic studies and CT dose trend analysis studies.
    American Journal of Roentgenology 09/2015; 205(4):827-833. DOI:10.2214/AJR.14.14135 · 2.73 Impact Factor
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    ABSTRACT: To clarify the relationship between facility-level mammography interpretive volume and breast cancer screening outcomes. We calculated annual mammography interpretive volumes from 2000-2009 for 116 facilities participating in the U.S. Breast Cancer Surveillance Consortium (BCSC). Radiology, pathology, cancer registry, and women's self-report information were used to determine the indication for each exam, cancer characteristics, and patient characteristics. We examined the effect of annual total volume and percentage of mammograms that were screening on cancer detection rates using multinomial logistic regression adjusting for age, race/ethnicity, time since last mammogram, and BCSC registries. "Good prognosis" tumours were defined as screen-detected invasive cancers that were <15 mm, early stage, and lymph node negative at diagnosis. From 3,098,481 screening mammograms, 9,899 cancers were screen-detected within one year of the exam. Approximately 80% of facilities had annual total interpretive volumes of >2,000 mammograms, and 42% had >5,000. Higher total volume facilities were significantly more likely to diagnose invasive tumours with good prognoses (odds ratio [OR] 1.32; 95% confidence interval [CI] 1.10-1.60, for total volume of 5,000-10,000/year v. 1,000-2,000/year; p-for-trend <0.001). A concomitant decrease in tumours with poor prognosis was seen (OR 0.78; 95%CI 0.63-0.98 for total volume of 5,000-10,000/year v. 1,000-2,000/year). Mammography facilities with higher total interpretive volumes detected more good prognosis invasive tumours and fewer poor prognosis invasive tumours, suggesting that women attending these facilities may be more likely to benefit from screening. © The Author(s) 2015.
    Journal of Medical Screening 08/2015; DOI:10.1177/0969141315595254 · 3.10 Impact Factor
  • JAMA Internal Medicine 06/2015; 175(8). DOI:10.1001/jamainternmed.2015.2697 · 13.12 Impact Factor
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    ABSTRACT: Purpose To summarize data on computed tomographic (CT) radiation doses collected from consecutive CT examinations performed at 12 facilities that can contribute to the creation of reference levels. Materials and Methods The study was approved by the institutional review boards of the collaborating institutions and was compliant with HIPAA. Radiation dose metrics were prospectively and electronically collected from 199 656 consecutive CT examinations in 83 181 adults and 3871 consecutive CT examinations in 2609 children at the five University of California medical centers during 2013. The median volume CT dose index (CTDIvol), dose-length product (DLP), and effective dose, along with the interquartile range (IQR), were calculated separately for adults and children and stratified according to anatomic region. Distributions for DLP and effective dose are reported for single-phase examinations, multiphase examinations, and all examinations. Results For adults, the median CTDIvol was 50 mGy (IQR, 37-62 mGy) for the head, 12 mGy (IQR, 7-17 mGy) for the chest, and 12 mGy (IQR, 8-17 mGy) for the abdomen. The median DLPs for single-phase, multiphase, and all examinations, respectively, were as follows: head, 880 mGy · cm (IQR, 640-1120 mGy · cm), 1550 mGy · cm (IQR, 1150-2130 mGy · cm), and 960 mGy · cm (IQR, 690-1300 mGy · cm); chest, 420 mGy · cm (IQR, 260-610 mGy · cm), 880 mGy · cm (IQR, 570-1430 mGy · cm), and 550 mGy · cm (IQR 320-830 mGy · cm); and abdomen, 580 mGy · cm (IQR, 360-860 mGy · cm), 1220 mGy · cm (IQR, 850-1790 mGy · cm), and 960 mGy · cm (IQR, 600-1460 mGy · cm). Median effective doses for single-phase, multiphase, and all examinations, respectively, were as follows: head, 2 mSv (IQR, 1-3 mSv), 4 mSv (IQR, 3-8 mSv), and 2 mSv (IQR, 2-3 mSv); chest, 9 mSv (IQR, 5-13 mSv), 18 mSv (IQR, 12-29 mSv), and 11 mSv (IQR, 6-18 mSv); and abdomen, 10 mSv (IQR, 6-16 mSv), 22 mSv (IQR, 15-32 mSv), and 17 mSv (IQR, 11-26 mSv). In general, values for children were approximately 50% those for adults in the head and 25% those for adults in the chest and abdomen. Conclusion These summary dose data provide a starting point for institutional evaluation of CT radiation doses. (©) RSNA, 2015.
    Radiology 05/2015; DOI:10.1148/radiol.2015142728 · 6.87 Impact Factor
  • Rebecca Smith-Bindman
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    ABSTRACT: The paper covers three points. First, the doses we use for CT are higher than widely reported and are higher than what is needed for diagnosis and should be reduced. Second, these doses are in the range where extensive evidence indicates they will cause enough cancers to support efforts to reduce dose and therefore this risk. Third, that precise quantification of the risks from imaging radiation is less important than understanding that the risks are real, albeit small, and worth reducing, and that this reduction must be achieved using systems-based approaches.
    02/2015; 3(2). DOI:10.1007/s40134-014-0085-5
  • Rebecca Smith-Bindman
    New England Journal of Medicine 12/2014; 371(26):2531-2531. DOI:10.1056/NEJMc1412853 · 55.87 Impact Factor
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    ABSTRACT: Quality assessment is critical for healthcare reform, but data sources are lacking for measurement of many important healthcare outcomes. With over 49 million people covered by Medicare as of 2010, Medicare claims data offer a potentially valuable source that could be used in targeted health care quality improvement efforts. However, little is known about the operating characteristics of provider profiling methods using claims-based outcome measures that may estimate provider performance with error. Motivated by the example of screening mammography performance, we compared approaches to identifying providers failing to meet guideline targets using Medicare claims data. We used data from the Breast Cancer Surveillance Consortium and linked Medicare claims to compare claims-based and clinical estimates of cancer detection rate. We then demonstrated the performance of claim-based estimates across a broad range of operating characteristics using simulation studies. We found that identification of poor performing providers was extremely sensitive to algorithm specificity, with no approach identifying more than 65% of poor performing providers when claims-based measures had specificity of 0.995 or less. We conclude that claims have the potential to contribute important information on healthcare outcomes to quality improvement efforts. However, to achieve this potential, development of highly accurate claims-based outcome measures should remain a priority. Copyright © 2014 John Wiley & Sons, Ltd.
    Statistics in Medicine 10/2014; 34(1). DOI:10.1002/sim.6318 · 1.83 Impact Factor
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    ABSTRACT: Background: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. Methods: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. Results: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. Conclusions: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).
    New England Journal of Medicine 09/2014; 371(12):1100-1110. DOI:10.1056/NEJMoa1404446 · 55.87 Impact Factor
  • Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 07/2014; 11(7):746-7. DOI:10.1016/j.jacr.2014.05.012 · 2.84 Impact Factor
  • Rebecca Smith-Bindman
    JAMA Internal Medicine 06/2014; 174(6):1006. DOI:10.1001/jamainternmed.2014.38 · 13.12 Impact Factor
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    ABSTRACT: Urolithiasis (kidney stones) is a common reason for Emergency Department (ED) visits, accounting for nearly 1% of all visits in the United States. Computed Tomography (CT) has become the most common imaging test for these patients but there are few comparative effectiveness data to support its use in comparison to ultrasound. This paper describes the rationale and methods of STONE (Study of Tomography Of Nephrolithiasis Evaluation), a pragmatic randomized comparative effectiveness trial comparing different imaging strategies for patients with suspected urolithiasis. STONE is a multi-center, non-blinded pragmatic randomized comparative effectiveness trial of patients between age 18 and 75 with suspected nephrolithiasis seen in an ED setting. Patients were randomized to one of three initial imaging examinations: point-of-care ultrasound, ultrasound performed by a radiologist or CT. Participants then received diagnosis and treatment per usual care. The primary aim is to compare the rate of severe SAEs (Serious Adverse Events) between the three arms. In addition, a broad range of secondary outcomes was assessed at baseline and regularly for six months post-baseline using phone, email and mail questionnaires. Excluding 17 patients who withdrew after randomization, a total of 2759 patients were randomized and completed a baseline questionnaire (n=908, 893 and 958 in the Point-of-care Ultrasound, Radiology Ultrasound and Radiology CT arms, respectively). Follow-up is complete, and full or partial outcomes were assessed on over 90% of participants. The detailed methodology of STONE will provide a roadmap for comparative effectiveness studies of diagnostic imaging conducted in an ED setting.
    Contemporary clinical trials 04/2014; 38(1). DOI:10.1016/j.cct.2014.03.006 · 1.94 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e51-e52. DOI:10.1016/j.juro.2014.02.224 · 4.47 Impact Factor
  • Adam Reese · Emir Sandhu · Rebecca Smith-Bindman · Marshall Stoller · Brian Eisner
    The Journal of Urology 04/2014; 191(4):e865. DOI:10.1016/j.juro.2014.02.2355 · 4.47 Impact Factor
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    ABSTRACT: Purpose The National Quality Forum (NQF) is a nonprofit consensus organization that recently endorsed a measure focused on CT radiation doses. To comply, facilities must summarize the doses from consecutive scans within age and anatomic area strata and report the data in the medical record. Our purpose was to assess the time needed to assemble the data and to demonstrate how review of such data permits a facility to understand doses. Methods and Materials To assemble the data we used for analysis, we used the dose monitoring software eXposure to automatically export dose metrics from consecutive scans in 2010 and 2012. For a subset of 50 exams, we also collected dose metrics manually, copying data directly from the PACS into an excel spreadsheet. Results Manual data collection for 50 scans required 2 hours and 15 minutes. eXposure compiled the data in under an hour. All dose metrics demonstrated a 30% to 50% reduction between 2010 and 2012. There was also a significant decline and a reduction in the variability of the doses over time. Conclusion The NQF measure facilitates an institution's capacity to assess the doses they are using for CT as part of routine practice. The necessary data can be collected within a reasonable amount of time either with automatic software or manually. The collection and review of these data will allow facilities to compare their radiation dose distributions with national distributions and allow assessment of temporal trends in the doses they are using.
    Journal of the American College of Radiology: JACR 03/2014; 11(3):309–315. DOI:10.1016/j.jacr.2013.10.009 · 2.84 Impact Factor
  • Rebecca Smith-Bindman · John M Boone
    Journal of the American College of Radiology: JACR 03/2014; 11(3):229-30. DOI:10.1016/j.jacr.2013.10.031 · 2.84 Impact Factor
  • Nicole Wilson · Victoria Valencia · Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 03/2014; 11(3):231-2. DOI:10.1016/j.jacr.2013.12.012 · 2.84 Impact Factor
  • Cindy S Lee · Erika Bildsten Reinhardt · Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 03/2014; 11(3):255-6. DOI:10.1016/j.jacr.2013.12.013 · 2.84 Impact Factor
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    ABSTRACT: Purpose The aim of this study was to determine whether providing radiologic technologists with audit feedback on doses from CT examinations they conduct and education on dose-reduction strategies reduces patients' radiation exposure. Methods This prospective, controlled pilot study was conducted within an integrated health care system from November 2010 to October 2011. Ten technologists at 2 facilities received personalized dose audit reports and education on dose-reduction strategies; 9 technologists at a control facility received no intervention. Radiation exposure was measured by the dose-length product (DLP) from CT scans performed before (n = 1,630) and after (n = 1,499) the intervention and compared using quantile regression. Technologists were surveyed before and after the intervention. Results For abdominal CT, DLPs decreased by 3% to 12% at intervention facilities but not at the control facility. For brain CT, DLPs significantly decreased by 7% to 12% at one intervention facility; did not change at the second intervention facility, which had the lowest preintervention DLPs; and increased at the control facility. Technologists were more likely to report always thinking about radiation exposure and associated cancer risk and optimizing settings to reduce exposure after the intervention. Conclusions Personalized audit feedback and education can change technologists' attitudes about, and awareness of, radiation and can lower patient radiation exposure from CT imaging.
    Journal of the American College of Radiology: JACR 03/2014; 11(3):300–308. DOI:10.1016/j.jacr.2013.10.017 · 2.84 Impact Factor
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    ABSTRACT: IMPORTANCE There is wide variation in the management of thyroid nodules identified on ultrasound imaging. OBJECTIVE To quantify the risk of thyroid cancer associated with thyroid nodules based on ultrasound imaging characteristics. METHODS Retrospective case-control study of patients who underwent thyroid ultrasound imaging from January 1, 2000, through March 30, 2005. Thyroid cancers were identified through linkage with the California Cancer Registry. RESULTS A total of 8806 patients underwent 11 618 thyroid ultrasound examinations during the study period, including 105 subsequently diagnosed as having thyroid cancer. Thyroid nodules were common in patients diagnosed as having cancer (96.9%) and patients not diagnosed as having thyroid cancer (56.4%). Three ultrasound nodule characteristics-microcalcifications (odds ratio [OR], 8.1; 95% CI, 3.8-17.3), size greater than 2 cm (OR, 3.6; 95% CI, 1.7-7.6), and an entirely solid composition (OR, 4.0; 95% CI, 1.7-9.2)-were the only findings associated with the risk of thyroid cancer. If 1 characteristic is used as an indication for biopsy, most cases of thyroid cancer would be detected (sensitivity, 0.88; 95% CI, 0.80-0.94), with a high false-positive rate (0.44; 95% CI, 0.43-0.45) and a low positive likelihood ratio (2.0; 95% CI, 1.8-2.2), and 56 biopsies will be performed per cancer diagnosed. If 2 characteristics were required for biopsy, the sensitivity and false-positive rates would be lower (sensitivity, 0.52; 95% CI, 0.42-0.62; false-positive rate, 0.07; 95% CI, 0.07-0.08), the positive likelihood ratio would be higher (7.1; 95% CI, 6.2-8.2), and only 16 biopsies will be performed per cancer diagnosed. Compared with performing biopsy of all thyroid nodules larger than 5 mm, adoption of this more stringent rule requiring 2 abnormal nodule characteristics to prompt biopsy would reduce unnecessary biopsies by 90% while maintaining a low risk of cancer (5 per 1000 patients for whom biopsy is deferred). CONCLUSIONS AND RELEVANCE Thyroid ultrasound imaging could be used to identify patients who have a low risk of cancer for whom biopsy could be deferred. On the basis of these results, these findings should be validated in a large prospective cohort.
    JAMA Internal Medicine 08/2013; 173(19). DOI:10.1001/jamainternmed.2013.9245 · 13.12 Impact Factor
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    ABSTRACT: The breast cancer detection rate is a benchmark measure of screening mammography quality, but its computation requires linkage of mammography interpretive performance information with cancer incidence data. A Medicare claims-based measure of detected breast cancers could simplify measurement of this benchmark and facilitate mammography quality assessment and research. To validate a claims-based algorithm that can identify with high positive predictive value (PPV) incident breast cancers that were detected at screening mammography. Development of a claims-derived algorithm using classification and regression tree analyses within a random half-sample of Medicare screening mammography claims followed by validation of the algorithm in the remaining half-sample using clinical data on mammography results and cancer incidence from the Breast Cancer Surveillance Consortium (BCSC). Female fee-for-service Medicare enrollees aged 68 years and older who underwent screening mammography from 2001 to 2005 within BCSC registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=233,044 mammograms obtained by 104,997 women). Sensitivity, specificity, and PPV of algorithmic identification of incident breast cancers that were detected by radiologists relative to a reference standard based on BCSC mammography and cancer incidence data. An algorithm based on subsequent codes for breast cancer diagnoses and treatments and follow-up mammography identified incident screen-detected breast cancers with 92.9% sensitivity [95% confidence interval (CI), 91.0%-94.8%], 99.9% specificity (95% CI, 99.9%-99.9%), and a PPV of 88.0% (95% CI, 85.7%-90.4%). A simple claims-based algorithm can accurately identify incident breast cancers detected at screening mammography among Medicare enrollees. The algorithm may enable mammography quality assessment using Medicare claims alone.
    Medical care 08/2013; Publish Ahead of Print. DOI:10.1097/MLR.0b013e3182a303d7 · 3.23 Impact Factor

Publication Stats

5k Citations
998.58 Total Impact Points


  • 2015
    • Potomac Institute for Policy Studies
      Arlington, Virginia, United States
  • 1991–2014
    • University of California, San Francisco
      • • Department of Obstetrics, Gynecology and Reproductive Sciences
      • • Department of Epidemiology and Biostatistics
      San Francisco, California, United States
  • 2012
    • National Institutes of Health
      • Division of Cancer Epidemiology and Genetics
      Bethesda, MD, United States
  • 2010
    • University of San Francisco
      San Francisco, California, United States
  • 2008
    • Indiana University-Purdue University Indianapolis
      Indianapolis, Indiana, United States
  • 2007
    • Oregon Health and Science University
      • Department of Family Medicine
      Portland, Oregon, United States
  • 2001
    • University of the Pacific (California - USA)
      Stockton, California, United States
  • 1998
    • San Francisco VA Medical Center
      San Francisco, California, United States