Rebecca Smith-Bindman

University of California, San Francisco, San Francisco, California, United States

Are you Rebecca Smith-Bindman?

Claim your profile

Publications (102)734.5 Total impact

  • [Show abstract] [Hide abstract]
    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; · 2.04 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    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. · 54.42 Impact Factor
  • Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 07/2014; 11(7):746-7.
  • [Show abstract] [Hide abstract]
    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; · 1.51 Impact Factor
  • Nicole Wilson, Victoria Valencia, Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 03/2014; 11(3):231-2.
  • Rebecca Smith-Bindman, John M Boone
    Journal of the American College of Radiology: JACR 03/2014; 11(3):229-30.
  • Cindy S Lee, Erika Bildsten Reinhardt, Rebecca Smith-Bindman
    Journal of the American College of Radiology: JACR 03/2014; 11(3):255-6.
  • [Show abstract] [Hide abstract]
    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 01/2014; 11(3):309–315.
  • [Show abstract] [Hide abstract]
    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 01/2014; 11(3):300–308.
  • [Show abstract] [Hide abstract]
    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; · 13.25 Impact Factor
  • [Show abstract] [Hide abstract]
    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; · 3.24 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Increased use of computed tomography (CT) in pediatrics raises concerns about cancer risk from exposure to ionizing radiation. OBJECTIVES To quantify trends in the use of CT in pediatrics and the associated radiation exposure and cancer risk. DESIGN Retrospective observational study. SETTING Seven US health care systems. PARTICIPANTS The use of CT was evaluated for children younger than 15 years of age from 1996 to 2010, including 4 857 736 child-years of observation. Radiation doses were calculated for 744 CT scans performed between 2001 and 2011. MAIN OUTCOMES AND MEASURES Rates of CT use, organ and effective doses, and projected lifetime attributable risks of cancer. RESULTS The use of CT doubled for children younger than 5 years of age and tripled for children 5 to 14 years of age between 1996 and 2005, remained stable between 2006 and 2007, and then began to decline. Effective doses varied from 0.03 to 69.2 mSv per scan. An effective dose of 20 mSv or higher was delivered by 14% to 25% of abdomen/pelvis scans, 6% to 14% of spine scans, and 3% to 8% of chest scans. Projected lifetime attributable risks of solid cancer were higher for younger patients and girls than for older patients and boys, and they were also higher for patients who underwent CT scans of the abdomen/pelvis or spine than for patients who underwent other types of CT scans. For girls, a radiation-induced solid cancer is projected to result from every 300 to 390 abdomen/pelvis scans, 330 to 480 chest scans, and 270 to 800 spine scans, depending on age. The risk of leukemia was highest from head scans for children younger than 5 years of age at a rate of 1.9 cases per 10 000 CT scans. Nationally, 4 million pediatric CT scans of the head, abdomen/pelvis, chest, or spine performed each year are projected to cause 4870 future cancers. Reducing the highest 25% of doses to the median might prevent 43% of these cancers. CONCLUSIONS AND RELEVANCE The increased use of CT in pediatrics, combined with the wide variability in radiation doses, has resulted in many children receiving a high-dose examination. Dose-reduction strategies targeted to the highest quartile of doses could dramatically reduce the number of radiation-induced cancers.
    JAMA pediatrics. 06/2013;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Identifying the distributions and determinants of fluoroscopy time for invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). Background: Invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) are significant contributors to radiation exposure from medical imaging in the US. Fluoroscopy time is a potentially-modifiable determinant of radiation exposure for these procedures, but has not been well characterized in contemporary practice. Methods: We evaluated the distribution of fluoroscopy time in patients undergoing ICA and/or PCI in the CathPCI Registry(®) , stratifying patients by numerous clinical scenarios. Hierarchical models were used to determine patient, procedure, operator and hospital-level factors associated with fluoroscopy time for these procedures. Results: Our study included a total of 3,295,348 ICA and PCI procedures performed by 9,600 operators from January 2005 through June 2009. There was wide variation in fluoroscopy times for these procedures with median [IQR] fluoroscopy times of 2.6 [1.7 - 4.5] minutes for ICA, 6.7 [4.2 - 10.8] minutes for ICA in patients with prior coronary artery bypass grafting (CABG), 10.1 [6.0 - 17.4] minutes for PCI, 10.7 [7.0 - 16.9] minutes for PCI with ICA, and 16.0 [10.6 - 24.0] minutes for PCI and ICA in patients with prior CABG. Prolonged fluoroscopy times (>30 minutes) were rare for ICA, but occurred in 6.7% of PCIs and 14.7% of PCIs in patients with prior CABG. After accounting for patient characteristics and procedure complexity, operator and hospital-level factors explained nearly 20% of the variation in fluoroscopy time. Conclusions: Fluoroscopy times vary widely during ICA and PCI with operator and hospital-level factors contributing substantially to these differences. A better understanding of potentially-modifiable sources of this variation will elucidate opportunities for enhancing the radiation safety of these procedures. © 2013 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 05/2013; · 2.51 Impact Factor
  • R. SMITH-BINDMAN
    IADR/AADR/CADR General Session and Exhibition 2013; 03/2013
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE Utilization of chest and cardiac CT, and cardiac medicine, has grown rapidly over the last 10 years. The impact of this increased use of imaging on radiation exposure to breast tissue and subsequent risk of breast cancer has not been determined METHOD AND MATERIALS We evaluated imaging and associated radiation exposure among female members enrolled in a large integrated health care system between 2000 and 2010, including over 250,000 enrollees each year. We collected CT dose parameters on 1,656 patients and used a newly developed, automated Monte Carlo computational method to estimate breast and effective doses. For nuclear medicine, data were abstracted on the volume of injected radiopharmaceutical for 5,507 exams and Monte Carlo methods were used to estimate breast doses. The breast-specific absorbed doses and the Preston 2002 pooled model for radiation-effects on breast cancer risk were used to estimate women’s 10 year risk of developing breast cancer based on age at exposure to CT. Using Breast Cancer Surveillance Consortium data, we estimated women’s 10 year risk of breast cancer based on the Gail model and SEER age-specific cancer incidence data and compared the imaging-related risk to the underlying Gail risk. RESULTS Overall 124 CTs and 42 nuclear medicine exams were obtained per 1000 female enrollees per year, with rapid increase between 2000 and 2010. Breast doses from CT were variable, with the highest breast doses delivered by multiple-phase cardiac [median 51.6 mGy, IQR 21.2, 73.1] and chest CT [median 34 mGy; IQR 16, 74). A child or young adult who underwent two cardiac or chest CTs before the age of 23 has a higher 10-year risk of developing breast cancer from these exams than her underlying risk of developing breast cancer in the same period (Figure). Thus a child or young adult who undergoes two or more chest or cardiac CTs more than doubles her 10-year risk of breast cancer. CONCLUSION Women should understand there is a small but real potential risk of breast cancer associated with cardiac and chest CT, and the risk increases with the number of scans. CLINICAL RELEVANCE/APPLICATION Cardiac and Chest CT deliver significant doses of radiation to the breast in children and young adults and repeated imaging can more than double a woman's 10 year risk of breat cancer.
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE No widely endorsed measure is used to record patient stochastic risk following ionizing radiation exposures from medical imaging, hindering facility level quality assessment, and tracking of patient exposures over time. Organ doses derived using Monte Carlo (MC) simulation coupled with corresponding lifetime attributable cancer risk estimates (LAR) from BEIR-VII models are the reference standard, but are time-consuming to calculate and not practical for routine clinical use. E based on CT-derived dose length product (DLP) and conversion-factors (k) is more feasible to widely collect and record, but E was not intended for use as a patient-specific measure. We assessed how this simple estimate of E relates to an accurate estimate of E derived using MC estimates of organ doses and whether it can be used to provide a reasonably reliable estimate of stochastic cancer risks. METHOD AND MATERIALS Scan parameters were abstracted for 3,982 randomly selected patients who underwent CT at one of five integrated health care systems. We calculated E using the DLP for each scan and k conversion factors, and estimated LARs from E using nominal detriment coefficients per unit E. For comparison, we used an automated computational method to estimate organ doses using a MC transport method that couples a CT scanner model with a series of pediatric and adult hybrid phantoms. E was then calculated and LARs were estimated using BEIR VII models. The simple methods of estimating E and LAR were compared to the more complex methods within anatomic and age strata using a concordance correlation coefficient (CCC), and the simple estimate of E was compared with the accurate LAR. RESULTS The CCC were moderate to strong for nearly all comparisons. The CCC were higher in the abdomen (E=0.83; LAR=0.82) and chest (E=0.72; LAR=0.65) compared with the head (E=0.38; LAR=0.38). Agreement was low for E and LAR among infants; their exclusion gave improved CCC (E=0.88; LAR=0.81). E was highly correlated with the accurate LAR (0.85). CONCLUSION E based on DLP and conversion factors, together with nominal detriment coefficients, can be used to provide a simple and reasonable measure of the stochastic risk from medical radiation from CT imaging. CLINICAL RELEVANCE/APPLICATION E based on CT derived dose-length product and published conversion factors is a simple measure for evaluating patient radiation exposure and generally reflects future cancer risk from organ doses.
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE The NQF is a national, non-profit, consensus organization that endorses standards for measuring and reporting on performance. NQF recently endorsed a measure focused on radiation doses delivered through CT. To comply with the measure, facilities must summarize the doses delivered on consecutive patients 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 these data will permit a facility to understand their doses. METHOD AND MATERIALS We assembled data on doses in two fashions. First, a data abstractor manually reviewed consecutive CT examination and the corresponding dose reports contained within the Picture Archiving Communications System, recording CTDIvol, dose length product (DLP), and chest circumference, and calculating E using DLP - k conversion factors. CTDIvol and chest circumference were combined to calculate the size specific dose estimate (SSDE). Second, we used a CT dose analytic software product, eXposure to extract information from the PACS that automatically summarizes the dose metrics. RESULTS Manual data collection took 27 hours, whereas eXposure compiled the data in under an hour. The distribution in the doses used for chest CTs conducted in adult patients that were conducted in March of 2008, 2010, and 2012 are included (Figure). All dose measures demonstrated around a 50% reduction in the doses between 2008 and 2012. Median CTDIvol ( 15.5 to 7.5 mGy); DLP (428 to 190); E (8.5 to 3.7 mSv), and SSDE (17.4 to 7.3). There was also a significant decline in the dose received by those in the top 10%, 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 collection and review of these data will allow facilities to compare their radiation dose distributions to national distributions and allow assessment of temporal trends in the doses they are using. CLINICAL RELEVANCE/APPLICATION It is important for facilities to know the doses that they are using when they conduct CT. Widespread use of the NQF Measure could contribute to greater awareness in the doses facilities use and contr
    Radiological Society of North America 2012 Scientific Assembly and Annual Meeting; 11/2012
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND:: Medicare claims data may be a fruitful data source for research or quality measurement in mammography. However, it is uncertain whether claims data can accurately distinguish screening from diagnostic mammograms, particularly when claims are not linked with cancer registry data. OBJECTIVES:: To validate claims-based algorithms that can identify screening mammograms with high positive predictive value (PPV) in claims data with and without cancer registry linkage. RESEARCH DESIGN:: Development of claims-derived algorithms using classification and regression tree analyses within a random half-sample of bilateral mammogram claims with validation in the remaining half-sample. SUBJECTS:: Female fee-for-service Medicare enrollees aged 66 years and older, who underwent bilateral mammography from 1999 to 2005 within Breast Cancer Surveillance Consortium (BCSC) registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=383,730 mammograms obtained from 146,346 women). MEASURES:: Sensitivity, specificity, and PPV of algorithmic designation of a "screening" purpose of the mammogram using a BCSC-derived reference standard. RESULTS:: In claims data without cancer registry linkage, a 3-step claims-derived algorithm identified screening mammograms with 97.1% sensitivity, 69.4% specificity, and a PPV of 94.9%. In claims that are linked to cancer registry data, a similar 3-step algorithm had higher sensitivity (99.7%), similar specificity (62.7%), and higher PPV (97.4%). CONCLUSIONS:: Simple algorithms can identify Medicare claims for screening mammography with high predictive values in Medicare claims alone and in claims linked with cancer registry data.
    Medical care 08/2012; · 3.24 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Use of diagnostic imaging has increased significantly within fee-for-service models of care. Little is known about patterns of imaging among members of integrated health care systems. To estimate trends in imaging utilization and associated radiation exposure among members of integrated health care systems. Retrospective analysis of electronic records of members of 6 large integrated health systems from different regions of the United States. Review of medical records allowed direct estimation of radiation exposure from selected tests. Between 1 million and 2 million member-patients were included each year from 1996 to 2010. Advanced diagnostic imaging rates and cumulative annual radiation exposure from medical imaging. During the 15-year study period, enrollees underwent a total of 30.9 million imaging examinations (25.8 million person-years), reflecting 1.18 tests (95% CI, 1.17-1.19) per person per year, of which 35% were for advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine, and ultrasound). Use of advanced diagnostic imaging increased from 1996 to 2010; CT examinations increased from 52 per 1000 enrollees in 1996 to 149 per 1000 in 2010, 7.8% annual increase (95% CI, 5.8%-9.8%); MRI use increased from 17 to 65 per 1000 enrollees, 10% annual growth (95% CI, 3.3%-16.5%); and ultrasound rates increased from 134 to 230 per 1000 enrollees, 3.9% annual growth (95% CI, 3.0%-4.9%). Although nuclear medicine use decreased from 32 to 21 per 1000 enrollees, 3% annual decline (95% CI, 7.7% decline to 1.3% increase), PET imaging rates increased after 2004 from 0.24 to 3.6 per 1000 enrollees, 57% annual growth. Although imaging use increased within all health systems, the adoption of different modalities for anatomic area assessment varied. Increased use of CT between 1996 and 2010 resulted in increased radiation exposure for enrollees, with a doubling in the mean per capita effective dose (1.2 mSv vs 2.3 mSv) and the proportion of enrollees who received high (>20-50 mSv) exposure (1.2% vs 2.5%) and very high (>50 mSv) annual radiation exposure (0.6% vs 1.4%). By 2010, 6.8% of enrollees who underwent imaging received high annual radiation exposure (>20-50 mSv) and 3.9% received very high annual exposure (>50 mSv). Within integrated health care systems, there was a large increase in the rate of advanced diagnostic imaging and associated radiation exposure between 1996 and 2010.
    JAMA The Journal of the American Medical Association 06/2012; 307(22):2400-9. · 29.98 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: While Medicare claims are a potential resource for clinical mammography research or quality monitoring, the validity of key data elements remains uncertain. Claims codes for digital mammography and computer-aided detection (CAD), for example, have not been validated against a credible external reference standard. We matched Medicare mammography claims for women who received bilateral mammograms from 2003 to 2006 to corresponding mammography data from the Breast Cancer Surveillance Consortium (BCSC) registries in four U.S. states (N = 253,727 mammograms received by 120,709 women). We assessed the accuracy of the claims-based classifications of bilateral mammograms as either digital versus film and CAD versus non-CAD relative to a reference standard derived from BCSC data. Claims data correctly classified the large majority of film and digital mammograms (97.2% and 97.3%, respectively), yielding excellent agreement beyond chance (κ = 0.90). Claims data correctly classified the large majority of CAD mammograms (96.6%) but a lower percentage of non-CAD mammograms (86.7%). Agreement beyond chance remained high for CAD classification (κ = 0.83). From 2003 to 2006, the predictive values of claims-based digital and CAD classifications increased as the sample prevalences of each technology increased. Medicare claims data can accurately distinguish film and digital bilateral mammograms and mammograms conducted with and without CAD. The validity of Medicare claims data regarding film versus digital mammography and CAD suggests that these data elements can be useful in research and quality improvement.
    Cancer Epidemiology Biomarkers &amp Prevention 06/2012; 21(8):1344-7. · 4.56 Impact Factor

Publication Stats

3k Citations
734.50 Total Impact Points

Institutions

  • 1991–2014
    • University of California, San Francisco
      • • Department of Radiology and Biomedical Imaging
      • • Division of Hospital Medicine
      • • Veterans Affairs Medical Center
      • • Department of Epidemiology and Biostatistics
      San Francisco, California, United States
  • 2012
    • University of California, Davis
      • Department of Family and Community Medicine
      Davis, CA, United States
  • 2006–2012
    • National Institutes of Health
      • • Division of Cancer Epidemiology and Genetics
      • • Division of Cancer Prevention
      Bethesda, MD, United States
    • San Francisco VA Medical Center
      San Francisco, California, United States
    • Massachusetts General Hospital
      • Department of Radiology
      Boston, MA, United States
  • 2011
    • University of California, Berkeley
      • School of Public Health
      Berkeley, CA, United States
  • 2009
    • California Pacific Medical Center Research Institute
      San Francisco, California, United States
  • 2008
    • University of Illinois at Chicago
      Chicago, Illinois, United States
    • University of Auckland
      • Faculty of Medical and Health Sciences
      Auckland, Auckland, New Zealand
    • Santa Clara Valley Medical Center
      San Jose, California, United States
  • 2005–2008
    • CSU Mentor
      Long Beach, California, United States
  • 2007
    • Group Health Cooperative
      • Group Health Research Institute
      Seattle, Washington, United States
    • Oregon Health and Science University
      • Department of Family Medicine
      Portland, Oregon, United States
    • Moffitt Cancer Center
      • Department of Biostatistics
      Tampa, Florida, United States
  • 2004
    • UConn Health Center
      • Department of Genetics and Developmental Biology
      Farmington, CT, United States