Rebecca Smith-Bindman

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

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Publications (130)1133.99 Total impact

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    ABSTRACT: Purpose To determine if ultrasonographic (US) findings, including Doppler US findings, are associated with subsequent pancreas transplant failure. Materials and Methods A cohort of adult patients who underwent pancreas transplantation at a tertiary institution over the course of 10 years (from 2003 to 2012) was retrospectively evaluated for failure, which was defined as return to insulin therapy or surgical graft removal. The institutional review board provided a waiver of informed consent. All US images obtained within the 1st postoperative year were reviewed for three findings: arterial flow (presence or absence of intraparenchymal forward diastole flow), splenic vein thrombus, and edema. These findings were correlated with pancreas graft failure within 1-year after surgery by using Cox proportional hazards models and hazard ratios. Results A total of 228 transplants were included (mean patient age, 41.6 years; range, 19-57 years; 122 men, 106 women). Absent or reversed arterial diastolic flow was identified in nine of 20 failed transplants (sensitivity, 45%; 95% confidence interval [CI]: 23, 68) and in 15 of 208 transplants that survived (specificity, 93% [193 of 208]; 95% CI: 89, 96). The Cox proportional hazard ratio was 6.2 (95% CI: 3.1, 12.4). Splenic vein thrombus was identified in 10 of 20 failed transplants (sensitivity, 50%; 95% CI: 27, 73) and in 25 of 208 transplants that survived (specificity, 88% [183 of 208]; 95% CI: 83, 92). The Cox proportional hazard ratio was 4.2 (95% CI: 2.4, 7.4). Edema had the lowest specificity (Cox proportional hazard ratio, 2.0; 95% CI: 1.3, 2.9). In the multivariate analysis, only absent or reversed arterial diastolic flow remained significantly associated with transplant failure (adjusted hazard ratio, 3.6; 95% CI: 1.0, 12.8; P = .045). Conclusion Absent or reversed diastolic arterial Doppler flow has a stronger association with transplant failure than does splenic vein thrombus or edema. (©) RSNA, 2016.
    No preview · Article · Jan 2016 · Radiology
  • Rebecca Smith-Bindman · Marilyn L Kwan · Diana L Miglioretti

    No preview · Article · Jan 2016 · Radiology
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    ABSTRACT: Background: Decreasing the use of high-cost tests may reduce health care costs. Objective: To compare costs of care for patients presenting to the emergency department (ED) with suspected kidney stones randomized to 1 of 3 initial imaging tests. Research design: Patients were randomized to point-of-care ultrasound (POC US, least costly), radiology ultrasound (RAD US), or computed tomography (CT, most costly). Subsequent testing and treatment were the choice of the treating physician. Subjects: A total of 2759 patients at 15 EDs were randomized to POC US (n=908), RAD US, (n=893), or CT (n=958). Mean age was 40.4 years; 51.8% were male. Measures: All medical care documented in the trial database in the 7 days following enrollment was abstracted and coded to estimate costs using national average 2012 Medicare reimbursements. Costs for initial ED care and total 7-day costs were compared using nonparametric bootstrap to account for clustering of patients within medical centers. Results: Initial ED visit costs were modestly lower for patients assigned to RAD US: $423 ($411, $434) compared with patients assigned to CT: $448 ($438, $459) (P<0.0001). Total costs were not significantly different between groups: $1014 ($912, $1129) for POC US, $970 ($878, $1078) for RAD US, and $959 ($870, $1044) for CT. Hospital admissions contributed over 50% of total costs, though only 11% of patients were admitted. Mean total costs (and admission rates) varied substantially by site from $749 to $1239. Conclusions: Assignment to a less costly test had no impact on overall health care costs for ED patients. System-level interventions addressing variation in admission rates from the ED might have greater impact on costs.
    No preview · Article · Jan 2016 · Medical care
  • Rebecca Smith-Bindman · Diana Miglioretti

    No preview · Article · Dec 2015 · New England Journal of Medicine

  • No preview · Article · Dec 2015
  • Ralph C. Wang · Stephen Bent · Ellen Weber · Jersey Neilson · Rebecca Smith-Bindman · Jahan Fahimi
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    ABSTRACT: Study objective: Validation studies have confirmed the accuracy of clinical decision rules for the evaluation of pretest probability of pulmonary embolism. It has been assumed that clinical decision rules will also decrease testing in actual practice, but the evidence for this is unclear. We perform a systematic review of impact analyses on clinical decision rules for pulmonary embolism. Methods: MEDLINE, EMBASE, and the Cochrane Library were searched without language restriction for studies assessing the effect of clinical decision rules on efficiency (computed tomography [CT] angiography use and yield) and safety (missed pulmonary embolism) through October 2014. Two reviewers independently extracted data on study characteristics, methods, risk of bias, and outcomes. Results: Eight studies (n=6,677) contained sufficient information, including 1 randomized trial and 7 observational studies. Because of heterogeneity, the results of 4 studies of moderate to high quality assessing the Wells criteria were pooled. The pooled CT angiography yield was 9% (95% confidence interval [CI] 6% to 12%) in the control group and 12% (95% CI 11% to 14%) in the intervention group, for a 3% increase in yield (95% CI 1% to 5%), relative risk 1.3 (95% CI 1.1 to 1.6). We were unable to report a pooled estimate of CT angiography use. Of 2 studies with sufficient information, there was no difference in the rate of missed pulmonary embolism between intervention and control groups. No studies used a cluster-randomized design. Conclusion: Among participants with suspected pulmonary embolism, implementation of the Wells criteria was associated with a modest increase in CT angiography yield. There is a lack of cluster-randomized trials to confirm the efficacy of clinical decision rules for the diagnosis of pulmonary embolism.
    No preview · Article · Dec 2015 · Annals of emergency medicine
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    ABSTRACT: Objective: To determine how frequently patients with advanced imaging for back or abdominal pain achieve outcomes that are identified by patients as important and whether those achieving those outcomes are more satisfied. Methods: Cross-sectional analysis of survey responses from patients of an 800-physician multi-specialty group in Minnesota in 2013. A total of 201 patients with abdominal pain and 167 patients with back pain 1 year earlier that was serious enough for a computed tomography or magnetic resonance imaging scan (67% of those contacted). The main outcomes were the frequency of occurrence of 19 outcomes previously identified by patients as important, plus satisfaction with the results of care. Results: The majority of patients surveyed had achieved most of the desired outcomes. For abdominal pain, 17 of 19 of the desired outcomes were achieved by >50% of patients, while 11 of 19 desired outcomes were achieved by >50% of patients with back pain. Seven of the desired outcomes were significantly associated with satisfaction. Conclusion: Achieving outcomes important to patients is associated with greater patient satisfaction. Such measures are potentially valuable measures of quality.
    No preview · Article · Nov 2015 · The Journal of the American Board of Family Medicine
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    ABSTRACT: Study objective: The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis. Methods: We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013. In accordance with STONE predictors, we categorized participants into low-, moderate-, or high-score groups. We determined the performance of the STONE score and physician gestalt for ureteral stone. Results: Eight hundred forty-five participants were included for analysis; 331 (39%) had a ureteral stone. The global performance of the STONE score was superior to physician gestalt (area under the receiver operating characteristic curve=0.78 [95% confidence interval {CI} 0.74 to 0.81] versus 0.68 [95% CI 0.64 to 0.71]). The prevalence of ureteral stone on CT scan ranged from 14% (95% CI 9% to 19%) to 73% (95% CI 67% to 78%) in the low-, moderate-, and high-score groups. The sensitivity and specificity of a high score were 53% (95% CI 48% to 59%) and 87% (95% CI 84% to 90%), respectively. Conclusion: The STONE score can successfully aggregate patients into low-, medium-, and high-risk groups and predicts ureteral stone with a higher specificity than physician gestalt. However, in its present form, the STONE score lacks sufficient accuracy to allow clinicians to defer CT scan for suspected ureteral stone.
    Full-text · Article · Oct 2015 · Annals of emergency medicine
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    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.
    No preview · Article · Sep 2015 · American Journal of Roentgenology
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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.
    No preview · Article · Aug 2015 · Journal of Medical Screening

  • No preview · Article · Jun 2015 · JAMA Internal Medicine
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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.
    No preview · Article · May 2015 · Radiology
  • John Mongan · Jeffrey Kline · Rebecca Smith-Bindman
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    ABSTRACT: Despite low prevalence of pulmonary embolism (PE) in young adults, they are frequently imaged for PE, which involves radiation exposure and substantial financial cost. Determine the use and positive proportions for PE imaging by age, differences in clinical presentation of PE by age and the projected impact of an age-targeted decision rule. Analysis of two national population-based datasets: the 2009 Nationwide Emergency Department Sample, a 20% sample of US emergency departments (EDs) and the 2003-2006 Pulmonary Embolism Rule-out Criteria (PERC) dataset, a multisite cohort of ED patients with suspected PE from 12 US EDs. Prevalence of PE was 10 times lower in young patients (18-35 years) than in older patients (>65 years) (0.06% vs 0.60%, p<0.001), but young patients were imaged for PE almost as frequently as older patients (2.3% vs 3.2%). This resulted in a lower proportion of positive examinations in young adults than older adults (2.3% vs 17.4%, p<0.001 in women; 4.0% vs 21.4%, p<0.001 in men). Clinical predictors of PE varied by age. Tachycardia was a significant predictor of PE in older patients (OR: 1.2-1.9, p<0.001), but not young patients. Fever was a significant predictor only in young patients (OR: 1.4-7.2, p<0.01). A modification of the previously described PERC rule to include age-specific risk factors could reduce PE imaging by 51% in young patients, with a missed PE rate of 0.6% in those excluded from imaging. Young patients are frequently imaged for PE and have lower positive imaging rates than older patients. After further validation, application of our proposed rule for excluding young patients from PE imaging could reduce imaging, increase the positive rate of imaging and result in a low rate of missed PE among those excluded from imaging. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
    No preview · Article · Mar 2015 · Emergency Medicine Journal
  • 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.
    No preview · Article · Feb 2015
  • Rebecca Smith-Bindman

    No preview · Article · Dec 2014 · New England Journal of Medicine
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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.
    Full-text · Article · Oct 2014 · Statistics in Medicine
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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.).
    Full-text · Article · Sep 2014 · New England Journal of Medicine
  • Rebecca Smith-Bindman

    No preview · Article · Jul 2014 · Journal of the American College of Radiology: JACR
  • Rebecca Smith-Bindman

    No preview · Article · Jun 2014 · JAMA Internal Medicine
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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.
    No preview · Article · Apr 2014 · Contemporary clinical trials

Publication Stats

6k Citations
1,133.99 Total Impact Points


  • 1991-2015
    • 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