Scanners, schedules, and statutes: A tale of trauma, policy, and profit.

EMTALA (Emergency Medicine Treatment and Labor Act) is an important federal mandate intended to improve access to emergency medical services for patients regardless of financial means. The act imposes strict guidelines on emergency departments, associated referral specialists, and ancillary services. Radiology departments must comply with all ETMALA requirements to avoid potentially incapacitating penalties to their institutions.

Radiology residency oversight: A Qui Tam wake-up call.

Like every physician practice, academic radiology practices must pay heed to all governmental regulations. The federal False Claims Act serves to protect US taxpayers and requires strict adherence. Violations, often brought forth by whistleblowers, can carry steep financial repercussions.

Lung Cancer Diagnosed Through Screening, Lung Nodule, and Neither Program: A Prospective Observational Study of the Detecting Early Lung Cancer (DELUGE) in the Mississippi Delta Cohort.

PURPOSE: Lung cancer screening saves lives, but implementation is challenging. We evaluated two approaches to early lung cancer detection-low-dose computed tomography screening (LDCT) and program-based management of incidentally detected lung nodules. METHODS: A prospective observational study enrolled patients in the early detection programs. For context, we compared them with patients managed in a Multidisciplinary Care Program. We compared clinical stage distribution, surgical resection rates, 3- and 5-year survival rates, and eligibility for LDCT screening of patients diagnosed with lung cancer. RESULTS: From 2015 to May 2021, 22,886 patients were enrolled: 5,659 in LDCT, 15,461 in Lung Nodule, and 1,766 in Multidisciplinary Care. Of 150, 698, and 1,010 patients diagnosed with lung cancer in the respective programs, 61%, 60%, and 44% were diagnosed at clinical stage I or II, whereas 19%, 20%, and 29% were stage IV (P = .0005); 47%, 42%, and 32% had curative-intent surgery (P < .0001); aggregate 3-year overall survival rates were 80% (95% CI, 73 to 88) versus 64% (60 to 68) versus 49% (46 to 53); 5-year overall survival rates were 76% (67 to 87) versus 60% (56 to 65) versus 44% (40 to 48), respectively. Only 46% of 1,858 patients with lung cancer would have been deemed eligible for LDCT by US Preventive Services Task Force (USPSTF) 2013 criteria, and 54% by 2021 criteria. Even if all eligible patients by USPSTF 2021 criteria had been enrolled into LDCT, the Nodule Program would have detected 20% of the stage I-II lung cancer in the entire cohort. CONCLUSION: LDCT and Lung Nodule Programs are complementary, expanding access to early lung cancer detection and curative treatment to different-risk populations. Implementing Lung Nodule Programs may alleviate emerging disparities in access to early lung cancer detection.

The Relative Survival Impact of Guideline-Concordant Clinical Staging and Stage-Appropriate Treatment of Potentially Curable Non-Small Cell Lung Cancer.

BACKGROUND: Lung cancer management guidelines strive to improve outcomes. Theoretically, thorough staging promotes optimal treatment selection. We examined the association between guideline-concordant invasive mediastinal nodal staging, guideline-concordant treatment, and non-small cell lung cancer survival. RESEARCH QUESTION: What is the current practice of invasive mediastinal nodal staging for patients with lung cancer in a structured multidisciplinary care environment? Is guideline-concordant staging associated with guideline-concordant treatment? How do they relate to survival? STUDY DESIGN AND METHODS: We evaluated patients with nonmetastatic non-small cell lung cancer diagnosed from 2014 through 2019 in the Multidisciplinary Thoracic Oncology Program of the Baptist Cancer Center, Memphis, Tennessee. We examined patterns of mediastinal nodal staging and stage-stratified treatment, grouping patients into cohorts with guideline-concordant staging alone, guideline-concordant treatment alone, both, or neither. We evaluated overall survival with Kaplan-Meier curves and Cox proportional hazards models. RESULTS: Of 882 patients, 456 (52%) received any invasive mediastinal staging. Seventy-four percent received guideline-concordant staging; guideline-discordant staging decreased from 34% in 2014 to 18% in 2019 (P < .0001). Recipients of guideline-concordant staging were more likely to receive guideline-concordant treatment (83% vs 66%; P < .0001). Sixty-one percent received both guideline-concordant invasive mediastinal staging and guideline-concordant treatment; 13% received guideline-concordant staging alone; 17% received guideline-concordant treatment alone; and 9% received neither. Survival was greatest in patients who received both (adjusted hazard ratio [aHR], 0.41; 95% CI, 0.26-0.63), followed by those who received guideline-concordant treatment alone (aHR, 0.60; 95% CI, 0.36-0.99), and those who received guideline-concordant staging alone (aHR, 0.64; 95% CI, 0.37-1.09) compared with neither (P < .0001, log-rank test). INTERPRETATION: Levels of guideline-concordant staging were high, were rising, and were associated with guideline-concordant treatment selection in this multidisciplinary care cohort. Guideline-concordant staging and guideline-concordant treatment were complementary in their association with improved survival, supporting the connection between these two processes and lung cancer outcomes.

Survival Impact of an Enhanced Multidisciplinary Thoracic Oncology Conference in a Regional Community Health Care System.

INTRODUCTION: We compared NSCLC treatment and survival within and outside a multidisciplinary model of care from a large community health care system. METHODS: We implemented a rigorously benchmarked "enhanced" Multidisciplinary Thoracic Oncology Conference (eMTOC) and used Tumor Registry data (2011-2017) to evaluate guideline-concordant care. Because eMTOC was located in metropolitan Memphis, we separated non-MTOC patient by metropolitan and regional location. We categorized National Comprehensive Cancer Network guideline-concordant treatment as "preferred," or "appropriate" (allowable under certain circumstances). We compared demographic and clinical characteristics across cohorts using chi-square tests and survival using Cox regression, adjusted for multiple testing. We also performed propensity-matched and adjusted survival analyses. RESULTS: Of 6259 patients, 14% were in eMTOC, 55% metropolitan non-MTOC, and 31% regional non-MTOC cohorts. eMTOC had the highest rates of African Americans (34% versus 28% versus 22%), stages I to IIIB (63 versus 40 versus 50), urban residents (81 versus 78 versus 20), stage-preferred treatment (66 versus 57 versus 48), guideline-concordant treatment (78 versus 70 versus 63), and lowest percentage of nontreatment (6 versus 21 versus 28); all p values were less than 0.001. Compared with eMTOC, hazard for death was higher in metropolitan (1.5, 95% confidence interval: 1.4-1.7) and regional (1.7, 1.5-1.9) non-MTOC; hazards were higher in regional non-MTOC versus metropolitan (1.1, 1.0-1.2); all p values were less than 0.05 after adjustment. Results were generally similar after propensity analysis with and without adjusting for guideline-concordant treatment. CONCLUSIONS: Multidisciplinary NSCLC care planning was associated with significantly higher rates of guideline-concordant care and survival, providing evidence for rigorous implementation of this model of care.

Implementing lung cancer screening in the real world: opportunity, challenges and solutions.

The World Health Organization estimates that, in 2012, there were 1,589,925 deaths from lung cancer worldwide. Screening for lung cancer with low-dose computed tomography (LDCT) has the potential to significantly alter this statistic, by identifying lung cancers in earlier stages, enabling curative treatment. Challenges remain, however, in replicating the 20% mortality benefit demonstrated by the National Lung Screening Trial (NLST), in populations outside the confines of a research trial, not only in the US but around the world. We review the history of lung cancer screening, the current evidence for LDCT screening, and the key elements needed for a successful screening program.

Cardiac CT and coronary CTA: early Medicare claims analysis of national and regional utilization and coverage.

PURPOSE: The aim of this study was to assess trends in utilization and Medicare coverage of cardiac CT and coronary CT angiography (CCTA). METHODS: Medicare claims for cardiac CT and CCTA were identified for the first 3 complete years for which Current Procedural Terminology(®) tracking codes existed (2006-2008). The frequencies of billed and denied services were extracted on national and regional bases, along with reporting physician specialty and site of service. RESULTS: Total annual claims for cardiac CT and CCTA services for Medicare fee-for-service beneficiaries increased from 58,124 to 95,269 (+64%) between 2006 and 2008. The overall percentage of denied claims decreased from 34% to 21% (20,014 of 58,124 to 20,062 of 95,269, P < .001), with the highest denial rate for calcium scoring studies (declining from 82% to 61%) and the lowest rate for CCTA (29% to 14%). Annual overall regional denial rates ranged from 8.9% to 80.6%. Of all 254,672 base services, 138,136 claims (54%) were submitted by cardiologists, 90,767 (36%) by radiologists, and 13,445 (5%) by others. In 12,324 cases (5%), provider specialty was undetermined. Two-thirds (67%) of services were reported in the office setting (170,511), followed by the outpatient hospital (64,008 [25%]), inpatient hospital (15,922 [6%]), ER (1,577 [1%]), and all other (2,654 [1%]) settings. CONCLUSION: Most cardiac CT and CCTA services are reported by cardiologists and most takes place in private office and outpatient hospital settings. During the first 3 years of Current Procedural Terminology tracking codes, the utilization of cardiac CT and CCTA by Medicare fee-for-service beneficiaries increased by 64%. Despite perceptions that new technology tracking codes are rarely payable, a large majority of all examinations are reimbursed by Medicare. Coverage varies regionally but overall has improved, setting the stage for expanded patient access.

NIH state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening.

OBJECTIVE: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on enhancing use and quality of colorectal cancer screening. PARTICIPANTS: A non-DHHS, nonadvocate 13-member panel representing the fields of cancer surveillance, health services research, community-based research, informed decision-making, access to care, health care policy, health communication, health economics, health disparities, epidemiology, statistics, thoracic radiology, internal medicine, gastroenterology, public health, end-of-life care, and a public representative. In addition, 20 experts from pertinent fields presented data to the panel and conference audience. EVIDENCE: Presentations by experts and a systematic review of the literature prepared by the RTI International-University of North Carolina Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience. CONFERENCE PROCESS: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. CONCLUSIONS: The panel found that despite substantial progress toward higher colorectal cancer screening rates nationally, screening rates fall short of desirable levels. Targeted initiatives to improve screening rates and reduce disparities in underscreened communities and population subgroups could further reduce colorectal cancer morbidity and mortality. This could be achieved by utilizing the full range of screening options and evidence-based interventions for increasing screening rates. With additional investments in quality monitoring, Americans could be assured that all screening achieves high rates of cancer prevention and early detection. To close the gap in screening, this report identifies the following priority areas for implementation and research to enhance the use and quality of colorectal cancer screening: • Eliminate financial barriers to colorectal cancer screening and appropriate follow up. • Widely implement interventions that have proven effective at increasing colorectal cancer screening, including patient reminder systems and one-on-one interactions with providers, educators, or navigators. • Conduct research to assess the effectiveness of tailoring programs to match the characteristics and preferences of target population groups to increase colorectal cancer screening. • Implement systems to ensure appropriate follow-up of positive colorectal cancer screening results. • Develop systems to assure high quality of colorectal cancer screening programs. • Conduct studies to determine the comparative effectiveness of the various colorectal cancer screening methods in usual practice settings.

Uncoupling protein-1 and related messenger ribonucleic acids in human epicardial and other adipose tissues: epicardial fat functioning as brown fat.

CONTEXT: Uncoupling protein-1 (UCP-1) is the inner mitochondrial membrane protein that is a specific marker for and mediator of nonshivering thermogenesis in brown adipocytes. OBJECTIVE: This study was performed to better understand the putative thermogenic function of human epicardial fat. DESIGN: We measured the expression of UCP-1 and brown adipocyte differentiation transcription factors PR-domain-missing 16 (PRDM16) and peroxisome-proliferator-activated receptor gamma co-activator-1 alpha (PGC-1 alpha) in epicardial, substernal, and sc thoracic, abdominal, and leg fat. SETTING: The study was conducted at a tertiary care hospital cardiac center. PATIENTS: Forty-four patients had coronary artery bypass surgery, and six had heart valve replacement. INTERVENTIONS: Fat samples were taken at open heart surgery. RESULTS: UCP-1 expression was 5-fold higher in epicardial fat than substernal fat and barely detectable in sc fat. Epicardial fat UCP-1 expression decreased with age, increased with body mass index, was similar in women and men and patients on and not on statin therapy, and showed no relationship to epicardial fat volume or waist circumference. UCP-1 expression was similar in patients without and with severe coronary atherosclerosis and metabolic syndrome or type 2 diabetes. PRDM16 and PGC-1 alpha expression was 2-fold greater in epicardial than sc fat. Epicardial fat UCP-1, PRDM16, and PGC1-alpha mRNAs were similar in diabetics treated with thiazolidinediones compared to diabetics not treated with thiazolidinediones. CONCLUSION: Because UCP-1 is expressed at high levels in epicardial fat as compared to other fat depots, the possibility should be considered that epicardial fat functions like brown fat to defend the myocardium and coronary vessels against hypothermia. This process could be blunted in the elderly.