An Examination of Racial and Ethnic Disparities in the Use of Prostate Biopsy and Magnetic Resonance Imaging in Prostate Cancer Screening.

INTRODUCTION: We assessed racial and ethnic disparities in the use of prostate biopsy or MRI following an elevated PSA result. METHODS: We retrospectively evaluated insurance claims from Optum's de-identified Clinformatics Data Mart database from January 1, 2011 to December 31, 2017. This was a large commercially insured cohort from across the United States. We included all male enrollees over 40 years old receiving an elevated PSA result with no prior prostate biopsy or MRI and no confirmed urinary tract infection within 6 weeks of PSA test. RESULTS: A total of 765,409 participants met inclusion criteria with 43,711 (5.71%) receiving a PSA result above 4 ng/mL. Of these, 7,399 received either a prostate biopsy or MRI within 180 days. Men between ages 40-54 (29.48%) were most likely to receive prostate biopsy or MRI after an elevated PSA, followed by those between 55-64 (24.91%), 65-74 (18.56%), 75-84 (6.33%), and above 85 (3.62%). Compared to White patients, Black patients were more likely to receive either a prostate biopsy or MRI (OR: 1.16, 95% CI: 1.01, 1.32) following an elevated PSA level, while Asian (OR: 0.72, 95% CI: 0.54, 0.96) and Hispanic (OR: 0.83, 95% CI: 0.70, 0/97) patients were less likely. CONCLUSIONS: Physicians appear to be following the reported statistical incidence of prostate cancer by race and ethnicity when using prostate biopsy or MRI for patients with elevated PSA levels. These results demonstrate the importance of publishing statistical data on disease incidence by race and ethnicity for informing physicians' decision-making.

Comparison of Lung Cancer Screening Eligibility and Use between Commercial, Medicare, and Medicare Advantage Enrollees.

OBJECTIVE: Lung cancer screening does not require patient cost-sharing for insured people in the U.S. Little is known about whether other factors associated with patient selection into different insurance plans affect screening rates. We examined screening rates for enrollees in commercial, Medicare Fee-for-Service (FFS), and Medicare Advantage plans. METHODS: County-level smoking rates from the 2017 County Health Rankings were used to estimate the number of enrollees eligible for lung cancer screening in two large retrospective claims databases covering: a 5% national sample of Medicare FFS enrollees; and 100% sample of enrollees associated with large commercial and Medicare Advantage carriers. Screening rates were estimated using observed claims, stratified by payer, before aggregation into national estimates by payer and demographics. Chi-square tests were used to examine differences in screening rates between payers. RESULTS: There were 1,077,142 enrollees estimated to be eligible for screening. The overall estimated screening rate for enrollees by payer was 1.75% for commercial plans, 3.37% for Medicare FFS, and 4.56% for Medicare Advantage plans. Screening rates were estimated to be lowest among females (1.55%-4.02%), those aged 75-77 years (0.63%-2.87%), those residing in rural areas (1.88%-3.56%), and those in the West (1.16%-3.65%). Among Medicare FFS enrollees, screening rates by race/ethnicity were non-Hispanic White (3.71%), non-Hispanic Black (2.17%) and Other (1.68%). CONCLUSIONS: Considerable variation exists in lung cancer screening between different payers and across patient characteristics. Efforts targeting historically vulnerable populations could present opportunities to increase screening.

Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram.

Importance: Out-of-pocket costs (OOPCs) have been largely eliminated for screening mammography. However, patients still face OOPCs when undergoing subsequent diagnostic tests after the initial screening, which represents a potential barrier to those who require follow-up testing after initial testing. Objective: To examine the association between the degree of patient cost-sharing and the use of diagnostic breast cancer imaging after undergoing a screening mammogram. Design, Setting, and Participants: This retrospective cohort study used medical claims from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The large commercially insured cohort included female patients aged 40 years or older with no prior history of breast cancer undergoing a screening mammogram examination. Data were collected from January 1, 2015, to December 31, 2017, and analysis was conducted from January 2021 to September 2022. Exposures: A k-means clustering machine learning algorithm was used to classify patient insurance plans by dominant cost-sharing mechanism. Plan types were then ranked by OOPCs. Main Outcomes and Measures: A multivariable 2-part hurdle regression model was used to examine the association between patient OOPCs and the number and type of diagnostic breast services undergone by patients observed to undergo subsequent testing. Results: In our sample, 230 845 women (220 023 [95.3%] aged 40 to 64 years; 16 810 [7.3%] Black, 16 398 [7.1%] Hispanic, and 164 702 [71.3%] White) underwent a screening mammogram in 2016. These patients were covered by 22 828 distinct insurance plans associated with 6 025 741 enrollees and 44 911 473 distinct medical claims. Plans dominated by coinsurance were found to have the lowest mean (SD) OOPCs ($945 [$1456]), followed by balanced plans ($1017 [$1386]), plans dominated by copays ($1020 [$1408]), and plans dominated by deductibles ($1186 [$1522]). Women underwent significantly fewer subsequent breast imaging procedures in dominantly copay (24 [95% CI, 11-37] procedures per 1000 women) and dominantly deductible (16 [95% CI, 5-28] procedures per 1000 women) plans compared with coinsurance plans. Patients from all plan types underwent fewer breast magnetic resonance imaging (MRI) scans than patients in the lowest OOPC plan (balanced, 5 [95% CI, 2-12] MRIs per 1000 women; copay, 6 [95% CI, 3-6] MRI per 100 women; deductible, 6 [95% CI, 3-9] MRIs per 1000 women. Conclusions and Relevance: Despite policies designed to remove financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of breast cancer.

Recent trends in high-volume Medicare stroke thrombectomy provider characteristics.

BACKGROUND: Intracranial mechanical thrombectomy (MT) is increasingly indicated for use in acute ischemic stroke patients. We analyzed recent trends in the characteristics and geographic distributions of physicians providing this service with frequency to Medicare beneficiaries. METHODS: We linked public data sources to elucidate and visualize trends in high-volume MT providers between 2016 and 2019. RESULTS: High-volume MT providers increased by 184% between 2016 and 2019. The number of neurosurgeons, neurologists, and radiologists in this physician population increased by 251%, 205%, and 139%, respectively. Male practitioners accounted for 96% of providers in the most recent year of analysis. International medical graduates accounted for roughly one-third of these physicians across all 4 years of analysis. As of 2019, the three states with the most high-volume MT providers were Florida, California, and Texas, accounting for 7%, 7%, and 6% of providers, respectively. CONCLUSIONS: High-volume providers of MT services for Medicare beneficiaries represent a dynamic and rapidly expanding subset of physicians with diverse specialty backgrounds.

Racial and Ethnic Disparities in the Use of Prostate Magnetic Resonance Imaging Following an Elevated Prostate-Specific Antigen Test.

Importance: Prostate cancer screening and diagnosis exhibit known racial and ethnic disparities. Whether these disparities persist in prostate magnetic resonance imaging (MRI) utilization after elevated prostate-specific antigen (PSA) results is poorly understood. Objective: To assess potential racial and ethnic disparities in prostate MRI utilization following elevated PSA results. Design, Setting, and Participants: This cohort study of 794 809 insured US men was drawn from deidentified medical claims between January 2011 and December 2017 obtained from a commercial claims database. Eligible participants were aged 40 years and older and received a single PSA result and no prior PSA screening or prostate MRI claims. Analysis was performed in January 2021. Main Outcomes and Measures: Multivariable logistic regression was used to examine associations between elevated PSA results and follow-up prostate MRI. For patients receiving prostate MRI, multivariable regressions were estimated for the time between PSA and subsequent prostate MRI. PSA thresholds explored included PSA levels above 2.5 ng/mL, 4 ng/mL, and 10 ng/mL. Analyses were stratified by race, ethnicity, and age. Results: Of 794 809 participants, 51 500 (6.5%) had PSA levels above 4 ng/mL; of these, 1524 (3.0%) underwent prostate MRI within 180 days. In this sample, mean (SD) age was 59.8 (11.3) years (range 40-89 years); 31 350 (3.9%) were Asian, 75 935 (9.6%) were Black, 107 956 (13.6%) were Hispanic, and 455 214 (57.3%) were White. Compared with White patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% (odds ratio [OR], 0.78; 95% CI, 0.65-0.89) and 35.0% (OR, 0.65; 95% CI, 0.50-0.85) less likely to undergo subsequent prostate MRI, respectively. Asian patients with PSA levels higher than 4 ng/mL (OR, 0.76; 95% CI, 0.58-0.99) and Hispanic patients with PSA levels above 10 ng/mL (OR, 0.77; 95% CI, 0.59-0.99) were also less likely to undergo subsequent prostate MRI compared with White patients. Black patients between ages 65 and 74 years with PSA above 4 ng/mL and 10 ng/mL were 23.6% (OR, 0.76; 95% CI, 0.64-0.91) and 43.9% (OR, 0.56; 95% CI, 0.35-0.91) less likely to undergo MRI, respectively. Race and ethnicity were not significantly associated with mean time between PSA and MRI. Conclusions and Relevance: Among men with elevated PSA results, racial and ethnic disparities were evident in subsequent prostate MRI utilization and were more pronounced at higher PSA thresholds. Further research is needed to better understand and mitigate physician decision-making biases and other potential sources of disparities in prostate cancer diagnosis and management.

Radiologist Characteristics Associated with Interpretive Performance of Screening Mammography: A National Mammography Database (NMD) Study.

Background Factors affecting radiologists' performance in screening mammography interpretation remain poorly understood. Purpose To identify radiologists characteristics that affect screening mammography interpretation performance. Materials and Methods This retrospective study included 1223 radiologists in the National Mammography Database (NMD) from 2008 to 2019 who could be linked to Centers for Medicare & Medicaid Services (CMS) datasets. NMD screening performance metrics were extracted. Acceptable ranges were defined as follows: recall rate (RR) between 5% and 12%; cancer detection rate (CDR) of at least 2.5 per 1000 screening examinations; positive predictive value of recall (PPV1) between 3% and 8%; positive predictive value of biopsies recommended (PPV2) between 20% and 40%; positive predictive value of biopsies performed (PPV3) between the 25th and 75th percentile of study sample; invasive CDR of at least the 25th percentile of the study sample; and percentage of ductal carcinoma in situ (DCIS) of at least the 25th percentile of the study sample. Radiologist characteristics extracted from CMS datasets included demographics, subspecialization, and clinical practice patterns. Multivariable stepwise logistic regression models were performed to identify characteristics independently associated with acceptable performance for the seven metrics. The most influential characteristics were defined as those independently associated with the majority of the metrics (at least four). Results Relative to radiologists practicing in the Northeast, those in the Midwest were more likely to achieve acceptable RR, PPV1, PPV2, and CDR (odds ratio [OR], 1.4-2.5); those practicing in the West were more likely to achieve acceptable RR, PPV2, and PPV3 (OR, 1.7-2.1) but less likely to achieve acceptable invasive CDR (OR, 0.6). Relative to general radiologists, breast imagers were more likely to achieve acceptable PPV1, invasive CDR, percentage DCIS, and CDR (OR, 1.4-4.4). Those performing diagnostic mammography were more likely to achieve acceptable PPV1, PPV2, PPV3, invasive CDR, and CDR (OR, 1.9-2.9). Those performing breast US were less likely to achieve acceptable PPV1, PPV2, percentage DCIS, and CDR (OR, 0.5-0.7). Conclusion The geographic location of the radiology practice, subspecialization in breast imaging, and performance of diagnostic mammography are associated with better screening mammography performance; performance of breast US is associated with lower performance. ©RSNA, 2021 Online supplemental material is available for this article.

Developmental hip dysplasia and hip ultrasound frequency in a large American payer database.

Developmental dysplasia of the hip (DDH) is an important contributor to musculoskeletal morbidity, but effective strategies to screen for DDH remain controversial. The current utilization of hip ultrasound (US) screening for DDH in the United States is not defined. This study utilized Optum's de-identified Clinformatics® Data Mart, a large commercial and Medicare Advantage claims database. The frequency of DDH and hip US utilization was estimated using billing data on an average of 2.9 million relevant beneficiaries included annually from 2007 through 2017. A total of 6806 DDH cases were identified with an average annual prevalence of 1.7 per 1000 infants, which was stable during the study period. Girls were more likely to be screened and diagnosed with DDH, comprising 72% of DDH cases with an OR of 2.55 (95% CI 2.42-2.69), p < 0.001. Hip US screening was employed in 0.9% of the infant population on average but increased substantially from 2007 (0.4%) to 2017 (2.2%). Most common billing diagnoses included hip deformity (27.4%), breech delivery (20.4%), and physical exam abnormality (17.7%). The average imaging costs per patient for all screened children was $108.94. Insurance claims reflect the current American practice of selective hip US with relative adherence to American Academy of Pediatrics guidelines based on reported diagnoses. While hip US utilization increased during the study period, prevalence of DDH diagnoses did not increase. Our results suggest that expansion of hip US screening may not effectively increase DDH detection although further investigation is needed to ascertain optimal screening strategies to improve patient outcomes.

Characteristics of COVID-19 Community Practice Declines in Noninvasive Diagnostic Imaging Professional Work.

PURPOSE: The operational and financial impact of the widespread coronavirus disease 2019 (COVID-19) curtailment of imaging services on radiology practices is unknown. We aimed to characterize recent COVID-19-related community practice noninvasive diagnostic imaging professional work declines. METHODS: Using imaging metadata from nine community radiology practices across the United States between January 2019 and May 2020, we mapped work relative value unit (wRVU)-weighted stand-alone noninvasive diagnostic imaging service codes to both modality and body region. Weekly 2020 versus 2019 wRVU changes were analyzed by modality, body region, and site of service. Practice share χ2 testing was performed. RESULTS: Aggregate weekly wRVUs ranged from a high of 120,450 (February 2020) to a low of 55,188 (April 2020). During that -52% wRVU nadir, outpatient declines were greatest (-66%). All practices followed similar aggregate trends in the distribution of wRVUs between each 2020 versus 2019 week (P = .96-.98). As a percentage of total all-practice wRVUs, declines in CT (20,046 of 63,992; 31%) and radiography and fluoroscopy (19,196; 30%) were greatest. By body region, declines in abdomen and pelvis (16,203; 25%) and breast (12,032; 19%) imaging were greatest. Mammography (-17%) and abdominal and pelvic CT (-14%) accounted for the largest shares of total all-practice wRVU reductions. Across modality-region groups, declines were far greatest for mammography (-92%). CONCLUSIONS: Substantial COVID-19-related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography. Decline patterns could facilitate pandemic second wave planning. Overall implications for practice workflows, practice finances, patient access, and payment policy are manifold.

National Trends in Oncologic Diagnostic Imaging.

OBJECTIVE: To characterize national trends in oncologic imaging (OI) utilization. METHODS: This retrospective cross-sectional study used 2004 and 2016 CMS 5% Carrier Claims Research Identifiable Files. Radiologist-performed, primary noninvasive diagnostic imaging examinations were identified from billed Current Procedural Terminology codes; CT, MRI, and PET/CT examinations were categorized as "advanced" imaging. OI examinations were identified from imaging claims' primary International Classification of Diseases-9 and International Classification of Diseases-10 codes. Imaging services were stratified by academic practice status and place of service. State-level correlations of oncologic advanced imaging utilization (examinations per 1,000 beneficiaries) with cancer prevalence and radiologist supply were assessed by Spearman correlation coefficient. RESULTS: The national Medicare sample included 5,051,095 diagnostic imaging examinations (1,220,224 of them advanced) in 2004 and 5,023,115 diagnostic imaging examinations (1,504,608 of them advanced) in 2016. In 2004 and 2016, OI represented 4.3% and 3.9%, respectively, of all imaging versus 10.8% and 9.5%, respectively, of advanced imaging. The percentage of advanced OI done in academic practices rose from 18.8% in 2004 to 34.1% in 2016, leaving 65.9% outside academia. In 2016, 58.0% of advanced OI was performed in the hospital outpatient setting and 23.9% in the physician office setting. In 2016, state-level oncologic advanced imaging utilization correlated with state-level radiologist supply (r = +0.489, P < .001) but not with state-level cancer prevalence (r = -0.139, P = .329). DISCUSSION: OI usage varied between practice settings. Although the percentage of advanced OI done in academic settings nearly doubled from 2004 to 2016, the majority remained in nonacademic practices. State-level oncologic advanced imaging utilization correlated with radiologist supply but not cancer prevalence.

Invasive Procedural Treatments for Symptomatic Uterine Fibroids: A Cost Analysis.

PURPOSE: The aim of this study was to evaluate the contemporary use of procedural interventions to treat symptomatic uterine fibroids and assess associated health care system costs. METHODS: Using the IBM Watson MarketScan Commercial Claims and Encounters database for 2009 to 2015 and relevant International Classification of Diseases diagnosis codes, women aged 18 to 55 years with clinically significant uterine fibroids were identified. Using Current Procedural Terminology codes, relevant procedural interventions were identified (hysterectomy, endometrial ablation, myomectomy, and uterine fibroid embolization [UFE]). Costs were defined as total actual payments by insurers and patients (per procedure and per episode of care) and were adjusted and compared using generalized linear models. RESULTS: Of 241,757 invasive procedures for fibroids, hysterectomy was most common (76.5%), followed by endometrial ablation (14.5%), myomectomy (4.7%), and UFE (4.3%). Hysterectomy was more common in older women and those in rural areas (65.2% of patients <40 years of age, 77.6% of those 40-49 years of age, and 83.6% of those 50-55 years of age; 83.9% of patients outside versus 75.3% within metropolitan statistical areas). Per procedure, adjusted mean costs were $3,188 (95% confidence interval [CI], $3,114-$3,264) for hysterectomy, $2,781 (95% CI, $2,695-$2,870) for ablation, $4,436 (95% CI, $4,256-$4,623) for myomectomy, and $6,161 (95% CI, $5,736-$6,617) for UFE. Adjusted mean costs for entire episodes of care were $14,676 (95% CI, $14,496-$14,858) for hysterectomy, $6,702 (95% CI, $6,534-$6,875) for endometrial ablation, $14,791 (95% CI, $14,465-$15,125) for myomectomy, and $13,873 (95% CI, $13,182-$14,599) for UFE. CONCLUSIONS: Of invasive procedures for symptomatic uterine fibroids, hysterectomy was used more frequently than endometrial ablation, myomectomy, and UFE combined. Per procedure and per episode, ablation was least costly. Costs per episode were similar for hysterectomy, myomectomy, and UFE.

Implications of achieving TICI 2b vs TICI 3 reperfusion in patients with ischemic stroke: a cost-effectiveness analysis.

BACKGROUND: The benefit of endovascular thrombectomy (EVT) in stroke patients with large-vessel occlusion (LVO) depends on the degree of recanalization achieved. We aimed to determine the health outcomes and cost implications of achieving TICI 2b vs TICI 3 reperfusion in acute stroke patients with LVO. METHODS: A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years (QALY) of EVT-treated patients, and costs based on the degree of reperfusion achieved. The study was performed with a societal perspective in the United States' setting. The base case calculations were performed in three age groups: 55-, 65-, and 75-year-old patients. RESULTS: Within 90 days, achieving TICI 3 resulted in a cost saving of $3676 per patient and health benefit of 11 days in perfect health as compared with TICI 2b. In the long term, for the three age groups, achieving TICI 3 resulted in cost savings of $46,498, $25,832, and $15 719 respectively, and health benefits of 2.14 QALYs, 1.71 QALYs, and 1.23 QALYs. Every 1% increase in TICI 3 in 55-year-old patients nationwide resulted in a cost saving of $3.4 million and a health benefit of 156 QALYs. Among 65-year-old patients, the corresponding cost savings and health benefit were $1.9 million and 125 QALYs. CONCLUSION: There are substantial cost and health implications in achieving complete vs incomplete reperfusion after EVT. Our study provides a framework to assess the cost-benefit analysis of emerging diagnostic and therapeutic techniques that might improve patient selection, and increase the chances of achieving complete reperfusion.

Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on Imaging Case Volumes.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has had significant economic impact on radiology with markedly decreased imaging case volumes. The purpose of this study was to quantify the imaging volumes during the COVID-19 pandemic across patient service locations and imaging modality types. METHODS: Imaging case volumes in a large health care system were retrospectively studied, analyzing weekly imaging volumes by patient service locations (emergency department, inpatient, outpatient) and modality types (x-ray, mammography, CT, MRI, ultrasound, interventional radiology, nuclear medicine) in years 2020 and 2019. The data set was split to compare pre-COVID-19 (weeks 1-9) and post-COVID-19 (weeks 10-16) periods. Independent-samples t tests compared the mean weekly volumes in 2020 and 2019. RESULTS: Total imaging volume in 2020 (weeks 1-16) declined by 12.29% (from 522,645 to 458,438) compared with 2019. Post-COVID-19 (weeks 10-16) revealed a greater decrease (28.10%) in imaging volumes across all patient service locations (range 13.60%-56.59%) and modality types (range 14.22%-58.42%). Total mean weekly volume in 2020 post-COVID-19 (24,383 [95% confidence interval 19,478-29,288]) was statistically reduced (P = .003) compared with 33,913 [95% confidence interval 33,429-34,396] in 2019 across all patient service locations and modality types. The greatest decline in 2020 was seen at week 16 specifically for outpatient imaging (88%) affecting all modality types: mammography (94%), nuclear medicine (85%), MRI (74%), ultrasound (64%), interventional (56%), CT (46%), and x-ray (22%). DISCUSSION: Because the duration of the COVID-19 pandemic remains uncertain, these results may assist in guiding short- and long-term practice decisions based on the magnitude of imaging volume decline across different patient service locations and specific imaging modality types.

Leveraging the Mammography Setting to Raise Awareness and Facilitate Referral to Lung Cancer Screening: A Qualitative Analysis.

PURPOSE: Despite compelling support for the benefits of low-dose CT (LDCT) screening for lung cancer among high-risk individuals, awareness of LDCT screening and uptake remain low. The aim of this project was to explore the perspectives of ACR mammography screening program directors (MPDs) regarding efforts to raise LDCT screening awareness and appropriate referrals by identifying high-risk individuals participating in routine mammography. METHODS: MPDs were recruited from ACR-accredited mammography facilities to participate in semistructured interviews after the completion of an online survey. Interviews were conducted over the telephone, recorded, transcribed, and subsequently reviewed for accuracy. Twenty MPDs were interviewed, and 18 interviews were transcribed and included in the thematic analysis. A theme codebook was developed, and all interviews were coded using NVivo by two trained reviewers. RESULTS: Key themes were organized into four broad domains: (1) general attitudes toward the integration of LDCT screening, (2) identifying mammography patients at high risk for lung cancer, (3) counseling about LDCT screening, and (4) strategies to identify high-risk women and increase awareness and knowledge of LDCT screening. Overall, MPDs recognized the benefits of integrating mammography and LDCT screening and were receptive to educating and referring women for LDCT screening. However, training and workflow changes are needed to ensure successful implementation. CONCLUSIONS: Qualitative data suggest that MPDs are amenable to leveraging the mammography setting to engage women about LDCT screening; however, additional tools, training, and/or staffing may be necessary to leverage the full potential of reaching women at high risk for lung cancer within the context of mammographic screening.

Digital Breast Tomosynthesis Implementation: Considerations for Emerging Breast Cancer Screening Bundled Payment Models.

PURPOSE: Bundled payments have been touted as mechanisms to optimize quality and costs. A recent feasibility study evaluating bundled payments for screening mammography episodes predated widespread adoption of digital breast tomosynthesis (DBT). We explore a similar model reflecting emerging acceptance of DBT in breast cancer screening. METHODS: Using 4-year data for 59,094 screening episodes from two large facilities within a large academic health system, we utilized published methodology to calibrate Medicare national allowable reference prices for women undergoing screening mammography before and after practice-wide implementation of DBT. RESULTS: Excluding DBT, Medicare-normalized bundled prices for traditional breast imaging 364 days downstream to screening mammography are extremely similar pre- and post-DBT implementation ($182.86 in 2013; $182.68 in 2015). The addition of DBT increased a DBT-inclusive bundled price by $53.16 (an amount lower than the $56.13 Medicare allowable fee for screening DBT) but was associated with significantly reduced recall rates (13.0% versus 9.4%; P < .0001). Without or with DBT, screening episode bundled prices remained sensitive to bundle-included services and varied little by patient age, race, or insurance status. CONCLUSIONS: Prior non-DBT approaches to bundled payment models for breast cancer screening remain viable as DBT becomes the standard of care, with bundle prices varying little by patient age, race, or insurance status. Higher DBT-inclusive bundled prices, however, highlight the need to explore societal costs more broadly (eg, reduced time away from work from fewer recalls) as bundled payment models evolve.

Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015.

Importance: Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population. Objective: To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients. Design, Setting, and Participants: A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries. Main Outcomes and Measures: Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018. Results: More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015. Conclusions and Relevance: This study's findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

Use of Breast Cancer Screening and Its Association with Later Use of Preventive Services among Medicare Beneficiaries.

Purpose To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. Materials and Methods U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. Results The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. Conclusion In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening.

Evolving Use of Prebiopsy Prostate Magnetic Resonance Imaging in the Medicare Population.

PURPOSE: We assessed the changing use of prebiopsy prostate magnetic resonance imaging in Medicare beneficiaries. MATERIALS AND METHODS: Men who underwent prostate biopsy were identified in 5% Medicare RIFs (Research Identifiable Files) from October 2010 through September 2015. We evaluated the rate of prebiopsy prostate magnetic resonance imaging, defined as any pelvic MRI 6 months or less before biopsy with a prostate indication diagnosis code. Temporal changes were determined as well as variation by geography and among populations. RESULTS: In male Medicare beneficiaries the prebiopsy magnetic resonance imaging use rate increased from 0.1% in 2010 to 0.7% in 2011, to 1.2% in 2012, to 2.9% in 2013, to 4.7% in 2014 and to 10.3% in 2015. In 2015 the prebiopsy prostate magnetic resonance imaging rate varied significantly by patient age, including 5.7% for greater than 80 years vs 8.4% to 9.3% for other age ranges (p = 0.040) as well as by race, including 5.8% in African American vs 10.1% in Caucasian men (p = 0.009) and geographic region, including 6.3% in the Midwest to 12.5% in the Northeast (p <0.001). The rate was highest in Wyoming at 25.0%, New York at 23.7% and Minnesota at 20.5% but it was less than 1% in 10 states. CONCLUSIONS: Historical Medicare claims provide novel insights into the dramatically increasing adoption of magnetic resonance imaging prior to prostate biopsy. Following earlier minimal use the performance increased sharply beginning in 2013, exceeding 10% in 2015. However, substantial racial and geographic variation exists in adoption. Continued educational, research and policy efforts are warranted to optimize the role of prebiopsy magnetic resonance imaging and minimize sociodemographic and geographic disparities.

A County-Level Analysis of the US Radiologist Workforce: Physician Supply and Subspecialty Characteristics.

PURPOSE: To explore associations between county-level measures of radiologist supply and subspecialization and county structural and health-related characteristics. METHODS: Medicare Physician and Other Supplier Public Use Files were used to subspecialty characterize 32,844 radiologists participating in Medicare between 2012 and 2014. Measures of radiologist supply and subspecialization were computed for 3,143 US counties. Additional county characteristics were identified using the 2014 County Health Rankings database. Mann-Whitney tests and Spearman correlations were performed. RESULTS: Counties with at least one (versus no) Medicare-participating radiologist had significantly (P < .001) larger populations (197,050 ± 457,056 versus 20,253 ± 23,689), lower rural percentages (39.5% ± 26.5% versus 74.6% ± 25.6%), higher household incomes ($47,608 ± $12,493 versus $42,510 ± $9,893), higher mammography screening rates (62.4% ± 7.0% versus 56.6% ± 15.3%), and lower premature deaths (7,581 ± 2,085 versus 7,784 ± 3,409 years of life lost). Counties' radiologists per 100,000 population and percent of subspecialized radiologists showed moderate positive correlations with counties' population (r = +0.505-+0.599) and moderate negative correlations with counties' rural percentage (r = -0.434 to -0.523). Radiologist supply and degree of subspecialization both showed concurrent positive or negative weak associations with counties' percent age 65+ (r = -0.256 to -0.271), percent Hispanic (r = +0.209-+0.234), and income (r = +0.230-+0.316). Radiologists per 100,000 population showed weak positive correlation with mammography screening (r = +0.214); percent of radiologists subspecialized showed weak negative correlation with premature death (r = -0.226). CONCLUSION: Geographic disparities in radiologist supply at the community level are compounded by superimposed variation in the degree of subspecialization of those radiologists. The potential impact of such access disparities on county-level health warrants further investigation.

Changing Utilization of Noninvasive Diagnostic Imaging Over 2 Decades: An Examination Family-Focused Analysis of Medicare Claims Using the Neiman Imaging Types of Service Categorization System.

OBJECTIVE: The objective of our study was to use a new modality and body region categorization system to assess changing utilization of noninvasive diagnostic imaging in the Medicare fee-for-service population over a recent 20-year period (1994-2013). MATERIALS AND METHODS: All Medicare Part B Physician Fee Schedule services billed between 1994 and 2013 were identified using Physician/Supplier Procedure Summary master files. Billed codes for diagnostic imaging were classified using the Neiman Imaging Types of Service (NITOS) coding system by both modality and body region. Utilization rates per 1000 beneficiaries were calculated for families of services. RESULTS: Among all diagnostic imaging modalities, growth was greatest for MRI (+312%) and CT (+151%) and was lower for ultrasound, nuclear medicine, and radiography and fluoroscopy (range, +1% to +31%). Among body regions, service growth was greatest for brain (+126%) and spine (+74%) imaging; showed milder growth (range, +18% to +67%) for imaging of the head and neck, breast, abdomen and pelvis, and extremity; and showed slight declines (range, -2% to -7%) for cardiac and chest imaging overall. The following specific imaging service families showed massive (> +100%) growth: cardiac CT, cardiac MRI, and breast MRI. CONCLUSION: NITOS categorization permits identification of temporal shifts in noninvasive diagnostic imaging by specific modality- and region-focused families, providing a granular understanding and reproducible analysis of global changes in imaging overall. Service family-level perspectives may help inform ongoing policy efforts to optimize imaging utilization and appropriateness.