Pre- and post-magnetic resonance imaging features of suspicious internal mammary lymph nodes in breast cancer patients receiving neo-adjuvant therapy: Are any imaging features predictive of malignancy?

Internal mammary lymph nodes constitute a major lymphatic chain draining the breast and a route of spread for breast cancer metastases. Both physiologic and metastatic internal mammary lymph nodes enhance on breast magnetic resonance imaging, and the clinical significance of their prevalence, size, and morphology when visualized in a patient with breast cancer remains unknown. We studied the characteristics of internal mammary lymph nodes visualized on breast MRI studies before and after neo-adjuvant therapy in twenty-three patients with newly diagnosed breast cancer. A measured decrease in internal mammary lymph node size on post-neo-adjuvant therapy MRI indicated metastatic involvement. Determining suspicious features of internal mammary nodes on initial diagnostic MRI can aid radiologists in reporting probable IMLN metastases and may alter the course of care for patients with breast cancer. This study concludes that metastatic internal mammary lymph nodes should be considered when more than two ipsilateral internal mammary lymph nodes measuring 6 mm or greater are seen on diagnostic MRI in a patient with newly diagnosed breast cancer.

Bundled Payment Models for Actinic Keratosis Management.

IMPORTANCE: Recent legislation encourages alternative payment models, such as bundled payments. There are no clear recommendations on bundled payment design, and research on bundled payments for dermatologic care is limited. OBJECTIVE: To investigate several methods to develop bundled payment models for actinic keratosis (AK) management and the likely effect on the cost of AK management. DESIGN, SETTING, AND PARTICIPANTS: Cohort cost identification study using claims from Highmark Insurance and the MarketScan Commercial Claims and Encounters databases. Patients with claims for AK during the study period, January 2010 to December 2012, were included (N = 118 129). Utilization measures, such as visits and procedures, and direct costs were calculated and 8 bundled payment models were developed. Indirect costs were not included. MAIN OUTCOMES AND MEASURES: The actual health care costs and theoretical cost differences for the bundled payments. Costs are reported in 2012 US dollars and were adjusted for inflation. The proportion of patients and clinicians with annual AK claim costs less than or equal to the bundled payments were calculated. RESULTS: Eight bundled payment models were developed and 2, based on the 75th percentile payment, did not result in theoretical savings for any of the patient samples (increased annual spending of $1.04 million to $6.88 million). The median-based payment without adjustments resulted in the largest theoretical savings (decreased spending of $2.22 million to $6.43 million). In contrast, the mean-based payment with adjustments resulted in the smallest theoretical savings. The median-based with indirect payment (65.2% for patients and 62.0% for clinicians) and mean-based adjusted payments, with (68.9% and 66.2%) and without (68.1% and 65.6%) discount, were equal to or greater than the actual health care costs for similar proportions of patients and clinicians, respectively. In addition, both resulted in a decrease in overall health care costs for the patient cohort. CONCLUSIONS AND RELEVANCE: It is important to consider alternative payment models, such as bundled payments, in preparation for payment reform. The dermatology profession needs to understand disease management in dollar terms to advocate on behalf of clinicians and patients for fair and reasonable reimbursement, regardless of payment type.