Missed Screening Mammography Appointments: Patient Sociodemographic Characteristics and Mammography Completion After 1 Year.

OBJECTIVE: Patients who miss screening mammogram appointments without notifying the health care system (no-show) risk care delays. We investigate sociodemographic characteristics of patients who experience screening mammogram no-shows at a community health center and whether and when the missed examinations are completed. METHODS: We included patients with screening mammogram appointments at a community health center between January 1, 2021, and December 31, 2021. Language, race, ethnicity, insurance type, residential ZIP code tabulation area (ZCTA) poverty, appointment outcome (no-show, same-day cancelation, completed), and dates of completed screening mammograms after no-show appointments with ≥1-year follow-up were collected. Multivariable analyses were used to assess associations between patient characteristics and appointment outcomes. RESULTS: Of 6,159 patients, 12.1% (743 of 6,159) experienced no-shows. The no-show group differed from the completed group by language, race and ethnicity, insurance type, and poverty level (all P < .05). Patients with no-shows more often had: primary language other than English (32.0% [238 of 743] versus 26.7% [1,265 of 4,741]), race and ethnicity other than White non-Hispanic (42.3% [314 of 743] versus 33.6% [1,595 of 4,742]), Medicaid or means-tested insurance (62.0% [461 of 743] versus 34.4% [1,629 of 4,742]), and residential ZCTAs with ≥20% poverty (19.5% [145 of 743] versus 14.1% [670 of 4,742]). Independent predictors of no-shows were Black non-Hispanic race and ethnicity (adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.12-2.07; P = .007), Medicaid or other means-tested insurance (aOR, 2.75; 95% CI, 2.29-3.30; P < .001), and ZCTAs with ≥20% poverty (aOR, 1.76; 95% CI, 1.14-2.72; P = .011). At 1-year follow-up, 40.6% (302 of 743) of patients with no-shows had not completed screening mammogram. DISCUSSION: Screening mammogram no-shows is a health equity issue in which socio-economically disadvantaged and racially and ethnically minoritized patients are more likely to experience missed appointments and continued delays in screening mammogram completion.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland.

BACKGROUND: Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease. OBJECTIVE: Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes. DESIGN: Observational cohort study. PARTICIPANTS: One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021. INTERVENTIONS: Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support). MAIN MEASURES: Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations). KEY RESULTS: Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months. CONCLUSIONS: CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Impact of a Same-Day Breast Biopsy Program on Disparities in Time to Biopsy for Patients With Serious Mental Illness.

PURPOSE: The aim of this study was to investigate disparities in time between breast biopsy recommendation and completion and the impact of a same-day biopsy (SDB) program for patients with serious mental illness (SMI), with a focus on more vulnerable individuals with public payer insurance. METHODS: In August 2017, the authors' academic breast imaging center started routinely offering needle biopsies on the day of recommendation. Primary outcomes were the proportion of biopsies performed as SDBs and days from biopsy recommendation to completion over a 2.5-year pre- versus postintervention period, comparing all patients with SMI versus those without, and public payer-insured patients <65 years of age with SMI (SMI-PP) versus without SMI (non-SMI-PP). Multivariable proportional odds and logistic regression models were fit to assess association of SMI status, age, race/ethnicity, language, and insurance with days to biopsy and SDB within each period. RESULTS: There were 2,026 biopsies preintervention and 2,361 biopsies postintervention. Preintervention, 8.43% of patients with SMI (7 of 83) underwent SDB compared with 15.59% of those without SMI (303 of 1,943) (P = .076), and 2.7% of the SMI-PP subgroup (1 of 37) underwent SDB compared with 15.88% of the non-SMI-PP subgroup (47 of 296) (P = .031). Adjusted for age, race/ethnicity, and language, disparities persisted in odds for undergoing SDB (adjusted odds ratio, 0.13; 95% confidence interval, 0.02-0.92; P = .04) and having longer days to biopsy (adjusted odds ratio, 2.35; 95% confidence interval, 1.26-4.37; P = .01) for the SMI-PP subgroup compared with the non-SMI-PP subgroup in the preintervention period. There was no evidence of these disparities postintervention for the SMI-PP subgroup. SDB proportion increased from 15.3% (310 of 2,026) to 36.09% (852 of 2,361) (P < .001) across all patients. CONCLUSIONS: A same-day breast biopsy program mitigates disparities in time to biopsy for patients with SMI and helps improve breast cancer care equity for this vulnerable population.

Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic.

BACKGROUND. The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE. The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS. A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.10-0.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.50-1.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION. Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT. An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care.

Screening Mammography Recovery After COVID-19 Pandemic Facility Closures: Associations of Facility Access and Racial and Ethnic Screening Disparities.

BACKGROUND. Screening mammography facilities closed during the COVID-19 pandemic in spring 2020. Recovery of screening volumes has varied across patient subgroups and facilities. OBJECTIVE. We compared screening mammography volumes and patient and facility characteristics between periods before COVID-19 and early and later postclosure recovery periods. METHODS. This retrospective study included screening mammograms performed in the same 2-month period (May 26-July 26) in 2019 (pre-COVID-19), 2020 (early recovery), and 2021 (late recovery after targeted interventions to expand access) and across multiple facility types (urban, suburban, community health center). Suburban sites had highest proportion of White patients and the greatest scheduling flexibility and expanded appointments during initial reopening. Findings were compared across years. RESULTS. For White patients, volumes decreased 36.6% from 6550 in 2019 (4384 in 2020) and then increased 61.0% to 6579 in 2021; for patients with races other than White, volumes decreased 53.9% from 1321 in 2019 (609 in 2020) and then increased 136.8% to 1442 in 2021. The percentage of mammograms in patients with races other than White was 16.8% in 2019, 12.2% in 2020, and 18.0% in 2021. The proportion performed at the urban center was 55.3% in 2019, 42.2% in 2020, and 45.9% in 2021; the proportion at suburban sites was 34.0% in 2019, 49.2% in 2020, and 43.5% in 2021. Pre-COVID-19 volumes were reached by the sixth week after reopening for suburban sites but were not reached during early recovery for the other sites. The proportion that were performed on Saturday for suburban sites was similar across periods, whereas the proportion performed on Saturday for the urban site was 7.6% in 2019, 5.3% in 2020, and 8.8% in 2021; the community health center did not offer Saturday appointments during recovery. CONCLUSION. After reopening, screening shifted from urban to suburban settings, with a disproportionate screening decrease in patients with races other than White. Initial delayed access at facilities serving underserved populations exacerbated disparities. Interventions to expand access resulted in late recovery volumes exceeding prepandemic volumes in patients with races other than White. CLINICAL IMPACT. Interventions to support equitable access across facilities serving diverse patient populations may mitigate potential widening disparities in breast cancer diagnosis during the pandemic.

Patient Sociodemographic Characteristics Associated With Saturday Breast Imaging Clinic Utilization.

OBJECTIVE: To determine patient sociodemographic characteristics associated with breast imaging utilization on Saturdays to inform potential initiatives designed to improve access and reduce disparities in breast cancer care. METHODS: This was an IRB-approved retrospective cross-sectional study. All adult women (aged ≥18 years) who received a screening or diagnostic examination at our breast imaging facility from January 1, 2016 to December 31, 2017 were included. Patient characteristics including age, race, primary language, partnership status, insurance status, and primary care physician status were collected using the electronic medical record. Multiple variable logistic regression analyses were performed to evaluate patient characteristics associated with utilization. RESULTS: Of 53 695 patients who underwent a screening examination and 10 363 patients who underwent a diagnostic examination over our study period, 9.6% (5135/53 695) and 2.0% (209/10 363) of patients obtained their respective examination on a Saturday. In our multiple variable logistic regression analyses, racial/ethnic minorities (odds ratio [OR], 1.5; 95% confidence interval [CI]: 1.4-1.6; P < 0.01) and women who speak English as a second language (OR, 1.1; 95% CI: 1.0-1.3; P = 0.03) were more likely to obtain their screening mammogram on Saturday than their respective counterparts. CONCLUSION: Racial/ethnic minorities and women who speak English as a second language were more likely to obtain their screening mammogram on Saturdays than their respective counterparts. Initiatives to extend availability of breast imaging exams outside of standard business hours increases access for historically underserved groups, which can be used as a tool to reduce breast cancer-related disparities in care.

Guideline-Discordant Lung Cancer Screening: Emerging Demand and Provided Indications.

PURPOSE: It is unclear whether patients and providers have started to knowingly request lung cancer screening (LCS) outside US guidelines and insurance coverage for risk factors besides a history of heavy smoking. The authors analyzed their institution's best practices advisory (BPA) clinical decision support system to determine whether providers knowingly order guideline-discordant LCS and the indications given. METHODS: CT examinations ordered for LCS at an academic medical center that triggered BPA alerts from November 2018 to December 2019 were reviewed. Alerts were triggered by attempts to order examinations outside Medicare coverage, which resembles most US guidelines. Providers can override alerts to order the examinations. Primary outcomes were the number of examinations performed using orders with overridden BPA alerts and indications given. Qualitative exploratory and directed content analyses identified motivators and decision-making processes that drove guideline-discordant screening use. RESULTS: Forty-two patients underwent guideline-discordant LCS, constituting 1.9% of all patients screened (42 of 2,248): 42.9% (18 of 42) were <54 or >77 years old, 14.3% (6 of 42) had never smoked, 40.5% (17 of 42) had quit >15 years earlier, and 31% (13 of 42) had smoked <30 pack-years; 45.2% (19 of 42) fell outside all US guidelines. The most common indication was a family history of lung cancer (21.4% [9 of 42]). Perceptions of elevated cancer risk from both patients and referring providers drove guideline-discordant screening use. CONCLUSIONS: Referring providers knowingly ordered screening CT examinations outside Medicare coverage and US guidelines, including for never smokers, for indications including a family history of lung cancer. LCS programs may need tailored strategies to guide these patients and providers, such as help with cancer risk assessment.

Factors affecting patient adherence to lung cancer screening: A multisite analysis.

OBJECTIVE: To identify factors associated with delayed adherence to follow-up in lung cancer screening. METHODS: Utilizing a data warehouse and lung cancer screening registry, variables were collected from a referred sample of 3110 unique participants with follow-up CT during the study period (1 January 2016 to 17 October 2018). Adherence was defined as undergoing chest CT within 90 days and 30 days of the recommended time for follow-up and was determined using proportions and multiple variable logistic regression models across the American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS®) categories. RESULTS: Of 1954 lung cancer screening participants (51.9% (1014/1954) males, 48.1% (940/1954) female; mean age 65.7 (range 45-87), smoking history median 40 pack-years, 60.2% and 44.5% did not follow-up within 30 and 90 days, respectively. Participants receiving Lung-RADS® category 1 or 2 presented later than those with Lung-RADS® category 3 at 90 days (coefficient -27.24, 95% CI -51.31, -3.16, p = 0.027). Participants with Lung-RADS® category 1 presented later than those with Lung-RADS® category 2 at both 90- and 30-days past due (OR 0.76 95% CI [0.59-0.97], p = 0.029 and OR 0.63 95% CI [0.48-0.83], p = 0.001, respectively). CONCLUSIONS: Adherence to follow-up was higher among participants receiving more suspicious Lung-RADS® results at index screening CT and among those who had undergone more non-lung cancer screening imaging examinations prior to index lung cancer screening CT. These observations may inform strategies aimed at prospectively identifying participants at risk for delayed or nonadherence to prevent potential morbidity and mortality from incident lung cancers.

Opportunities for Radiology Trainee Education Amid the COVID-19 Pandemic: Lessons From an Academic Breast Imaging Program.

The COVID-19 pandemic required restructuring of Radiology trainee education across US institutions. While reduced clinical imaging volume and mandates to maintain physical distancing presented new challenges to traditional medical education during this period, new opportunities developed to support our division in providing high-quality training for residents and fellows. The Accreditation Council for Graduate Medical Education (ACGME) Core Competencies for Diagnostic Radiology helped guide division leadership in restructuring and reframing breast imaging education during this time of drastic change and persistent uncertainty. Here, we reflect on the educational challenges and opportunities faced by our academic breast imaging division during the height of the COVID-19 pandemic across each of the ACGME Core Competencies. We also discuss how systems and processes developed out of necessity during the first peak of the pandemic may continue to support radiology training during phased reopening and beyond.

Pediatric accountable health communities: Insights on needed capabilities and potential solutions.

BACKGROUND: Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs. METHODS: We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019. RESULTS: To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility. CONCLUSIONS: Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing. IMPLICATIONS: Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models. LEVEL OF EVIDENCE: Level V.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits.

PURPOSE: The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening. METHODS: In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses. RESULTS: Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001). CONCLUSIONS: The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

Screening Mammography Visits as Opportunities to Engage Smokers With Tobacco Cessation Services and Lung Cancer Screening.

OBJECTIVE: Tobacco use is the leading cause of preventable mortality in the United States. Screening mammography (SM) visits present opportunities for radiology practices to reduce tobacco-related morbidity and mortality. Our study evaluates implementation of a program that provides tobacco cessation service referrals and screens for lung cancer screening (LCS) eligibility among smokers presenting for SM at a community health center. METHODS: In 2018, two sets of questions were added to our SM patient intake questionnaire to assess (1) smoking history and (2) interest in referral to the health center-based tobacco cessation program for mailed information, telephone-based consultation, and in-person counseling. Primary outcomes were proportion of current smokers who requested a referral and of all smokers who were LCS-eligible. Bivariate logistic regression analyses compared sociodemographic characteristics of smokers who requested versus declined a referral. RESULTS: Of the 89.3% (1,907 of 2,136) who responded, 10.5% (201 of 1,907) were current and 29.1% (555 of 1,907) were former smokers. Of current smokers, 26.4% (53 of 201) requested referrals: mailed information by 23.9% (48 of 201), in-person counseling by 9% (18 of 201), and telephone-based consultation by 7.5% (15 of 201). No sociodemographic predictors for referral requests were identified. Of all smokers, 9.3% (70 of 756) were eligible for LCS, of which 31.4% (22 of 70) were up to date. CONCLUSION: One in ten women who underwent SM at our community health center were current smokers, of which one-quarter requested tobacco cessation referrals. Among LCS-eligible smokers, one-third were up to date. SM presents opportunities for radiology practices to advance population health goals such as tobacco cessation and LCS.

Medicaid and CHIP Child Health Beneficiary Incentives: Program Landscape and Stakeholder Insights.

OBJECTIVES: To describe the landscape of Medicaid and the Children's Health Insurance Program beneficiary incentive programs for child health and garner key stakeholder insights on incentive program rationale, child and family engagement, and program evaluation. METHODS: We identified beneficiary health incentive programs from 2005 to 2018 through a search of peer-reviewed and publicly available documents and through semistructured interviews with 80 key stakeholders (Medicaid and managed-care leadership, program evaluators, patient advocates, etc). This study highlights insights from 23 of these stakeholders with expertise on programs targeting child health (<18 years old) to understand program rationale, beneficiary engagement, and program evaluation. RESULTS: We identified 82 child health-targeted beneficiary incentive programs in Medicaid and the Children's Health Insurance Program. Programs most commonly incentivized well-child checks (n = 77), preventive screenings (n = 30), and chronic disease management (n = 30). All programs included financial incentives (eg, gift cards, premium incentives); some also offered incentive material prizes (n = 12; eg, car seats). Loss-framed incentives were uncommon (n = 1; eg, lost benefits) and strongly discouraged by stakeholders. Stakeholders suggested family engagement strategies including multigenerational incentives or incentives addressing social determinants of health. Regarding evaluation, stakeholders suggested incentivizing evidence-based preventive services (eg, vaccinations) rather than well-child check attendance, and considering proximal measures of child well-being (eg, school functioning). CONCLUSIONS: As the landscape of beneficiary incentive programs for child health evolves, policy makers have unique opportunities to leverage intergenerational and social approaches for family engagement and to more effectively increase and evaluate programs' impact.

Assessing Eligibility for Lung Cancer Screening Among Women Undergoing Screening Mammography: Cross-Sectional Survey Results From the National Health Interview Survey.

PURPOSE: Millions of women undergo mammography screening each year, presenting an opportunity for radiologists to identify women eligible for lung cancer screening (LCS) with low-dose chest CT and smoking cessation counseling. The purpose of our study was to estimate the proportion of women eligible for LCS and tobacco cessation counseling among women reporting mammography screening within the previous 2 years using nationally representative cross-sectional survey data. METHODS: Women between the ages of 55 and 74 years in the 2015 National Health Interview Survey without history of lung or breast cancer who reported mammography use in the previous 2 years were included. The primary outcome was the weighted proportion of women eligible for LCS. Secondary outcomes included self-reported receipt of LCS and current smoking. Bivariate and multiple variable logistic regression analyses were performed to evaluate the association between primary and secondary outcomes and sociodemographics, accounting for complex survey design elements. RESULTS: Among 3,806 women meeting inclusion criteria, 7.1% were eligible for LCS and 9.8% were current smokers. Multivariable analyses demonstrated that LCS-eligible women were more likely to be white, younger, and non-college-educated and have lower household incomes (all P < .001). Among all LCS-eligible women, 58% reported undergoing mammography screening within the previous 2 years. Among LCS-eligible women who underwent screening mammography, 7.9% reported undergoing LCS. CONCLUSIONS: The majority of LCS-eligible women received mammography screening but did not receive LCS. Mammography encounters may represent prime opportunities to increase LCS participation among patients already receiving imaging-based screening services.

Trends in Hospital Performance on the Medicare National Outpatient Imaging Metrics: A 5-Year Longitudinal Cohort Analysis.

PURPOSE: Medicare established its Hospital Outpatient Quality Reporting Program (HOQRP) to promote and incentivize quality care and appropriate utilization in the hospital outpatient setting. The program includes "imaging efficiency" metrics evaluating appropriate utilization of imaging examinations. Our purpose was to evaluate the longitudinal performance of the nation's hospitals on the HOQPR's imaging efficiency metrics. METHODS: Data were obtained from CMS Hospital Compare for hospitals participating in the Medicare HOQRP during both initial (January 1, 2011, to December 31, 2011) and follow-up (July 1, 2015, to June 30, 2016) periods. The six reported imaging efficiency metrics were: MRI lumbar spine for low back pain, mammography follow-up rates, abdomen and chest CT double scans (imaging with and without intravenous contrast), cardiac imaging for preoperative risk assessment for low-risk surgery, and simultaneous use of brain and sinus CT. Differences in imaging efficiency metrics were calculated using fixed effects linear regression models. RESULTS: Baseline and follow-up data were available for 3,960 hospitals. Median changes were MRI lumbar spine for low back pain: +3.6% (range: -27.9% to +31.4%; P < .001); mammography follow-up: -0.3% (range: -69.5% to +62.6%; P = .03); double scan abdomen CT: -1.9% (range: -73.5% to +32.3%; P < .001); double scan chest CT: -0.4% (range: -73.2% to +28.0%; P < .001); preoperative cardiac imaging: -0.7% (range: -10.0% to +9.9%; P < .001); simultaneous brain and sinus CT: -0.9% (range: -11.8% to +7.8%; P < .001). CONCLUSION: Medicare's nationwide hospital outpatient imaging efficiency reporting initiative was associating with worse performance in lumbar spine MRI utilization and small improvements in double CT scans. Because quality metrics are increasingly imposed on health care providers, health service researchers will need to rigorously evaluate their effectiveness before and during early implementation.

Barriers to Lung Cancer Screening Engagement from the Patient and Provider Perspective.

Lung cancer remains the leading cause of cancer mortality in the United States. Lung cancer screening (LCS) with low-dose CT reduces mortality among high-risk current and former smokers and has been covered by public and private insurers without cost sharing since 2015. Patients and referring providers confront numerous barriers to participation in screening. To best serve in multidisciplinary efforts to expand LCS nationwide, radiologists must be knowledgeable of these challenges. A better understanding of the difficulties confronted by other stakeholders will help radiologists continue to collaboratively guide the growth of LCS programs in their communities. This article reviews barriers to participation in LCS for patients and referring providers, as well as possible solutions and interventions currently underway.

ΔNp63 Inhibits Oxidative Stress-Induced Cell Death, Including Ferroptosis, and Cooperates with the BCL-2 Family to Promote Clonogenic Survival.

The BCL-2 family proteins are central regulators of apoptosis. However, cells deficient for BAX and BAK or overexpressing BCL-2 still succumb to oxidative stress upon DNA damage or matrix detachment. Here, we show that ΔNp63α overexpression protects cells from oxidative stress induced by oxidants, DNA damage, anoikis, or ferroptosis-inducing agents. Conversely, ΔNp63α deficiency increases oxidative stress. Mechanistically, ΔNp63α orchestrates redox homeostasis through transcriptional control of glutathione biogenesis, utilization, and regeneration. Analysis of a lung squamous cell carcinoma dataset from The Cancer Genome Atlas (TCGA) reveals that TP63 amplification/overexpression upregulates the glutathione metabolism pathway in primary human tumors. Strikingly, overexpression of ΔNp63α promotes clonogenic survival of p53-/-Bax-/-Bak-/- cells against DNA damage. Furthermore, co-expression of BCL-2 and ΔNp63α confers clonogenic survival against matrix detachment, disrupts the luminal clearance of mammary acini, and promotes cancer metastasis. Our findings highlight the need for a simultaneous blockade of apoptosis and oxidative stress to promote long-term cellular well-being.