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Background Breast cancer in the U.S. - estimated at 232,670 incident cases in 2014 - has the highest aggregate economic burden of care relative to other female cancers. Yet, the amount of cost attributed to diagnostic/preoperative work up has not been characterized. We examined the costs of imaging and biopsy among women enrolled in Medicare who did and did not receive diagnostic/preoperative Magnetic Resonance Imaging (MRI). Methods Using Surveillance, Epidemiology and End Results (SEER)- Medicare data, we compared the per capita costs (PCC) based on amount paid, between diagnosis date and primary surgical treatment for a breast cancer diagnosis (2005–2009) with and without diagnostic/preoperative MRI. We compared the groups with and without MRI using multivariable models, adjusting for woman and tumor characteristics. Results Of the 53,653 women in the cohort, within the diagnostic/preoperative window, 20 % ( N  = 10,776) received diagnostic/preoperative MRI. Total unadjusted median costs were almost double for women with MRI vs. without ($2,251 vs. $1,152). Adjusted costs were higher among women receiving MRI, with significant differences in total costs ($1,065), imaging costs ($928), and biopsies costs ($138). Conclusion Costs of diagnostic/preoperative workups among women with MRI are higher than those without. Using these cost estimates in comparative effectiveness models should be considered when assessing the benefits and harms of diagnostic/preoperative MRI.

PURPOSE:We compared the frequency and sequence of breast imaging and biopsy use for the diagnostic and preoperative workup of breast cancer according to breast magnetic resonance imaging (MRI) use among older women. MATERIALS AND METHODS:Using SEER-Medicare data from 2004 to 2010, we identified women with and without breast MRI as part of their diagnostic and preoperative breast cancer workup and measured the number and sequence of breast imaging and biopsy events per woman. RESULTS:A total of 10,766 (20%) women had an MRI in the diagnostic/preoperative period, 32,178 (60%) had mammogram and ultrasound, and 10,669 (20%) had mammography alone. MRI use increased across study years, tripling from 2005 to 2009 (9%–29%). Women with MRI had higher rates of breast imaging and biopsy compared with those with mammogram and ultrasound or those with mammography alone (5.8 vs. 4.1 vs. 2.8, respectively). There were 4254 unique sequences of breast events; the dominant patterns for women with MRI were an MRI occurring at the end of the care pathway. Among women receiving an MRI postdiagnosis, 26% had a subsequent biopsy compared with 51% receiving a subsequent biopsy in the subgroup without MRI. CONCLUSIONS:Older women who receive breast MRI undergo additional breast imaging and biopsy events. There is much variability in the diagnostic/preoperative work-up in older women, demonstrating the opportunity to increase standardization to optimize care for all women.

Preoperative magnetic resonance imaging (MRI) use has increased among older women diagnosed with breast cancer. MRI detects additional malignancy, but its impact on locoregional surgery and radiation treatment remains unclear. We examined the associations of preoperative MRI with initial locoregional treatment type (mastectomy, breast conserving surgery [BCS] with radiation therapy [RT], and BCS without RT) and BCS reoperation rates for Surveillance, Epidemiology, and End Results Medicare women diagnosed with stages 0 to III breast cancer from 2005 to 2009 (n = 55,997). We found no association of initial locoregional treatment of mastectomy (odds ratios [OR], 1.04; 95% confidence intervals, .98 to 1.11) or reoperation after initial BCS (OR, .96; 95% confidence intervals, .89 to 1.03) between women with preoperative MRI (16.2%) compared to women without MRI. However, women with MRI who had initial BCS were more likely to undergo RT (OR, 1.09 [1.02 to 1.16]). Preoperative breast MRI in Medicare-enrolled women with stages 0 to III breast cancer was not associated with increased mastectomy. However, in older women with MRI undergoing BCS, there was a greater use of RT. •Preoperative MRI in women stage 0-III breast cancer does not increase mastectomy.•There was a greater use of radiation therapy in older women with MRI undergoing BCS.•Results mitigate concerns about unnecessary MRI-associated mastectomies.

Our study aimed to determine, for patients who had undergone recent colonoscopy, associations between specific colonoscopy patient characteristics, exam characteristics and patients’ perception of colonoscopy reducing their risk of dying from colorectal cancer. A cross-sectional analysis was conducted using data (2004–2008) from the New Hampshire Colonoscopy Registry, consisting of a Self-report Questionnaire, Colonoscopy Report form, and a Follow-up Questionnaire, which measured agreement responses to the statement, “Having a colonoscopy decreased my chances of dying from colon cancer”. Chi-square tests and logistic regression were used to assess differences in patient responses by patient and colonoscopy characteristics. A majority of patients ( N  = 5,672, 81%) agreed that having a colonoscopy decreased their chances of dying from colon cancer. Patients with a personal history of polyps were more likely to agree that colonoscopy reduced their chances of dying compared to patients without prior polypectomy [OR (95% CI) = 1.34 (1.06, 1.69)] and patients with a family history of colorectal cancer were 33% more likely to agree to the statement than those without a family history [OR (95% CI) = 1.33 (1.12, 1.58)]. Personal history of polyps and family history of colorectal cancer are significant predictors of patients’ positive perception of colonoscopy, suggesting that personal experience, rather than the potential preventive effect of colonoscopy itself, may influence the perceived benefit of colonoscopy. Intervention efforts should be made to effectively disseminate knowledge of the preventive benefit of colonoscopy.

Background. Patterns of surveillance among breast cancer survivors are not well characterized and lack evidence-based practice guidelines, particularly for imaging modalities other than mammography. We characterized breast imaging and related biopsy longitudinally among breast cancer survivors in relation to women's characteristics. Methods. Using data from a state-wide (New Hampshire) breast cancer screening registry linked to Medicare claims, we examined use of mammography, ultrasound (US), magnetic resonance imaging (MRI), and biopsy among breast cancer survivors. We used generalized estimating equations (GEE) to model associations of breast surveillance with women's characteristics. Results. The proportion of women with mammography was high over the follow-up period (81.5% at 78 months), but use of US or MRI was much lower (8.0%--first follow-up window, 4.7% by 78 months). Biopsy use was consistent throughout surveillance periods (7.4%-9.4%). Surveillance was lower among older women and for those with a higher stage of diagnosis. Primary therapy was significantly associated with greater likelihood of breast surveillance. Conclusions. Breast cancer surveillance patterns for mammography, US, MRI, and related biopsy seem to be associated with age, stage, and treatment, but need a larger evidence-base for clinical recommendations.

Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopist's withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection. We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection. Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8-9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase. A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Objective To examine the association between breast density and risk of breast ductal carcinoma in situ (DCIS). Methods We assessed breast density in relation to DCIS risk using combined data from statewide mammography registries in NH and VT. The prospective analyses were based on 572 DCIS cases arising in 154,936 women (58,496 premenopausal and 96,440 postmenopausal). Women in the study were followed on average 4.1 years. Breast density was scored by community radiologists using BIRADS categories (fatty, scattered density, heterogeneous density, extreme density). Results In premenopausal women, based on 157 cases, the RR for DCIS risk were 0.29 (95% CI: 0.0.04, 2.24) for fatty breasts, 2.06 (95% CI: 1.39, 3.05) for heterogeneous density, and 2.40 (95% CI: 1.47, 3.91) for extreme density, relative to scattered density. In postmenopausal women, based on 369 cases, the RR for DCIS risk were 0.58 (95% CI: 0.37, 0.93) for fatty breasts, 1.41 (95% CI: 1.12, 1.78) for heterogeneous density, and 1.49 (95% CI: 0.93, 2.37) for extreme density, relative to scattered density. The possible interaction between breast density and menopausal status in relation to DCIS risk was not statistically significant. Conclusions We observed an association between breast density and DCIS risk. Although the association seemed stronger in premenopausal women, there was no evidence of an interaction involving breast density and menopausal status.

Background: Interventions to improve adherence to regular mammography screening have had conflicting results. Many studies have depended on women's self-report rather than clinical evidence of a mammography encounter. Methods: We tested the impact of two interventions on a population-based sample of NH women who were not receiving routine mammography to determine if adherence to screening could be improved. The interventions included a mailing of women's health information and a telephone counseling intervention based on the Transtheoretical Model. Participant eligibility and outcome measures were based on clinical events obtained from a population-based mammography registry. Results: Two hundred and fifty eight women completed all aspects of the intervention study. The women were randomly assigned to one of two study groups: 51% received the mail intervention and 49% received the telephone intervention. Among women who received the telephone counseling intervention, 67% percent reported being in either an action or maintenance stage at Call 1, which increased to 84% at Call 2 (p<0.001). Seventy-six percent of women identified barriers to screening mammography at Call 1, which decreased to 44% at Call 2 (p<0.01). The most frequently identified barrier was confusion over the guidelines for screening mammography. At the first assessment time interval, greater than 60% of women were up-to-date for screening mammography in the group that received telephone counseling versus 48% in the group that received health information by mail (p = 0.04). However, women's status as up-to-date fell for both groups between the first and second assessment time intervals. Conclusions: Tailored telephone counseling based on the Transtheoretical Model can improve adherence to screening mammography, though the duration of this effect is in question.

OBJECTIVES: The reported prevalence of occupational allergy to natural rubber latex is 8% to 17%, and that of latex-induced occupational asthma is 2.5% to 6%. Conversion of medical facilities to \"latex-safe\" can reduce employee sensitization, impairment, and disability. The purpose of this study was to determine the cost of a latex-safe approach, compared with that of continued latex glove use, and to identify the level of worker disability required to make the latex-safe approach financially preferable to a health care institution. METHODS: The costs of 2 strategies--latex-safe vs the status quo--were calculated from the perspective of 3 health care institutions. A break-even point was calculated for each facility. RESULTS: In all facilities, the cost of using nonlatex gloves exceeded the cost of using latex gloves. In all 3 facilities, however, 1% or fewer of those at risk would have to become fully disabled or fewer than 2% would have to become partially disabled for the continued use of latex gloves to exceed the cost of the latex-safe approach. CONCLUSION: Health care facilities, regardless of size, are likely to benefit financially from becoming latex-safe even if latex-related disability levels are extremely low.

BackgroundUse of breast cancer screening is influenced by factors associated with patients, primary care providers, practices, and health systems.ObjectiveWe examined the relative effects of these nested levels on four breast cancer screening metrics.DesignA web-based survey was completed at 15 primary care practices within two health systems representing 306 primary care providers (PCPs) serving 46,944 women with a primary care visit between 1/2011–9/2014. Analyses occurred between 1/2017 and 5/2017.Main MeasuresAcross four nested levels (patient, PCP, primary care practice, and health system), frequency distributions and adjusted rates of primary care practice characteristics and survey results for four breast screening metrics (percent screened overall, and percent screened age 40–49, 50–74, and 75+) were reported. We used hierarchical multi-level mixed and random effects analysis to assess the relative influences of PCP, primary care practice, and health system on the breast screening metrics.Key ResultsOverall, the proportion of women undergoing breast cancer screening was 73.1% (73.4% for ages 40–49, 76.5% for 50–74, and 51.1% for 75+). Patient ethnicity and number of primary care visits were strongly associated with screening rates. After adjusting for woman-level factors, 24% of the overall variation among PCPs was attributable to the primary care practice level, 35% to the health system level, and 41% to the residual variation among PCPs within practice. No specific provider-level characteristics were found to be statistically significant determinants of screening rates.ConclusionsAfter accounting for woman-level characteristics, the remaining variation in breast cancer screening was largely due to provider and health system variation.