The Use of High-Risk Criteria in Screening Patients for Blunt Cerebrovascular Injury: A Survey

RATIONALE AND OBJECTIVES

Blunt cerebrovascular injury (BCVI) is uncommon, but delayed detection can have disastrous consequences. The Denver criteria are the most commonly used screening criteria. We aim to examine the utilization of screening criteria in the emergency department (ED) of our institution and assess whether patients with risk factors were imaged.

MATERIALS AND METHODS

A survey questionnaire was sent out to radiologists in a large academic institution. A search was performed in the database on the use of CT angiography (CTA) and MR angiography (MRA) among patients with risk factors in the last 11 years.

RESULTS

The survey was sent to 173 radiologists, with 41 responses (35 complete). Most of the physicians (30 out of 35) surveyed selected CTA as their preferred modality to screen for BCVI, whereas the remaining physicians selected MRA. None of the respondents reported routine use of Denver screening criteria or grading scale in their readouts. Only five respondents selected risk factors in the Denver criteria correctly. In the institution search, among the 1331 patients with blunt trauma and risk factors for BCVI, 537 underwent at least one angiographic study (40.3%). There was an increase in the screening rate after February 2010 in all risk factors, but only statistically significant among patients with foramen transversarium fractures and C1-C3 fractures.

CONCLUSIONS

Both the Denver screening criteria and grading scale of vascular injury have been underutilized in the ED for patients with risk factors. Greater awareness and utilization of imaging can potentially result in decreased incidence of subsequent stroke in patients with blunt injury.

Abstract P3-10-03: Socioeconomic disparities in needle biopsy prior to breast cancer surgery across physician referral networks

Introduction

Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks.

Methods

We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups.

Results

In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p<.001). The majority of the variance (59%) in NB use was at the patient level, 22% was at the surgeon level, and 13.7% at the peer group level. The use of NB varied substantially across peer groups, with a median of 69% (interquartile range [51%, 84%]). Even after accounting for physician, peer group, and HRR variation, patients in the lowest stratum of SES were significantly less likely to have received NB compared to all other patient (OR = 0.88; p=.04). Finally, we found that the association between SES and NB varied significantly across referral networks (P<0.05)

Conclusions

Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks.Introduction

Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks.

Methods

We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups.

Results

In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p<.001). The majority of the variance (59%) in NB use was at the patient level, 22% was at the surgeon level, and 13.7% at the peer group level. The use of NB varied substantially across peer groups, with a median of 69% (interquartile range [51%, 84%]). Even after accounting for physician, peer group, and HRR variation, patients in the lowest stratum of SES were significantly less likely to have received NB compared to all other patient (OR = 0.88; p=.04). Finally, we found that the association between SES and NB varied significantly across referral networks (P<0.05)

Conclusions

Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks.

Citation Format: Killelea BK, Herrin J, Soulos PR, Pollack CE, Forman HP, Yu J, Xu X, Tannenbaum S, Wang S, Gross CP. Socioeconomic disparities in needle biopsy prior to breast cancer surgery across physician referral networks [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-03.

Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis

OBJECTIVES

To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance.

METHODS

We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported.

RESULTS

Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable.

CONCLUSIONS

There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study.

KEY POINTS

• There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.

Tomosynthesis in the Diagnostic Setting: Changing Rates of BI-RADS Final Assessment over Time

Purpose To evaluate the effect of tomosynthesis in diagnostic mammography on the Breast Imaging Reporting and Data System (BI-RADS) final assessment categories over time. Materials and Methods This retrospective study was approved by the institutional review board. The authors reviewed all diagnostic mammograms obtained during a 12-month interval before (two-dimensional [2D] mammography [June 2, 2010, to June 1, 2011]) and for 3 consecutive years after (tomosynthesis year 1 [2012], tomosynthesis year 2 [2013], and tomosynthesis year 3 [2014]) the implementation of tomosynthesis. The requirement to obtain informed consent was waived. The rates of BI-RADS final assessment categories 1-5 were compared between the 2D and tomosynthesis groups. The positive predictive values after biopsy (PPV3) for BI-RADS category 4 and 5 cases were compared. The mammographic features (masses, architectural distortions, calcifications, focal asymmetries) of lesions categorized as probably benign (BI-RADS category 3) and those for which biopsy was recommended (BI-RADS category 4 or 5) were reviewed. The χ(2) test was used to compare the rates of BI-RADS final assessment categories 1-5 between the two groups, and multivariate logistic regression analysis was performed to compare all diagnostic studies categorized as BI-RADS 3-5. Results There was an increase in the percentage of cases reported as negative or benign (BI-RADS category 1 or 2) with tomosynthesis (58.7% with 2D mammography vs 75.8% with tomosynthesis at year 3, P < .0001). A reduction in the percentage of probably benign (BI-RADS category 3) final assessments also occurred (33.3% with 2D mammography vs 16.4% with tomosynthesis at year 3, P < .0001). Although the rates of BI-RADS 4 or 5 assessments did not change significantly with tomosynthesis (8.0% with 2D mammography vs 7.8% with tomosynthesis at year 3, P = .2), there was a significant increase in the PPV3 (29.6% vs 50%, respectively; P < .0001). These trends increased during the 3 years of tomosynthesis use. Conclusion Tomosynthesis in the diagnostic setting resulted in progressive shifts in the BI-RADS final assessment categories over time, with a significant increase in the proportion of studies classified as normal, a continued decrease in the rate of studies categorized as probably benign, and improved diagnostic confidence in biopsy recommendations. (©) RSNA, 2016.

Cost-effectiveness Analysis of Follow-up Strategies for Thunderclap Headache Patients With Negative Noncontrast CT

OBJECTIVES

Accurate diagnosis of acute subarachnoid hemorrhage (SAH) is critical in thunderclap headache patients due to high morbidity and mortality associated with missed aneurysmal bleeds. The objective of this study was to determine the utility of computed tomography angiography (CTA) in managing patients with acute, severe headaches and negative noncontrast CT and assess the cost-effectiveness of three different screening strategies-no follow up, CTA, and lumbar puncture (LP).

METHODS

A modeling-based economic evaluation was performed with a time horizon of 1 year for thunderclap headache patients in the emergency department with negative noncontrast CT for SAH. Sensitivity analyses were performed to determine the effect of sensitivity of CT and the prevalence of SAH on cost-effectiveness.

RESULTS

Lumbar puncture follow-up has the lowest cost and the highest utility in the mathematical model. The Monte Carlo simulation shows noncontrast CT with LP follow-up to be the most cost-effective strategy in 85.3% of all cases even at a $1 million/quality-adjusted life-years willingness-to-pay. Sensitivity analyses demonstrate that LP follow-up should be performed, except for when CT sensitivity exceeds 99.2% and the SAH prevalence is below 3.2%, where no follow-up may be considered.

CONCLUSIONS

Although CTA is frequently used for evaluation of thunderclap headache patients, its utility is not clearly defined. LP follow-up is shown to be the most cost-effective strategy for evaluation of thunderclap headache patients in most clinical settings.

Evaluation for Blunt Cerebrovascular Injury: Review of the Literature and a Cost-Effectiveness Analysis

BACKGROUND AND PURPOSE

Evaluation for blunt cerebrovascular injury has generated immense controversy with wide variations in recommendations regarding the need for evaluation and the optimal imaging technique. We review the literature and determine the most cost-effective strategy for evaluating blunt cerebrovascular injury in trauma patients.

MATERIALS AND METHODS

A comprehensive literature review was performed with data extracted to create a decision-tree analysis for 5 different strategies: anticoagulation for high-risk (based on the Denver screening criteria) patients, selective DSA or CTA (only high-risk patients), and DSA or CTA for all trauma patients. The economic evaluation was based on a health care payer perspective during a 1-year horizon. Statistical analyses were performed. The cost-effectiveness was compared through 2 main indicators: the incremental cost-effectiveness ratio and net monetary benefit.

RESULTS

Selective anticoagulation in high-risk patients was shown to be the most cost-effective strategy, with the lowest cost and greatest effectiveness (an average cost of $21.08 and average quality-adjusted life year of 0.7231). Selective CTA has comparable utility and only a slightly higher cost (an average cost of $48.84 and average quality-adjusted life year of 0.7229). DSA, whether performed selectively or for all patients, was not optimal from both the cost and utility perspectives. Sensitivity analyses demonstrated these results to be robust for a wide range of parameter values.

CONCLUSIONS

Selective CTA in high-risk patients is the optimal and cost-effective imaging strategy. It remains the dominant strategy over DSA, even assuming a low CTA sensitivity and irrespective of the proportion of patients at high-risk and the incidence of blunt cerebrovascular injury in high-risk patients.

Innovating in Health Care Management Education: Development of an Accelerated MBA and MPH Degree Program at Yale

Increasingly, there is recognition of the need for individuals with expertise in both management and public health to help health care organizations deliver high-quality and cost-effective care.

The Yale School of Public Health and Yale School of Management began offering an accelerated Master of Business Administration (MBA) and Master of Public Health (MPH) joint degree program in the summer of 2014. This new program enables students to earn MBA and MPH degrees simultaneously from 2 fully accredited schools in 22 months. Students will graduate with the knowledge and skills needed to become innovative leaders of health care organizations.

We discuss the rationale for the program, the developmental process, the curriculum, benefits of the program, and potential challenges.

Cost-Effectiveness of Angiographic Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Background and Purpose—

The purpose of this study is to perform a comprehensive cost-effectiveness analysis of all possible permutations of computed tomographic angiography (CTA) and digital subtraction angiography imaging strategies for both initial diagnosis and follow-up imaging in patients with perimesencephalic subarachnoid hemorrhage on noncontrast CT.

Methods—

Each possible imaging strategy was evaluated in a decision tree created with TreeAge Pro Suite 2014, with parameters derived from a meta-analysis of 40 studies and literature values. Base case and sensitivity analyses were performed to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was conducted with distributional variables to evaluate the robustness of the optimal strategy.

Results—

The base case scenario showed performing initial CTA with no follow-up angiographic studies in patients with perimesencephalic subarachnoid hemorrhage to be the most cost-effective strategy ($5422/quality adjusted life year). Using a willingness-to-pay threshold of $50 000/quality adjusted life year, the most cost-effective strategy based on net monetary benefit is CTA with no follow-up when the sensitivity of initial CTA is >97.9%, and CTA with CTA follow-up otherwise. The Monte Carlo simulation reported CTA with no follow-up to be the optimal strategy at willingness-to-pay of $50 000 in 99.99% of the iterations. Digital subtraction angiography, whether at initial diagnosis or as part of follow-up imaging, is never the optimal strategy in our model.

Conclusions—

CTA without follow-up imaging is the optimal strategy for evaluation of patients with perimesencephalic subarachnoid hemorrhage when modern CT scanners and a strict definition of perimesencephalic subarachnoid hemorrhage are used. Digital subtraction angiography and follow-up imaging are not optimal as they carry complications and associated costs.

A survey of policies and procedures on the communication and documentation of radiologic interpretations

Research into emergency medicine (EM) diagnostic errors identified imaging as a contributing factor in 94% of cases. Discrepancies between the preliminary (trainee) and the final (attending) diagnostic imaging interpretation represent a system issue that is particularly prone to creating diagnostic errors. Understanding the types of systematic communication and documentation strategies developed by academic radiology departments to address differences between preliminary and final radiology interpretations to clinicians are threshold steps toward minimizing this risk. This study investigates policies and practices associated with the communication and documentation of preliminary and final radiologic interpretations among U.S. academic radiology departments through a questionnaire directed at radiology department chairs.

Rising use of CT in child visits to the emergency department in the United States, 1995-2008

PURPOSE

To describe nationwide trends and factors associated with the use of computed tomography (CT) in children visiting emergency departments (EDs) in the United States between 1995 and 2008.

MATERIALS AND METHODS

This study was exempt from institutional review board oversight. Data from the 1995-2008 National Hospital Ambulatory Medical Care Survey were used to evaluate the number and percentage of visits associated with CT for patients younger than 18 years. A mean of 7375 visits were sampled each year. Data were subcategorized according to multiple patient and hospital characteristics. The Rao-Scott χ(2) test was performed to determine whether CT use was similar across subpopulations.

RESULTS

From 1995 to 2008, the number of pediatric ED visits that included CT examination increased from 0.33 to 1.65 million, a fivefold increase, with a compound annual growth rate of 13.2%. The percentage of visits associated with CT increased from 1.2% to 5.9%, a 4.8-fold increase, with a compound annual growth rate of 12.8%. The number of visits associated with CT at pediatric-focused and non-pediatric-focused EDs increased from 14,895 and 316,133, respectively, in 1995 to 212,716 and 1,438,413, respectively, in 2008. By the end of the study period, top chief complaints among those undergoing CT included head injury, abdominal pain, and headache.

CONCLUSION

Use of CT in children who visit the ED has increased substantially and occurs primarily at non-pediatric-focused facilities. This underscores the need for special attention to this vulnerable population to ensure that imaging is appropriately ordered, performed, and interpreted.