Joshua J. Fenton

The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality

BACKGROUND Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined. METHODS We conducted a prospective cohort study of adult respondents (N = 51,946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36,428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years. RESULTS Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53). CONCLUSION In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

Determinants of Racial/Ethnic Colorectal Cancer Screening Disparities

BACKGROUND The contributions of demographic, socioeconomic, access, language, and nativity factors to racial/ethnic colorectal cancer (CRC) screening disparities are uncertain. METHODS Using linked data from 22 973 respondents to the 2001-2005 Medical Expenditure Panel Survey and the 2000-2004 National Health Interview Survey, we modeled disparities in CRC screening (fecal occult blood testing [FOBT], endoscopy, and combined FOBT and endoscopy) between non-Hispanic whites and Asians, blacks, and Hispanics, sequentially adjusting for demographics, socioeconomic status, clinical and access variables, and race/ethnicity-related variables (language spoken at home and nativity). RESULTS With demographic adjustment, minorities reported less CRC screening (all measures) than non-Hispanic whites. Disparities were largest for combined screening in Asians (adjusted odds ratio [AOR], 0.40; 95% confidence interval [CI], 0.32-0.49) and Hispanics (AOR, 0.43; 95% CI, 0.39-0.48) and for endoscopic screening in Asians (AOR, 0.41; 95% CI, 0.33-0.50) and Hispanics (AOR, 0.43; 95% CI, 0.38-0.48). With full adjustment, all Hispanic/non-Hispanic white disparities and black/non-Hispanic white FOBT disparities were eliminated, whereas Asian/non-Hispanic white disparities remained significant (FOBT: AOR, 0.72 [95% CI, 0.52-1.00]; endoscopic screening: AOR, 0.63 [95% CI, 0.49-0.81]; and combined screening: AOR, 0.66 [95% CI, 0.52-0.84]). CONCLUSIONS Determinants of racial/ethnic CRC screening disparities vary among minority groups, suggesting the need for different interventions to mitigate those disparities. Whereas socioeconomic, access, and language barriers seem to drive the CRC screening disparities experienced by blacks and Hispanics, additional factors may exacerbate the disparities experienced by Asians.

Effectiveness of Computer-Aided Detection in Community Mammography Practice

BACKGROUND Computer-aided detection (CAD) is applied during screening mammography for millions of US women annually, although it is uncertain whether CAD improves breast cancer detection when used by community radiologists. METHODS We investigated the association between CAD use during film-screen screening mammography and specificity, sensitivity, positive predictive value, cancer detection rates, and prognostic characteristics of breast cancers (stage, size, and node involvement). Records from 684 956 women who received more than 1.6 million film-screen mammograms at Breast Cancer Surveillance Consortium facilities in seven states in the United States from 1998 to 2006 were analyzed. We used random-effects logistic regression to estimate associations between CAD and specificity (true-negative examinations among women without breast cancer), sensitivity (true-positive examinations among women with breast cancer diagnosed within 1 year of mammography), and positive predictive value (breast cancer diagnosed after positive mammograms) while adjusting for mammography registry, patient age, time since previous mammography, breast density, use of hormone replacement therapy, and year of examination (1998-2002 vs 2003-2006). All statistical tests were two-sided. RESULTS Of 90 total facilities, 25 (27.8%) adopted CAD and used it for an average of 27.5 study months. In adjusted analyses, CAD use was associated with statistically significantly lower specificity (OR = 0.87, 95% confidence interval [CI] = 0.85 to 0.89, P < .001) and positive predictive value (OR = 0.89, 95% CI = 0.80 to 0.99, P = .03). A non-statistically significant increase in overall sensitivity with CAD (OR = 1.06, 95% CI = 0.84 to 1.33, P = .62) was attributed to increased sensitivity for ductal carcinoma in situ (OR = 1.55, 95% CI = 0.83 to 2.91; P = .17), although sensitivity for invasive cancer was similar with or without CAD (OR = 0.96, 95% CI = 0.75 to 1.24; P = .77). CAD was not associated with higher breast cancer detection rates or more favorable stage, size, or lymph node status of invasive breast cancer. CONCLUSION CAD use during film-screen screening mammography in the United States is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer.

Mammography Facility Characteristics Associated With Interpretive Accuracy of Screening Mammography

Background Although interpretive performance varies substantially among radiologists, such variation has not been examined among mammography facilities. Understanding sources of facility variation could become a foundation for improving interpretive performance. Methods In this cross-sectional study conducted between 1996 and 2002, we surveyed 53 facilities to evaluate associations between facility structure, interpretive process characteristics, and interpretive performance of screening mammography (ie, sensitivity, specificity, positive predictive value [PPV1], and the likelihood of cancer among women who were referred for biopsy [PPV2]). Measures of interpretive performance were ascertained prospectively from mammography interpretations and cancer data collected by the Breast Cancer Surveillance Consortium. Logistic regression and receiver operating characteristic (ROC) curve analyses estimated the association between facility characteristics and mammography interpretive performance or accuracy (area under the ROC curve [AUC]). All P values were two-sided. Results Of the 53 eligible facilities, data on 44 could be analyzed. These 44 facilities accounted for 484 463 screening mammograms performed on 237 669 women, of whom 2686 were diagnosed with breast cancer during follow-up. Among the 44 facilities, mean sensitivity was 79.6% (95% confidence interval [CI] = 74.3% to 84.9%), mean specificity was 90.2% (95% CI = 88.3% to 92.0%), mean PPV1 was 4.1% (95% CI = 3.5% to 4.7%), and mean PPV2 was 38.8% (95% CI = 32.6% to 45.0%). The facilities varied statistically significantly in specificity (P < .001), PPV1 (P < .001), and PPV2 (P = .002) but not in sensitivity (P = .99). AUC was higher among facilities that offered screening mammograms alone vs those that offered screening and diagnostic mammograms (0.943 vs 0.911, P = .006), had a breast imaging specialist interpreting mammograms vs not (0.932 vs 0.905, P = .004), did not perform double reading vs independent double reading vs consensus double reading (0.925 vs 0.915 vs 0.887, P = .034), or conducted audit reviews two or more times per year vs annually vs at an unknown frequency (0.929 vs 0.904 vs 0.900, P = .018). Conclusion Mammography interpretive performance varies statistically significantly by facility.

Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force

Dense breasts are defined by mammographic appearance. The American College of Radiologys (ACRs) Breast Imaging Reporting and Data System (BI-RADS) classifies breasts as almost entirely fatty (BI-RADS category a), scattered areas of fibroglandular density (category b), heterogeneously dense (category c), or extremely dense (category d). About 27.6 million (43%) women aged 40 to 74 years in the United States have dense breasts; most of these are classified as category c (1). Higher breast density is associated with decreased mammographic sensitivity and specificity and also with increased breast cancer risk. The relative hazard of breast cancer for women with dense breasts ranged from 1.50 (women aged 65 to 74 years) to 1.83 (women aged 40 to 49 years) in an analysis of 1169248 women enrolled in the Breast Cancer Surveillance Consortium (unpublished data). Increased breast density has been associated with hormone replacement therapy use, younger age, and lower body mass index (2). Data on breast density and race or ethnicity are limited. In the United States, Asian women have higher breast density (3) but lower than average incidence of breast cancer (4). Increased breast density is not associated with higher breast cancer mortality among women with dense breasts diagnosed with breast cancer, after adjustment for stage and mode of detection (5). Supplemental breast cancer screening with additional screening modalities has been proposed to improve the early detection of breast cancers. No clinical guidelines explicitly recommend use of supplemental breast cancer screening on women with dense breasts (69), but as of September 2015, 24 states had enacted legislation requiring that women be notified of breast density with their mammography results; 9 more states are considering mandatory notification (10) (Appendix Table 1). Most states require specific language distinguishing dense (BI-RADS c and d) from nondense breasts, and 4 states require that insurers cover subsequent examinations and tests for women with dense breasts (1114). Federal legislation requiring breast density notification is pending (15). Appendix Table 1. Breast Density Legislation in the United States This report summarizes a systematic review of current evidence on the reproducibility of BI-RADS breast density determinations and on test performance characteristics and outcomes of supplemental screening of women with dense breasts by using hand-held ultrasonography (HHUS), automated whole-breast ultrasonography (ABUS), breast magnetic resonance imaging (MRI), and digital breast tomosynthesis (DBT). Mandatory reporting laws frame notification of women as dense/nondense, so this review focused on this categorization. Methods The review protocol included an analytic framework with 4 key questions (KQs) (Appendix Figure 1). Detailed methods, including search strategies, detailed inclusion criteria, and excluded studies, are available in the full evidence report (16). Appendix Figure 1. Analytic framework. BI-RADS = Breast Imaging Reporting and Data System; DCIS = ductal carcinoma in-situ; KQ = key question; MRI = magnetic resonance imaging. Data Sources and Searches MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched for relevant English-language studies published between January 2000 and July 2015. We reviewed reference lists from retrieved articles and references suggested by experts. Study Selection Two investigators independently reviewed abstracts and full-text articles for inclusion according to predetermined criteria (E.P.W. and J.H.T. for KQ 1, J.M. and J.J.F. for KQs 2 to 4). Included studies examining the reproducibility of BI-RADS breast density categorization focused on asymptomatic women aged 40 years or older undergoing digital or film mammography. Included studies on supplemental screening with HHUS, ABUS, MRI, or DBT reported outcomes for asymptomatic women with dense breasts aged 40 years and older. In studies that focused primarily on women at high risk for breast cancer (including those with preexisting breast cancer or high-risk breast lesions [such as ductal carcinoma in situ, atypical hyperplasia, and lobular carcinoma in situ], BRCA mutations, familial breast cancer syndromes, or previous chest-wall radiation) and studies that included women with nondense breasts, we analyzed the relevant subset when available in the publication or provided by the authors. A priori inclusion criteria limited studies on BI-RADS reproducibility to fair- or good-quality randomized, controlled trials; cohort studies; or test sets involving multiple blind readings by at least 3 readers. Studies on test performance characteristics and outcomes of supplemental screening modalities were limited to fair- or good-quality randomized, controlled trials; cohort studies; or diagnostic accuracy studies with reference standards applied to all participants. We examined sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), and available clinical outcomes (including cancer detection rates, recall rates, and biopsy rates). We defined recall as the need for any additional diagnostic testing after supplemental screening, including imaging and biopsy. Data Extraction and Quality Assessment Two investigators (E.P.W. and J.H.T. for KQ 1, J.M. and J.J.F. for KQs 2 to 4) critically appraised all included studies independently using the U.S. Preventive Services Task Forces (USPSTFs) design-specific criteria (17), supplemented with the National Institute for Health and Clinical Excellence methodology checklists (18) and the Quality Appraisal Tool for Studies of Diagnostic Reliability (19). According to USPSTF criteria, a good-quality study generally met all prespecified criteria; fair-quality studies did not meet all criteria but had no important limitations. Poor-quality studies had important limitations that could invalidate results (inadequate or biased application of reference standard; population limited to very high-risk patients). Data Synthesis and Analysis When available or provided by the authors, results of supplemental screening for subgroups of women with dense breasts were extracted; we excluded those with other risk factors for breast cancer. We calculated the sensitivity and specificity of the supplemental breast screening tests for women with negative mammography results. Only cancers detected by the supplemental test after negative mammography results and cancers found at interval follow-up were included. Hence, the values reported represent the sensitivity and specificity for detection of additional cancer in women with negative mammography findings. Similarly, we defined cancer detection rates, recall rates, and biopsy rates to include only those cancer cases, recalls, and biopsies related to supplemental screening after negative results on mammography. Meta-analysis was not performed because there were few good-quality studies. Role of the Funding Source This research was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF. The investigators worked with USPSTF members to develop and refine the scope, analytic frameworks, and KQs. AHRQ had no role in study selection, quality assessment, synthesis, or development of conclusions. AHRQ provided project oversight; reviewed the draft report; and distributed the draft for peer review, including to representatives of professional societies and federal agencies. AHRQ performed a final review of the manuscript to ensure that the analysis met methodological standards. The investigators are solely responsible for the content and the decision to submit the manuscript for publication. Results The literature search yielded 2067 unique citations; 128 full-text articles considered potentially relevant were reviewed to identify 24 unique studies meeting inclusion criteria (Appendix Figure 2). Table 1 (2043) provides the characteristics of included studies. No studies addressed the effect of supplemental screening (compared with women without supplemental screening) on breast cancer morbidity or mortality. Appendix Figure 2. Summary of evidence search and selection. KQ = key question. Table 1. Characteristics of Included Studies Accuracy and Reliability of BI-RADS Density Determination Absent a gold standard for breast density, studies could not evaluate the accuracy of BI-RADS density determinations. Five studies reported repeated assignment of categorical BI-RADS breast density classification by the same or different radiologists, altogether including more than 440000 women, almost all with data from 2 sequential screening mammograms. To reflect current U.S. practice, we included only studies based on the BI-RADS density categories. The 3 largest studies were set in the United States. Two used data from the Breast Cancer Surveillance Consortium (20, 22), and the third presented findings from community radiologists conducting repeated readings of a large screening test set (24). Two other small studies (not discussed here) were based on mammographic screening programs in Spain (21) and Italy (23). All United Statesbased studies reflected community practice by use of clinical readings from community screening programs or test set readings by practicing community radiologists without additional training. Overall, group prevalence of BI-RADS density ratings was similar across initial and subsequent examinations among community radiologists (Appendix Table 2), but there was greater disagreement at the individual level. On subsequent screening examinations, approximately 1 in 5 women (23%) was placed in a different BI-RADS density category (a, b, c, d) by the same radiologist, while approximately 1 in 3 was categorized differently when a different radiologist read the subsequent examination result (Table 2). Considering clinical interpretations that combine categories (dense representing those with BI-RAD

Persistent Racial and Ethnic Disparities in Up-to-Date Colorectal Cancer Testing in Medicare Enrollees

OBJECTIVES: To assess whether greater colonoscopy use among white as compared with nonwhite Medicare enrollees since Medicare established coverage for colorectal cancer (CRC) screening has been associated with a widening in white versus nonwhite disparities in up‐to‐date CRC testing status.

Quality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands

PURPOSE We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List. METHODS We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association–recommended preventive services, including regular hemoglobin A1C (HbA1C) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise. RESULTS After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA1C test (odds ratio [OR] = 0.35, 95% confidence interval [CI], 0.24–0.51), retinal examination (OR = 0.74, 95% CI, 0.63–0.86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58–0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least 1 HbA1C test (OR = 0.59, 95% CI, 0.35–1.01), retinal examination (OR = 0.68, 95% CI, 0.56–0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57–1.09) despite attending a similar mean number of total visits as higher-priority users. CONCLUSIONS Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.

Longitudinal Adherence With Fecal Occult Blood Test Screening in Community Practice

PURPOSE Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening. METHODS We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000–2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002–2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening. RESULTS Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%–45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%–9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%–48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61–12.96). CONCLUSIONS Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial.

Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, Setting, and Participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main Outcomes and Measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. Conclusions and Relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01485627

Trends in Colorectal Cancer Testing Among Medicare Subpopulations

BACKGROUND In 1998, Medicare initiated universal coverage for colorectal cancer (CRC) screening via fecal occult blood testing (FOBT) and sigmoidoscopy. In mid-2001, universal coverage was advanced to screening colonoscopy. This study sought to determine whether trends in CRC testing differed among racial/ethnic, age, or gender subgroups of the Medicare population. METHODS In 2006, claims from 1995 to 2003 were analyzed for annual 5% random samples of fee-for-service Medicare enrollees living in Surveillance, Epidemiology, and End Results (SEER) regions to calculate the annual, age-standardized percentages of subjects who received FOBT, sigmoidoscopy, or colonoscopy. Logistic regression then modeled trends in annual test use within racial/ethnic, age, and gender subgroups across three Medicare coverage periods (precoverage [1995-1997]; limited coverage [1998-mid-2001]; and full coverage [mid-2001-2003]). RESULTS The annual use of FOBT and sigmoidoscopy declined from 1995 to 2003 in all racial/ethnic groups, but the relative decline in sigmoidoscopy use was greater among whites compared to nonwhites. In contrast, colonoscopy use increased substantially in all racial/ethnic groups. However, relative to the precoverage period among whites, the full-coverage period was associated with significantly greater colonoscopy use among whites (OR=2.14; 95% CI=2.09, 2.19) than blacks (OR=1.86; 95% CI=1.75, 1.96); Asian/Pacific Islanders (OR=1.73; 95% CI=1.62, 1.86); or Hispanics (OR=1.65; 95% CI=1.49, 1.81). The use of colonoscopy during the full-coverage period was also differentially greater among enrollees aged <80 years. CRC testing trends were similar among male and female enrollees. CONCLUSIONS Colonoscopy is supplanting sigmoidoscopy as a CRC test among Medicare enrollees, while FOBT use is in decline. The transition from sigmoidoscopy to colonoscopy has occurred more quickly among white than nonwhite Medicare enrollees.