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Purpose: The effect of climate-driven events, such as wildfires, on health care delivery and cancer care is a growing concern. Patients with cancer undergoing radiation therapy are particularly vulnerable to treatment interruptions, which have a direct effect on survival. We report the results of a study characterizing the effect of wildfires on radiation oncology clinics and their patients. Methods and Materials: A survey of California radiation oncologists was used to evaluate emergency preparedness and the effect of wildfires on the delivery of radiation therapy services between 2017 and 2022. Descriptive statistics and Pearson's χ2 tests were performed to investigate potential relationships between provider characteristics, practice settings, and perceptions of the effect of wildfire events. California Department of Forestry and Fire Protection data were employed to map the geographic distribution of wildfires to clinic locations. Results: Response rate was 12.3% (51/415 radiation oncologists), representing 25% of clinics (43/176) in 41% (24/58) of California counties. Sixty-one percent (31/51) of respondents reported being affected by a wildfire, 2 of which are rural clinics (100%, 2/2) and 29 are (59%, 29/49) metropolitan practices. Of these, 18% (9/51) reported a clinic closure, and 29% (15/51) reported staffing shortages. Respondents reported effects on patients, including having to evacuate (55%, 28/51), cancel/reschedule treatments (53%, 27/51), and experiencing physical, mental, or financial hardship due to wildfires (45%, 23/51). Respondents described effects on clinical operations, including being forced to transfer patients (24%, 12/51), transportation interruptions (37%, 19/51), regional/community evacuations (35%, 18/51), and physical/mental health effects (27%, 14/51) on clinic personnel. Less than half of the respondents (47%, 24/51) reported their workplace had a wildfire emergency preparedness plan. Additionally, geographic analysis revealed that 100% (176/176) of clinics were located within 25 miles of a wildfire. Conclusions: This study highlights the effects of wildfires on radiation oncology clinics and patients and underscores the need for emergency preparedness planning to minimize the consequences of such disasters.

IntroductionStudies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual’s use of screening. However, another possible influence, the effect of regional differences in physicians’ beliefs and recommendations on screening use, has not been assessed.MethodsWe linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency.Results On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics.ConclusionStrategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.

Background: Although immune checkpoint inhibitor immunotherapies are contraindicated as first-line treatment of advanced non-small cell lung cancer (NSCLC) in patients with ALK rearrangement and EGFR mutation, many receive them. The purpose of this study was to examine the association between optimal first-line treatment in this population and clinical outcomes., Methods: Claims and genomic data from patients with advanced or metastatic NSCLC were extracted from a nationally representative GuardantINFORM dataset. Patients who had their first claim mentioning advanced or metastatic NSCLC between March 2019 and February 2020 and had ALK rearrangement or EGFR mutation detected by comprehensive genomic profiling were included in this study. Patients were classified as having received optimal or suboptimal first-line treatment. Claims were reviewed to determine real-world time to next treatment, real-world time to discontinuation, and health services utilization (emergency department, inpatient, and outpatient) in the 12 months following first-line treatment initiation. Survival analyses were conducted using Kaplan-Meier plots and Cox proportional hazard models. Health services utilization was compared between the groups using t tests and negative binomial models., Results: Of the 359 patients included, 280 (78.0%) received optimal first-line treatment. Optimally treated patients had longer median real-world time to next treatment (11.2 vs 4.4 months; P<.01) and real-world time to discontinuation (10.4 vs 1.9 months; P<.01). The optimal group had significantly fewer emergency department presentations (0.76 vs 1.27; P<.01) and outpatient visits (22.9 vs 42.7; P<.01) than the suboptimal group but did not significantly differ in inpatient utilization. Adjusted utilization analysis yielded similar findings., Conclusions: Patients with NSCLC who received optimal treatment, as determined by comprehensive genomic profiling using next-generation sequencing-based circulating tumor DNA testing (Guardant360), had significantly superior clinical and utilization outcomes, reinforcing existing guidelines recommending profiling at the onset of treatment.

Patients with high-deductible health plans will increasingly be motivated to contact their hospitals or various websites to try to obtain information about the costs of expensive services like advanced imaging. Unfortunately, they will not find price transparency but rather confusion and opaqueness. Hospital personnel and commercial websites often unwittingly provide erroneous pricing information. The reasons for this are explained. Detailed examples of the erroneous information are provided. State-mandated websites may be somewhat of an improvement, but their methodology seems to vary from state to state, and they too can be confusing. All this obviously creates problems for patients, who are left not knowing what their true costs will be. The situation also creates problems for radiologists and their hospitals. Because of misunderstandings that can occur during the information-gathering phase, the pricing information shown for many hospital facilities may be greatly inflated, placing them at a competitive disadvantage. Certain strategic solutions to the problems are available, and these are discussed., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A decade of rapidly rising outpatient advanced imaging utilization ended toward the end of the past decade, with slow growth since. This has been attributed to repetitive reimbursement cuts, medical radiation exposure concerns, increasing deductibles and patient copayments, and the influence of radiology benefit management companies. State Medicaid programs have been reluctant to institute radiology benefit management preauthorization programs since the time burden for obtaining test approval could cause providers to drop out. Also, these patients may lack the knowledge to appeal denials, and medically necessary tests could be denied with adverse outcomes. Little data exist demonstrating the efficacy of such programs in decreasing utilization and cost. We report a 2-year experience with an outpatient advanced imaging prior notification program for a large state Medicaid fee-for-service population. The program did not allow any denials, but nevertheless the data reveal a large, durable decrease in advanced imaging utilization and cost., (© The Author(s) 2015.)

Purpose: Seeking to control advanced diagnostic imaging costs, health insurance plans have instituted broad-based utilization management systems. Most processes ultimately contain denial provisions, meaning that the health plans will refuse to pay for requested studies if performed. The aim of this analysis was to determine whether removal of a denial provision would result in increased utilization of imaging services., Methods: A major US health plan used a no-denial preauthorization system in all but 4 geographic markets for all CT, MRI, PET, and nuclear cardiac imaging studies, constituting the experimental group. This study consisted of a retrospective review of 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group. A matched population with no such change in the review process served as the control group. Population-normalized utilization rates were measured for both pooled groups before and after the change., Results: Utilization decreased slightly more in the experimental group than in the control group (-0.10 requests per 1,000 covered lives; 95% confidence interval, -0.20 to 0.00; P = .050) after elimination of the denial provision. The rates of request approval, examination modification, withdrawal, and no consensus after peer-to-peer consultation did not significantly change., Conclusions: Eliminating denial provisions in utilization management for advanced diagnostic imaging does not result in increased utilization of such imaging., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Multidetector CT (MDCT) has improved imaging of the arteries in the lower extremities. The main advantages of this novel technology are the exceptionally fast scan times, high spatial resolution, increased anatomic coverage, and capability to generate high-quality multiplanar reformations and three-dimensional (3-D) renderings from raw data that can be reprocessed easily and quickly. The applications of MDCT in imaging the lower extremities are multiple and varied. They include the evaluation of peripheral arterial occlusive and aneurysmal disease, the patency and integrity of bypass grafts, and arterial injury owing to trauma. This article describes the techniques of lower extremity MDCT angiography and its use in a few clinical applications.

Endovascular aneurysm repair has proven to be a valuable alternative to open repair in selected patients. This less invasive procedure, however, requires long-term surveillance for its own set of potential complications, including perigraft leakage, or endoleak. This article focuses on the detection of these leaks, first defining and classifying endoleaks and then describing various means of detecting them, including computed tomographic angiography, magnetic resonance angiography, color-flow duplex ultrasonography, and conventional angiography.

The decision to salvage or amputate a severely injured limb is one of the most difficult an orthopaedic surgeon may face. The inclination to undertake heroic measures to save the limb should be tempered by the realization that doing so may lead to repeated hospitalizations, extensive complications, and a poor functional outcome. Several factors must be considered, including objective elements related to the patient's injury and physical condition and subjective considerations related to the patient's psychologic, social, and economic status. We present a framework, in the context of a case study, which may be used in deciding which patients can benefit from early amputation and review five predictive indices for limb salvage.

The cost differences between film-based mammography (FBM) and digital mammography (DM) were estimated after discussions with hospital personnel and industry representatives. Human resource costs were not included. The fixed cost of FBM per machine was estimated to be $50,000 and the variable cost $4.60 per examination. The fixed cost of DM per machine was estimated to be $102,000 and the variable cost $0.10 per examination. The total number of examinations required to break even was therefore 11,556. At a rate of 15 examinations per machine per day and with 251 working days per year, it would take 3.1 years to break even. In the first year after the break-even point had been attained, $16,943 would be saved for every 3765 examinations performed. Extrapolating to the USA as a whole, in which 23 million mammographic examinations are performed each year, suggests that the annual savings from going filmless would be more than $103 million.

This study examined the concurrent validity of the Millon Adolescent Clinical Inventory (MACI; Millon 1993) in the assessment of depression among 88 adolescent inpatients. Doleful Personality and Depressive Affect scales were moderately predictive of a clinical diagnosis of depression, but both scales were strongly associated with scores on the Children's Depression Inventory (Kovacs, 1992). The Suicidal Tendencies scale was weakly associated with placement on suicide precautions. Overall, these results provide moderate support for the use of the MACI in the assessment of hospitalized adolescents.

Two commonly used thrombolytic agents are streptokinase (SK) and tissue plasminogen activator (t-PA), which have different impacts on the incidence of mortality and thrombolysis-related acute intracranial hemorrhage. A decision-analytic model was developed to compare the use of SK and t-PA in the treatment of a patient with suspected acute myocardial infarction (AMI). The outcome was health-related quality of life as quantified in a measure of utility from the patient's point of view. The model included three outcome states: death, nonfatal yet disabling stroke, and survival with no disabling stroke. The utility for disabling stroke was determined relative to the reference states of no disabling stroke (1.00) and death (0.00) by means of the time trade-off estimation technique. Probabilities were derived from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery trial, which revealed that although administering t-PA results in a lower percentage of deaths compared to SK, it may lead to a higher percentage of strokes. A decision tree was constructed to model the options and outcomes. The tree was analyzed by standard decision analytic techniques using SMLTREE software, and the stability of the results was examined as values of parameters were varied systematically in a sensitivity analysis. In the baseline analysis, SK yielded 0.9235, whereas t-PA yielded 0.9329. The sensitivity analysis revealed that if the probability of a disabling stroke attributable to t-PA were greater than 2.08%, SK would yield the higher expected utility. This threshold value, however, was much greater than the probability established in major trials. The administration of t-PA leads to a slightly better outcome than does the administration of SK in a patient with suspected AMI.

Increasingly, clinicians obtain data from tests across modalities. Little actual information, however, exists as to normal patterns. An example is auditory and visual recall of digit span. The effects of modality on recall of digit span, sequence, and order were examined with 80 subjects (M age 24.3 yr.). Subjects were given the Wechsler Adult Intelligence Scale-Revised, and a research version of MicroCog: Assessment of Cognitive Functioning. Both contain forward and backward digit spans. Recall for visual presentation was significantly stronger than for auditory presentation of backward digit span. Recall for visual backward digit span was also superior to auditory backward digit span when the sequence of presentation was controlled. The mean number of digits recalled was higher when visual digit span was preceded by auditory digit span.