title: Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation.
abstract: OBJECTIVE
  Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes.
  
  
  METHODS
  We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication.
  
  
  RESULTS
  For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic.
  
  
  CONCLUSIONS
  Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR Erin.E.Hahn@kp.org.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Hahn
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Tania
authors.initials: T
authors.lastname: Tang
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Janet S
authors.initials: JS
authors.lastname: Lee
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Corrine
authors.initials: C
authors.lastname: Munoz-Plaza
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Joyce O
authors.initials: JO
authors.lastname: Adesina
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Ernest
authors.initials: E
authors.lastname: Shen
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Braden
authors.initials: B
authors.lastname: Rowley
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Jared L
authors.initials: JL
authors.lastname: Maeda
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: David M
authors.initials: DM
authors.lastname: Mosen
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: John C
authors.initials: JC
authors.lastname: Ruckdeschel
authors.affiliation: Kaiser Permanente Southern California, Pasadena; Southern California Permanente Medical Group, Los Angeles, CA; Intermountain Healthcare, Salt Lake City, UT; Mid-Atlantic Permanente Research Institute, Rockville, MD; and Kaiser Permanente Center for Health Research, Portland, OR.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D003952:Diagnostic Imaging / Q000592:standards* / Q000706:statistics & numerical data*; D057286:Electronic Health Records; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006279:Health Maintenance Organizations / Q000592:standards*; D054625:Healthcare Disparities / Q000592:standards; D006801:Humans; D008327:Mammography / Q000592:standards / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography / Q000592:standards / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011237:Predictive Value of Tests; D012042:Registries; D013997:Time Factors; D014481:United States; D055815:Young Adult