title: Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign.
abstract: OBJECTIVE
  The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures.
  
  
  OBJECTIVE
  To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated.
  
  
  METHODS
  Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions.
  
  
  METHODS
  In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa.
  
  
  RESULTS
  We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile.
  
  
  CONCLUSIONS
  At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.
authors.affiliation: US Department of Veterans Affairs, Washington, DC2Department of Urology, New York University School of Medicine, New York3Department of Population Health, New York University School of Medicine, New York4New York University Cancer Institute, New York.
authors.forename: Danil V
authors.initials: DV
authors.lastname: Makarov
authors.affiliation: Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut6Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Pamela R
authors.initials: PR
authors.lastname: Soulos
authors.affiliation: Department of Population Health, New York University School of Medicine, New York4New York University Cancer Institute, New York7Department of Medicine, New York University School of Medicine, New York.
authors.forename: Heather T
authors.initials: HT
authors.lastname: Gold
authors.affiliation: Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut8Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
authors.affiliation: Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.
authors.forename: Sounok
authors.initials: S
authors.lastname: Sen
authors.affiliation: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut10Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut11Department of Health Policy and Managem.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.affiliation: Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut6Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut12Department of Epidemiology and Public Health, Y.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D002391:Catchment Area, Health; D016009:Chi-Square Distribution; D003952:Diagnostic Imaging / Q000592:standards / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000639:trends*; D011237:Predictive Value of Tests; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D014481:United States / Q000453:epidemiology; D019564:Unnecessary Procedures / Q000592:standards / Q000706:statistics & numerical data / Q000639:trends*