Malpractice Reform does not Affect ED Utilization

Waxman et al report in NEJM their findings regarding the effect legal reform had in the practice of medicine, in three states, Texas, Georgia, and South Carolina, which between 2003 and 2005, enacted legislation that changed the malpractice standard for emergency care to gross negligence.  

Using a 5% random sample of Medicare fee-for-service beneficiaries, they identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. They compared patient-level outcomes, before and after legislation, in reform states and control states. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

For eight of the nine states–outcome combinations tested, they found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction in per-visit emergency department charges.

They conclude that legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates.

Surgical Biopsies for Breast Cancer are Overused in the United States

Ebert et al in an article published by JCO report their findings from a review of Medicare data from 89,712 patients with breast cancer and 12,405 surgeons, regarding three outcomes: surgeon consultation before versus after biopsy, use of needle biopsy, and number of surgeries for cancer treatment.

Surgical biopsy was the standard for breast diagnosis before the 1990s, when most patients with breast cancer presented with clinical symptoms. The growth of mammographic screening in the 1980s significantly increased the number of non-palpable lesions found that required diagnostic work-up with either needle biopsy or surgical biopsy following needle localization. In their analysis the  authors looked at factors associated with surgeon consultation before biopsy, Medicaid coverage, rural residence, residence more than 8 miles from a radiologic facility performing needle biopsy, and no mammogram within 60 days before consultation. Among patients with surgeon consultation before biopsy, factors such as absence of board certification, training outside the United States, low case volume, earlier decade of medical school graduation, and lack of specialization in surgical oncology were negatively correlated with receipt of needle biopsy.

Overall, 68.4 percent had a needle biopsy and 31.6 had a surgical biopsy. If the patient's initial appointment was with a surgeon instead of a radiologist, the surgical biopsy rate grew to nearly 50 percent.  Surgeons less likely to refer patients for a needle biopsy were those without board certification, trained outside the U.S., graduated from medical school before 1980 or not specialized in surgical oncology.

The study found that 70 percent of patients who had an excisional biopsy required multiple surgeries while only 33 percent of patients who had needle biopsies did.

As in some countries like the United Kingdom diagnosis for breast cancers is now made with needle biopsy in 95% of the cases, the authors conclude that surgical biopsy is overused in the United States, and is having a negative impact on breast cancer diagnosis and treatment.  

Contrast-enhanced PET/CT, more accurate, in metastatic pancreatic cancer

Yoneyana et al in their study that was published in the EuropeanJournal of Radiology report on the accuracy of contrast-enhanced (CE) 18F-fluorodeoxyglucose (FDG)–positron emission tomography (PET)/computed tomography (CT) in the staging of pancreatic cancer.

A total of 95 patients with primary pancreatic cancer underwent 18F-FDG PET/CT examinations.  The diagnostic accuracy between non-CE PET/CT and CE PET/CT was compared using as a reference standard histology in 48 patients (51%) and an obvious progression in number or size of the lesions on follow-up CT examinations in 47 patients (49%). 

Invasion of duodenum (n = 20, 21%), mesentery (n = 12, 13%), and retroperitoneum (n = 13, 14%) was correctly diagnosed by both modalities.  The diagnostic accuracy of nodal metastases of the two modalities was similar with metastases correctly diagnosed by CE PET/CT in 38 patients (88%) and by non-CE PET/CT in 45 patients (87%). Using CE PET/CT, distant metastases, scalene node metastasis, and peritoneal dissemination were correctly diagnosed in 39 patients (91%), while interpretation based on non-CE PET/CT revealed distant metastasis, scalene node metastasis, and peritoneal dissemination in 42 patients (81%).  Therefore, the diagnostic accuracy of CE PET/CT was significantly higher than that of non-CE PET/CT (p < 0.05) in distant metastases, scalene node metastasis, and peritoneal dissemination.

The authors concluded that the addition of contrast in PET/CT studies allows for a more precise assessment of distant metastases, scalene node metastases, and peritoneal dissemination in patients with pancreatic cancer.

PALB2 mutations and breast cancer risk

In their article in the NEJM Antoniou et al report the risk of breast cancer among 362 members of 154 families who had deleterious truncating, splice, or deletion mutations in PALB2.

The risk of breast cancer for female PALB2 mutation carriers, as compared with the general population, was eight to nine times as high among those younger than 40 years of age, six to eight times as high among those 40 to 60 years of age, and five times as high among those older than 60 years of age. The estimated cumulative risk of breast cancer among female mutation carriers was 14% by 50 years of age and 35% by 70 years of age. Breast-cancer risk was also significantly influenced by birth cohort and by other familial factors. The absolute breast-cancer risk for PALB2 female mutation carriers by 70 years of age ranged from 33% for those with no family history of breast cancer to 58% for those with two or more first-degree relatives with breast cancer at 50 years of age.

The authors concluded loss-of-function mutations in PALB2 are an important cause of hereditary breast cancer.