Faculty Bibliography

BACKGROUND:Broad consensus supports the use of primary care to address unmet need for mental health treatment. OBJECTIVE:To better understand whether primary care filled the gap when individuals were unable to access specialty mental health care. DESIGN/METHODS:2018 mixed methods study with a national US internet survey (completion rate 66%) and follow-up interviews. PARTICIPANTS/METHODS:Privately insured English-speaking adults ages 18-64 reporting serious psychological distress that used an outpatient mental health provider in the last year or attempted to use a mental health provider but did not ultimately use specialty services (N = 428). Follow-up interviews were conducted with 30 survey respondents. MAIN MEASURES/METHODS:Whether survey respondents obtained mental health care from their primary care provider (PCP), and if so, the rating of that care on a 1 to 10 scale, with ratings of 9 or 10 considered highly rated. Interviews explored patient-reported barriers and facilitators to engagement and satisfaction with care provided by PCPs. KEY RESULTS/RESULTS:Of the 22% that reported they tried to but did not access specialty mental health care, 53% reported receiving mental health care from a PCP. Respondents receiving care only from their PCP were less likely to rate their PCP care highly (21% versus 48%; p = 0.01). Interviewees reported experiences with PCP-provided mental health care related to three major themes: PCP engagement, relationship with the PCP, and PCP role. CONCLUSIONS:Primary care is partially filling the gap for mental health treatment when specialty care is not available. Patient experiences reinforce the need for screening and follow-up in primary care, clinician training, and referral to a trusted specialty consultant when needed.

BACKGROUND:Digital breast tomosynthesis (DBT) has become a prevalent mode of breast cancer screening in recent years. Although older women are commonly screened for breast cancer, little is known about screening outcomes using DBT among older women. OBJECTIVE:To assess proximal screening outcomes with DBT compared to traditional two-dimensional(2-D) mammography among women 67-74 and women 75 and older. DESIGN/METHODS:Cohort study. PARTICIPANTS/METHODS:Medicare fee-for-service beneficiaries aged 67 years and older with no history of prior cancer who received a screening mammogram in 2015. MAIN MEASURES/METHODS:Use of subsequent imaging (ultrasound and diagnostic mammography) as an indication of recall, breast cancer detection, and characteristics of breast cancer at the time of diagnosis. Analyses used weighted logistic regression to adjust for potential confounders. KEY RESULTS/RESULTS:Our study included 26,406 women aged 67-74 and 17,001 women 75 and older who were screened for breast cancer. Among women 75 and older, the rate of subsequent imaging among women screened with DBT did not differ significantly from 2-D mammography (91.8 versus 97.0 per 1,000 screening mammograms, p=0.37). In this age group, DBT was associated with 2.1 additional cancers detected per 1,000 screening mammograms compared to 2D (11.5 versus 9.4, p=0.003), though these additional cancers were almost exclusively in situ and stage I invasive cancers. For women 67-74 years old, DBT was associated with a higher rate of subsequent imaging than 2-D mammography (113.9 versus 100.3, p=0.004) and a higher rate of stage I invasive cancer detection (4.7 versus 3.7, p=0.002), but not other stages. CONCLUSIONS:Breast cancer screening with DBT was not associated with lower rates of subsequent imaging among older women. Most additional cancers detected with DBT were early stage. Whether detecting these additional early-stage cancers among older women improves health outcomes remains uncertain.

BACKGROUND:Digital breast tomosynthesis (DBT) may have a higher cancer detection rate and lower recall compared with 2-dimensional (2 D) mammography for breast cancer screening. The goal of this study was to evaluate screening outcomes with DBT in a real-world cohort and to characterize the population health impact of DBT as it is widely adopted. METHODS:This observational study evaluated breast cancer screening outcomes among women screened with 2 D mammography vs DBT. We used deidentified administrative data from a large private health insurer and included women aged 40-64 years screened between January 2015 and December 2017. Outcomes included recall, biopsy, and incident cancers detected. We used 2 complementary techniques: a patient-level analysis using multivariable logistic regression and an area-level analysis evaluating the relationship between population-level adoption of DBT use and outcomes. All statistical tests were 2-sided. RESULTS:Our sample included 7 602 869 mammograms in 4 580 698 women, 27.5% of whom received DBT. DBT was associated with modestly lower recall compared with 2 D mammography (113.6 recalls per 1000 screens, 99% confidence interval [CI] = 113.0 to 114.2 vs 115.4, 99% CI = 115.0 to 115.8, P < .001), although younger women aged 40-44 years had a larger reduction in recall (153 recalls per 1000 screens, 99% CI = 151 to 155 vs 164 recalls per 1000 screens, 99% CI = 163 to 166, P < .001). DBT was associated with higher biopsy rates than 2 D mammography (19.6 biopsies per 1000 screens, 99% CI = 19.3 to 19.8 vs 15.2, 99% CI = 15.1 to 15.4, P < .001) and a higher cancer detection rate (4.9 incident cancers per 1000 screens, 99% CI = 4.7 to 5.0 vs 3.8, 99% CI = 3.7 to 3.9, P < .001). Point estimates from the area-level analysis generally supported these findings. CONCLUSIONS:In a large population of privately insured women, DBT was associated with a slightly lower recall rate than 2 D mammography and a higher cancer detection rate. Whether this increased cancer detection improves clinical outcomes remains unknown.

Importance/UNASSIGNED:Ten years after the Mental Health Parity and Addiction Equity Act, patients continue to report insurance-related barriers to specialty mental health care. Objectives/UNASSIGNED:To assess privately insured patients' perceptions of the adequacy of their health plan's provider network (provider network includes physicians, clinicians, other health care professionals, and their institutions that constitute the network), whether practitioners frequently leave plans, and whether practitioner plan participation affected patients' plan choice. Design, Setting, and Participants/UNASSIGNED:A nationally representative, population-based internet survey study of English-speaking US adults participating in KnowledgePanel, an online research panel, was conducted from August to September 2018. Data analysis was performed from November 12, 2020, to May 12, 2021. From a sample of 29 854 panelists aged 18 to 64 years, 19 602 initiated the screener (completion rate of 66%), and 728 met study criteria: adults with private insurance receiving both specialty mental health and medical care in the past year. Exposure/UNASSIGNED:Health plan's provider network. Main Outcomes and Measures/UNASSIGNED:Self-report of plan inadequacy, whether a practitioner left the plan and the participant's responses (stopped treatment, switched practitioner, or continued treatment), and whether participation of a specific practitioner was considered when a health plan was chosen. Experiences with both mental health and medical provider networks were assessed. Analyses were weighted to match the sample to the US population. Weights provided by KnowledgePanel were also adjusted for panel recruitment, attrition, oversampling, and survey nonresponse. Results/UNASSIGNED:Of a total of 728 study participants, 204 (39%) were aged 18 to 34 years, 504 (61%) were women, 82 (17%) were Hispanic, and 551 (66%) were non-Hispanic White individuals. Serious psychological distress was reported by 262 participants (36%), and 214 participants (29%) also received mental health treatment from a primary care practitioner. Participants rated their mental health provider network as inadequate more frequently than their medical provider network (163 [21%] vs 70 [10%]; odds ratio [OR], 2.69; 95% CI, 1.64-4.40; P < .001). However, among the 193 participants also receiving mental health treatment from a primary care practitioner, there was no significant difference in the ratings of mental health and medical provider networks (44 [14%] vs 18 [9%]; OR, 1.55; 95% CI, 0.65-3.67; P = .32). Sixty participants (8%) reported that a mental health practitioner had left their plan's insurance network in the past 3 years. Of the 523 participants with a choice of plan, 98 (20%) considered whether a specific mental health practitioner was in network before choosing a plan. Conclusions and Relevance/UNASSIGNED:This study's findings suggest that more participants perceived their mental health networks to be inadequate compared with their medical networks. Increasing the availability of mental health treatment in primary care practices may aid plans in constructing adequate mental health provider networks and improve patient access to mental health care.

BACKGROUND:Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs. METHODS:We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation. RESULTS:Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually. CONCLUSIONS:The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.

BACKGROUND: Digital breast tomosynthesis (

BACKGROUND: Previous studies have estimated that breast cancer screening costs more than 7 billion dollars annually in the US. However, in recent years, screening technology has changed considerably with the introduction of digital breast tomosynthesis (