Patrice Wendling

CHICAGO — The use of mammography has increased dramatically in the United States, but that growth has come in two distinctly different phases, Dr. David C. Levin said at the annual meeting of the Radiological Society of North America.

Between 1996 and 2004, the total utilization rate of mammography, both screening and diagnostic, increased 48% from 282 to 418 per 1,000 female Medicare beneficiaries. Virtually all growth occurred in the late 1990s when a number of public health initiatives were directed at women to increase the awareness of periodic breast cancer screening. But from 2000 to 2004, the growth trend essentially flattened.

This may reflect decreased access due to a shortage of breast imagers or the closure of breast imaging centers as a result of low reimbursement rates, said Dr. Levin, professor of radiology, Jefferson Medical College, Philadelphia. It could also be a result of fewer public health initiatives related to breast cancer detection.

“I think that the issue of why fewer radiologists are willing to do mammography is a multifaceted problem,” he said in an interview. “The three main things are that it is perceived as being poorly compensated, it has a high malpractice exposure, and [it] is a stressful environment.”

While the use of screening mammography mirrored the overall growth trend, diagnostic mammography trended downward. From 1996 to 2004, the rate of utilization of diagnostic mammography dropped 39% from 153 to 93 per 1,000 women, while the rate for screening mammography increased 157% from 113 to 291 per 1,000 women.

Coding changes demanded by the Health Care Financing Administration could explain the decline in diagnostic mammography claims, Dr. Levin said. In the late 1990s, there was a blurred distinction between screening and diagnostic mammograms in that a lot of radiologists were asking for additional views during a screening mammogram and coding those visits as diagnostic mammograms. But HCFA said if there are no signs or symptoms, it has to be coded as a screening mammogram, he said.

There has been a continued rise in use of breast ultrasound in the United States, such that it is now used more than once for every three diagnostic mammograms. From 1996 to 2004, the number of breast ultrasounds more than doubled from 15 to 33 per 1,000 women, reported Dr. Levin and colleagues who conducted their research through the university's Center for Research on Utilization of Imaging Services.

The use of breast magnetic resonance imaging is very low, but it has begun to show an exponential growth trend in recent years. Just 0.02 per 1,000 women received a breast MRI in 1996, while 0.29 did so in 2004, a 1,350% increase.

The investigators calculated utilization rates based on CPT codes for mammography, breast ultrasound, and breast MRI in Medicare Part B databases for 1996 through 2004. During data tabulation, only global and professional claims were counted, but not technical claims, as this would have led to double counting, Dr. Levin said. Providers of all specialties were included. The analysis did not include the utilization of digital vs. film mammography, because specific codes were not available for digital mammography for the entire study period.

Radiologists continue to perform most (93%) breast imaging for women. Radiologists carried out 94% of mammograms, 89% of breast ultrasounds, and 93% of breast MRIs, according to the study, which was funded in part by the American College of Radiology.

Meanwhile, from 1996 to 2004, breast ultrasounds more than doubled from 15 to 33 per 1,000 women. DR. LEVIN

CHICAGO — The use of mammography has increased dramatically in the United States, but that growth has come in two distinctly different phases, Dr. David C. Levin said at the annual meeting of the Radiological Society of North America.

Between 1996 and 2004, the total utilization rate of mammography, both screening and diagnostic, increased 48% from 282 to 418 per 1,000 female Medicare beneficiaries. Virtually all growth occurred in the late 1990s when a number of public health initiatives were directed at women to increase the awareness of periodic breast cancer screening. But from 2000 to 2004, the growth trend essentially flattened.

This may reflect decreased access due to a shortage of breast imagers or the closure of breast imaging centers as a result of low reimbursement rates, said Dr. Levin, professor of radiology, Jefferson Medical College, Philadelphia. It could also be a result of fewer public health initiatives related to breast cancer detection.

“I think that the issue of why fewer radiologists are willing to do mammography is a multifaceted problem,” he said in an interview. “The three main things are that it is perceived as being poorly compensated, it has a high malpractice exposure, and [it] is a stressful environment.”

While the use of screening mammography mirrored the overall growth trend, diagnostic mammography trended downward. From 1996 to 2004, the rate of utilization of diagnostic mammography dropped 39% from 153 to 93 per 1,000 women, while the rate for screening mammography increased 157% from 113 to 291 per 1,000 women.

Coding changes demanded by the Health Care Financing Administration could explain the decline in diagnostic mammography claims, Dr. Levin said. In the late 1990s, there was a blurred distinction between screening and diagnostic mammograms in that a lot of radiologists were asking for additional views during a screening mammogram and coding those visits as diagnostic mammograms. But HCFA said if there are no signs or symptoms, it has to be coded as a screening mammogram, he said.

There has been a continued rise in use of breast ultrasound in the United States, such that it is now used more than once for every three diagnostic mammograms. From 1996 to 2004, the number of breast ultrasounds more than doubled from 15 to 33 per 1,000 women, reported Dr. Levin and colleagues who conducted their research through the university's Center for Research on Utilization of Imaging Services.

The use of breast magnetic resonance imaging is very low, but it has begun to show an exponential growth trend in recent years. Just 0.02 per 1,000 women received a breast MRI in 1996, while 0.29 did so in 2004, a 1,350% increase.

The investigators calculated utilization rates based on CPT codes for mammography, breast ultrasound, and breast MRI in Medicare Part B databases for 1996 through 2004. During data tabulation, only global and professional claims were counted, but not technical claims, as this would have led to double counting, Dr. Levin said. Providers of all specialties were included. The analysis did not include the utilization of digital vs. film mammography, because specific codes were not available for digital mammography for the entire study period.

Radiologists continue to perform most (93%) breast imaging for women. Radiologists carried out 94% of mammograms, 89% of breast ultrasounds, and 93% of breast MRIs, according to the study, which was funded in part by the American College of Radiology.

Meanwhile, from 1996 to 2004, breast ultrasounds more than doubled from 15 to 33 per 1,000 women. DR. LEVIN

CHICAGO — The use of mammography has increased dramatically in the United States, but that growth has come in two distinctly different phases, Dr. David C. Levin said at the annual meeting of the Radiological Society of North America.

Between 1996 and 2004, the total utilization rate of mammography, both screening and diagnostic, increased 48% from 282 to 418 per 1,000 female Medicare beneficiaries. Virtually all growth occurred in the late 1990s when a number of public health initiatives were directed at women to increase the awareness of periodic breast cancer screening. But from 2000 to 2004, the growth trend essentially flattened.

This may reflect decreased access due to a shortage of breast imagers or the closure of breast imaging centers as a result of low reimbursement rates, said Dr. Levin, professor of radiology, Jefferson Medical College, Philadelphia. It could also be a result of fewer public health initiatives related to breast cancer detection.

“I think that the issue of why fewer radiologists are willing to do mammography is a multifaceted problem,” he said in an interview. “The three main things are that it is perceived as being poorly compensated, it has a high malpractice exposure, and [it] is a stressful environment.”

While the use of screening mammography mirrored the overall growth trend, diagnostic mammography trended downward. From 1996 to 2004, the rate of utilization of diagnostic mammography dropped 39% from 153 to 93 per 1,000 women, while the rate for screening mammography increased 157% from 113 to 291 per 1,000 women.

Coding changes demanded by the Health Care Financing Administration could explain the decline in diagnostic mammography claims, Dr. Levin said. In the late 1990s, there was a blurred distinction between screening and diagnostic mammograms in that a lot of radiologists were asking for additional views during a screening mammogram and coding those visits as diagnostic mammograms. But HCFA said if there are no signs or symptoms, it has to be coded as a screening mammogram, he said.

There has been a continued rise in use of breast ultrasound in the United States, such that it is now used more than once for every three diagnostic mammograms. From 1996 to 2004, the number of breast ultrasounds more than doubled from 15 to 33 per 1,000 women, reported Dr. Levin and colleagues who conducted their research through the university's Center for Research on Utilization of Imaging Services.

The use of breast magnetic resonance imaging is very low, but it has begun to show an exponential growth trend in recent years. Just 0.02 per 1,000 women received a breast MRI in 1996, while 0.29 did so in 2004, a 1,350% increase.

The investigators calculated utilization rates based on CPT codes for mammography, breast ultrasound, and breast MRI in Medicare Part B databases for 1996 through 2004. During data tabulation, only global and professional claims were counted, but not technical claims, as this would have led to double counting, Dr. Levin said. Providers of all specialties were included. The analysis did not include the utilization of digital vs. film mammography, because specific codes were not available for digital mammography for the entire study period.

Radiologists continue to perform most (93%) breast imaging for women. Radiologists carried out 94% of mammograms, 89% of breast ultrasounds, and 93% of breast MRIs, according to the study, which was funded in part by the American College of Radiology.

Meanwhile, from 1996 to 2004, breast ultrasounds more than doubled from 15 to 33 per 1,000 women. DR. LEVIN

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

CHICAGO — One way to avoid diagnostic pitfalls in pediatric appendicitis is by using imaging studies effectively, Dr. George Taylor said at the annual meeting of the Radiological Society of North America.

The decision to use diagnostic computed tomography (CT) versus ultrasound should be based on a thorough understanding of the institution's strengths and weaknesses. “As in politics, all imaging is local,” said Dr. Taylor, chief of radiology at Children's Hospital Boston.

The trade-off with ultrasound is that it is radiation free, but the miss rate for ultrasound is highly dependant on the prevalence of appendicitis in the area. A local prevalence rate of 33% at Children's Hospital Boston meant that ultrasound imaging was missing 40% of appendicitis cases, Dr. Taylor said.

This finding is consistent with a recent meta-analysis that shows CT had a significantly higher sensitivity than did ultrasound in diagnostic studies of children and adults (Radiology 2006;241:83–94).

Dr. Taylor recommends using ultrasound first, followed by CT if the ultrasound findings are negative. When CT is used, efforts should be made to minimize radiation exposure by reducing the area scanned and optimizing the dose according to the child's weight and age.

The classic study on radiation risk (Am. J. Roentgenol. 2001;176:289–96) was based on the assumption that pediatric abdominal CT images were acquired at 404 milliampere-seconds (mAs) and scanned from the diaphragm to the symphysis pubis. However, Children's Hospital acquires CT images from the iliac crest to the symphysis pubis at 230 mAs. The scan results in a whole-body dose of 18–30 mCi.

At this dose, the increased risk of all cancers is 0.009%–0.15%. This is a small but significant increased risk that is acceptable when viewed against the background lifetime risk of cancer at 16%–20%, and the risk involved in having a perforated appendix, Dr. Taylor said.

Another decision to be made is the type of contrast agent used for CT scans. Among 589 children seen at Children's Hospital for suspected appendicitis, the overall visualization of the appendix was 92% for all contrast agents, 93% for rectal contrast only, 94% for rectal plus IV, and 78% for oral plus IV.

Rectal agents would appear to be the best approach, and indeed, oral and IV contrast agents were initially reserved for younger children, those with developmental delays, or those who couldn't tolerate rectal contrast. But a review of the records revealed that when only rectal contrast was used, there was so much diagnostic uncertainty that an additional CT scan was ordered in a stunning 46% of cases—a number that Dr. Taylor called unacceptable.

Because many of the additional scans required IV contrast, the hospital began using rectal and IV agents.

During the first 6 months, there was no change in the number of additional CT scans being ordered.

But after this transitional period, the percentage fell to about 3%, and after adopting an IV-only approach, there has not been a single repeat CT ordered in the last 3 years, he said.

Not only is the radiation exposure reduced, but so is the number of complaints voiced about the invasiveness of rectal contrast.

Other diagnostic challenges with CT include reduced visualization of the appendix because of a lack of mesenteric fat, especially in children younger than 6 years; a tendency to overdiagnose appendicitis; lower sensitivity for ovarian pathology; the risk of perforation with rectal contrast; and false-positive findings, most commonly associated with an appendix greater than 6 mm in size, Dr. Taylor said.

A local prevalence rate of 33% meant that ultrasound was missing 40% of appendicitis cases. DR. TAYLOR

Although this CT was suggestive of appendicitis, the patient was eventually diagnosed with a normal appendix and a case of viral gastroenteritis. Courtesy Dr. George Taylor

CHICAGO — One way to avoid diagnostic pitfalls in pediatric appendicitis is by using imaging studies effectively, Dr. George Taylor said at the annual meeting of the Radiological Society of North America.

The decision to use diagnostic computed tomography (CT) versus ultrasound should be based on a thorough understanding of the institution's strengths and weaknesses. “As in politics, all imaging is local,” said Dr. Taylor, chief of radiology at Children's Hospital Boston.

The trade-off with ultrasound is that it is radiation free, but the miss rate for ultrasound is highly dependant on the prevalence of appendicitis in the area. A local prevalence rate of 33% at Children's Hospital Boston meant that ultrasound imaging was missing 40% of appendicitis cases, Dr. Taylor said.

This finding is consistent with a recent meta-analysis that shows CT had a significantly higher sensitivity than did ultrasound in diagnostic studies of children and adults (Radiology 2006;241:83–94).

Dr. Taylor recommends using ultrasound first, followed by CT if the ultrasound findings are negative. When CT is used, efforts should be made to minimize radiation exposure by reducing the area scanned and optimizing the dose according to the child's weight and age.

The classic study on radiation risk (Am. J. Roentgenol. 2001;176:289–96) was based on the assumption that pediatric abdominal CT images were acquired at 404 milliampere-seconds (mAs) and scanned from the diaphragm to the symphysis pubis. However, Children's Hospital acquires CT images from the iliac crest to the symphysis pubis at 230 mAs. The scan results in a whole-body dose of 18–30 mCi.

At this dose, the increased risk of all cancers is 0.009%–0.15%. This is a small but significant increased risk that is acceptable when viewed against the background lifetime risk of cancer at 16%–20%, and the risk involved in having a perforated appendix, Dr. Taylor said.

Another decision to be made is the type of contrast agent used for CT scans. Among 589 children seen at Children's Hospital for suspected appendicitis, the overall visualization of the appendix was 92% for all contrast agents, 93% for rectal contrast only, 94% for rectal plus IV, and 78% for oral plus IV.

Rectal agents would appear to be the best approach, and indeed, oral and IV contrast agents were initially reserved for younger children, those with developmental delays, or those who couldn't tolerate rectal contrast. But a review of the records revealed that when only rectal contrast was used, there was so much diagnostic uncertainty that an additional CT scan was ordered in a stunning 46% of cases—a number that Dr. Taylor called unacceptable.

Because many of the additional scans required IV contrast, the hospital began using rectal and IV agents.

During the first 6 months, there was no change in the number of additional CT scans being ordered.

But after this transitional period, the percentage fell to about 3%, and after adopting an IV-only approach, there has not been a single repeat CT ordered in the last 3 years, he said.

Not only is the radiation exposure reduced, but so is the number of complaints voiced about the invasiveness of rectal contrast.

Other diagnostic challenges with CT include reduced visualization of the appendix because of a lack of mesenteric fat, especially in children younger than 6 years; a tendency to overdiagnose appendicitis; lower sensitivity for ovarian pathology; the risk of perforation with rectal contrast; and false-positive findings, most commonly associated with an appendix greater than 6 mm in size, Dr. Taylor said.

A local prevalence rate of 33% meant that ultrasound was missing 40% of appendicitis cases. DR. TAYLOR

Although this CT was suggestive of appendicitis, the patient was eventually diagnosed with a normal appendix and a case of viral gastroenteritis. Courtesy Dr. George Taylor

CHICAGO — One way to avoid diagnostic pitfalls in pediatric appendicitis is by using imaging studies effectively, Dr. George Taylor said at the annual meeting of the Radiological Society of North America.

The decision to use diagnostic computed tomography (CT) versus ultrasound should be based on a thorough understanding of the institution's strengths and weaknesses. “As in politics, all imaging is local,” said Dr. Taylor, chief of radiology at Children's Hospital Boston.

The trade-off with ultrasound is that it is radiation free, but the miss rate for ultrasound is highly dependant on the prevalence of appendicitis in the area. A local prevalence rate of 33% at Children's Hospital Boston meant that ultrasound imaging was missing 40% of appendicitis cases, Dr. Taylor said.

This finding is consistent with a recent meta-analysis that shows CT had a significantly higher sensitivity than did ultrasound in diagnostic studies of children and adults (Radiology 2006;241:83–94).

Dr. Taylor recommends using ultrasound first, followed by CT if the ultrasound findings are negative. When CT is used, efforts should be made to minimize radiation exposure by reducing the area scanned and optimizing the dose according to the child's weight and age.

The classic study on radiation risk (Am. J. Roentgenol. 2001;176:289–96) was based on the assumption that pediatric abdominal CT images were acquired at 404 milliampere-seconds (mAs) and scanned from the diaphragm to the symphysis pubis. However, Children's Hospital acquires CT images from the iliac crest to the symphysis pubis at 230 mAs. The scan results in a whole-body dose of 18–30 mCi.

At this dose, the increased risk of all cancers is 0.009%–0.15%. This is a small but significant increased risk that is acceptable when viewed against the background lifetime risk of cancer at 16%–20%, and the risk involved in having a perforated appendix, Dr. Taylor said.

Another decision to be made is the type of contrast agent used for CT scans. Among 589 children seen at Children's Hospital for suspected appendicitis, the overall visualization of the appendix was 92% for all contrast agents, 93% for rectal contrast only, 94% for rectal plus IV, and 78% for oral plus IV.

Rectal agents would appear to be the best approach, and indeed, oral and IV contrast agents were initially reserved for younger children, those with developmental delays, or those who couldn't tolerate rectal contrast. But a review of the records revealed that when only rectal contrast was used, there was so much diagnostic uncertainty that an additional CT scan was ordered in a stunning 46% of cases—a number that Dr. Taylor called unacceptable.

Because many of the additional scans required IV contrast, the hospital began using rectal and IV agents.

During the first 6 months, there was no change in the number of additional CT scans being ordered.

But after this transitional period, the percentage fell to about 3%, and after adopting an IV-only approach, there has not been a single repeat CT ordered in the last 3 years, he said.

Not only is the radiation exposure reduced, but so is the number of complaints voiced about the invasiveness of rectal contrast.

Other diagnostic challenges with CT include reduced visualization of the appendix because of a lack of mesenteric fat, especially in children younger than 6 years; a tendency to overdiagnose appendicitis; lower sensitivity for ovarian pathology; the risk of perforation with rectal contrast; and false-positive findings, most commonly associated with an appendix greater than 6 mm in size, Dr. Taylor said.

A local prevalence rate of 33% meant that ultrasound was missing 40% of appendicitis cases. DR. TAYLOR

Although this CT was suggestive of appendicitis, the patient was eventually diagnosed with a normal appendix and a case of viral gastroenteritis. Courtesy Dr. George Taylor

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos G. Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years who were hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests, with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of the Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

During the 2002–2003 flu season, the weekly prevalence of influenza virus infection peaked at 21% (range 0%–21%) in the 767 children tested in the outpatient setting. In contrast, the weekly prevalence of influenza peaked at about 60% and remained above 30% for 5 consecutive weeks among 975 children tested during the 2003–2004 flu season.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21%, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

During the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

“As our study shows, the knowledge of influenza circulation in the community is fundamental for the interpretation of rapid influenza test results,” wrote the authors, whose work was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement. Co-author Dr Katherine A. Poehling of the Department of Pediatrics, Vanderbilt University School of Medicine, received support from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Program and from a K23 grant from the National Institutes of Health and the National Institute of Allergy and Infectious Diseases.

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos G. Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years who were hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests, with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of the Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

During the 2002–2003 flu season, the weekly prevalence of influenza virus infection peaked at 21% (range 0%–21%) in the 767 children tested in the outpatient setting. In contrast, the weekly prevalence of influenza peaked at about 60% and remained above 30% for 5 consecutive weeks among 975 children tested during the 2003–2004 flu season.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21%, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

During the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

“As our study shows, the knowledge of influenza circulation in the community is fundamental for the interpretation of rapid influenza test results,” wrote the authors, whose work was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement. Co-author Dr Katherine A. Poehling of the Department of Pediatrics, Vanderbilt University School of Medicine, received support from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Program and from a K23 grant from the National Institutes of Health and the National Institute of Allergy and Infectious Diseases.

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos G. Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years who were hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests, with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of the Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

During the 2002–2003 flu season, the weekly prevalence of influenza virus infection peaked at 21% (range 0%–21%) in the 767 children tested in the outpatient setting. In contrast, the weekly prevalence of influenza peaked at about 60% and remained above 30% for 5 consecutive weeks among 975 children tested during the 2003–2004 flu season.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21%, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

During the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

“As our study shows, the knowledge of influenza circulation in the community is fundamental for the interpretation of rapid influenza test results,” wrote the authors, whose work was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement. Co-author Dr Katherine A. Poehling of the Department of Pediatrics, Vanderbilt University School of Medicine, received support from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Program and from a K23 grant from the National Institutes of Health and the National Institute of Allergy and Infectious Diseases.

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies).

Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI.

Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4).

Twenty-five of the cases were found by MRI only.

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies).

Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI.

Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4).

Twenty-five of the cases were found by MRI only.

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies).

Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI.

Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4).

Twenty-five of the cases were found by MRI only.

TUCSON, ARIZ. – Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. – Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. – Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. – Physicians and their patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000-$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. Cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

TUCSON, ARIZ. – Physicians and their patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000-$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. Cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

TUCSON, ARIZ. – Physicians and their patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000-$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. Cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

TUCSON, ARIZ. — Physicians and patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

TUCSON, ARIZ. — Physicians and patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

TUCSON, ARIZ. — Physicians and patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

All six cancers were infiltrating ductal carcinoma. The one cancer detected by all three modalities was a stage T2/N1/M0 cancer.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies). Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI. Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4). Twenty-five cases were found by MRI only.

A growing body of evidence suggests that atypical ductal hyperplasia is a genetically advanced precancerous lesion, and that, similar to DCIS, it is a nonobligatory, direct precursor of invasive ductal cancer, Dr. Riedl said.

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

All six cancers were infiltrating ductal carcinoma. The one cancer detected by all three modalities was a stage T2/N1/M0 cancer.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies). Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI. Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4). Twenty-five cases were found by MRI only.

A growing body of evidence suggests that atypical ductal hyperplasia is a genetically advanced precancerous lesion, and that, similar to DCIS, it is a nonobligatory, direct precursor of invasive ductal cancer, Dr. Riedl said.

CHICAGO — Magnetic resonance imaging detects more breast cancers in high-risk women, compared with mammography or ultrasound, according to two studies presented at the annual meeting of the Radiological Society of North America.

MRI was more sensitive but less specific in the detection of breast cancer than was mammography or ultrasound, data from the Austrian Screening Trial show. However, the lesser specificity of MRI was partially caused by a higher detection rate for atypical ductal hyperplasias, which are considered to be direct precursors of invasive ductal cancer, said Dr. Christopher Riedl of the Medical University of Vienna.

In the second study, screening MRI was associated with a higher biopsy rate, but was the only modality that detected all cancers identified in the study, conducted by the International Breast MRI Consortium and the Cancer Genetics Network. Findings of the prospective multicenter trial support single-site studies that show MRI has greater sensitivity and cancer yield than any other screening modality in high-risk populations, said Dr. Constance Lehman of the University of Washington in Seattle.

Dr. Lehman and associates performed screening mammography, MRI, and ultrasound within 90 days of each other in 171 asymptomatic women aged 25 years or older who had a known breast cancer susceptibility gene (BRCA) mutation or who were at a 20% or greater lifetime risk of breast cancer.

Sixteen biopsies were performed and six cancers were detected for an overall 3.5% diagnostic yield.

MRI detected all six cancers, while mammography detected two, and ultrasound detected one. The diagnostic yields for each test were: MRI 3.5%, mammography 1.2%, and ultrasound 0.6%, the investigators reported.

All six cancers were infiltrating ductal carcinoma. The one cancer detected by all three modalities was a stage T2/N1/M0 cancer.

MRI resulted in the highest rate of biopsies being performed (8.2% of women) compared with mammography (2.3%) and ultrasound (2.3%), she said.

Nine biopsies were performed on women whose only positive exam was an MRI. Cancer was diagnosed in four of those women, meaning that the risk of a benign biopsy based on an MRI-only positive exam was 2.9% (five of nine biopsies). Another way to interpret this finding is that, “if we screened a thousand high-risk women, adding MRI to mammography would add 29 additional benign biopsies with 30 additional invasive cancers predicted to be detected,” Dr. Lehman said.

The Austrian Screening Trial evaluated 327 women with a BRCA mutation or strong family history for breast cancer using annual MRI, mammography, and ultrasound screening between days 8 and 12 of their menstrual cycle to decrease false-positive rates due to hormonal influences. The women, aged 22–80 years (mean 41 years), underwent a total of 672 complete imaging rounds.

A total of 28 cancers were found, of which 39% were ductal carcinoma in situ (DCIS) and 61% were invasive cancers, Dr. Riedl and colleagues reported.

Of the 28 cancers, MRI detected 24, mammography 14, and ultrasound 12. Sensitivity was significantly higher for MRI (86%) than for mammography (50%) or ultrasound (43%). Almost one-half of the cancers (43%) were detected only by MRI. Of the 11 DCIS cases, MRI detected 10, mammography 5, and ultrasound 4. Five of the DCIS lesions were detected by MRI only.

MRI, mammography, and ultrasound led to 101, 25, and 26 false-positive findings, respectively, resulting in a significantly worse specificity for MRI (81%) than mammography (64%) or ultrasound (68%).

Of the total 108 false-positive findings, 39 were diagnosed as atypical ductal hyperplasia. Significantly more cases were detected by MRI (36) than by mammography (10) or ultrasound (4). Twenty-five cases were found by MRI only.

A growing body of evidence suggests that atypical ductal hyperplasia is a genetically advanced precancerous lesion, and that, similar to DCIS, it is a nonobligatory, direct precursor of invasive ductal cancer, Dr. Riedl said.

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years. The children had been hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of Vanderbilt University, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21% in the 767 children tested in the outpatient setting, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

Among 975 children tested during the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

The study was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement.

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years. The children had been hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of Vanderbilt University, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21% in the 767 children tested in the outpatient setting, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

Among 975 children tested during the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

The study was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement.

Rapid influenza antigen detection tests are helpful during the peak of an epidemic but are of limited use when prevalence is less than 10%, Dr. Carlos Grijalva and associates reported.

“Unfortunately, the prevalence of influenza among children presenting with fever or respiratory symptoms is usually not known at the time of testing; therefore it is often difficult to derive appropriate interpretations of rapid-test results,” the authors wrote (Pediatrics 2007;119:6–11).

Using data collected by the New Vaccine Surveillance Network in three U.S. counties over 4 consecutive years, the investigators compared provider-ordered rapid influenza test results with viral culture and reverse-transcription polymerase chain reaction (RT-PCR) results obtained from children older than 5 years. The children had been hospitalized with respiratory symptoms or fever from October 2000 through September 2004. Outpatient surveillance data, also collected by the network, was used to estimate the weekly prevalence of influenza.

Several types of rapid influenza tests with relatively similar reported sensitivities and specificities, were used, including Directigen A+B, Directigen A, Quick Vue A/B, and NOW Flu A/B.

Overall, 2,797 children were hospitalized during the 4 consecutive years of inpatient surveillance, and influenza infection was confirmed in 160 (6%). Only 270 of the 2,797 (10%) children had a rapid flu test ordered by the treating physician.

Of 41 children with influenza detected by standard methods, 26 were influenza-positive by a rapid test (sensitivity 63%). Among 229 children who tested negative for influenza by standard methods, 223 had a negative rapid-test result (specificity 97%), Dr. Grijalva of Vanderbilt University, Nashville, Tenn., reported.

Then the investigators used the sensitivity and specificity of rapid tests from the inpatient surveillance and the weekly prevalence of influenza in outpatient settings to determine times when the rapid tests were most predictive of influenza.

At the beginning of the mild 2002–2003 season, when the prevalence of influenza was 5%, the predictive value of the rapid tests was about 50%, meaning that a positive result was equally likely to represent a true influenza infection or a false-positive result. But, a negative rapid-test result represented a true negative about 98% of the time.

At the peak prevalence of 21% in the 767 children tested in the outpatient setting, the positive predictive value (PPV) was 85%. Throughout the entire season, the PPV of the rapid tests was 70% or greater for only 4 weeks, the authors wrote.

Among 975 children tested during the moderately severe 2003–2004 season, nearly 97% of positive rapid tests were true positives. In contrast, about 37% of children with a negative rapid-test result were false negatives. During the 7 weeks when the influenza prevalence was 15% or more, the PPV of the rapid tests was 80% or higher.

The study was funded by a Centers for Disease Control and Prevention New Vaccine Surveillance Network cooperative agreement.