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Characteristics of State Policies Impact Health Care Delivery: An Analysis of Mammographic Dense Breast Notification and Insurance Legislation

Horný, Michal, PhD, MSc*,†,‡; Shwartz, Michael, PhD§,∥; Duszak, Richard Jr, MD*; Christiansen, Cindy L., PhD; Cohen, Alan B., ScD§; Burgess, James F. Jr, PhD‡,∥

doi: 10.1097/MLR.0000000000000967
Original Articles

Background: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies.

Objective: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound.

Research Design: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws.

Subjects: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40–64 years that resided in a state that had implemented relevant legislation during that period.

Measures: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators.

Results: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect.

Conclusions: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

*Department of Radiology and Imaging Sciences, Emory University School of Medicine

Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, GA

Department of Health Law, Policy, and Management, Boston University School of Public Health

§Boston University Questrom School of Business

US Department of Veterans Affairs, Center for Healthcare Organization & Implementation Research, Boston, MA

The study was conducted as part of M.H.’s dissertation research, which was supported by a research grant from the Harvey L. Neiman Health Policy Institute. R.D. also receives research support from the Harvey L. Neiman Health Policy Institute.

Preliminary results of the analysis were presented at the AcademyHealth Annual Research Meeting, June 25, 2017, New Orleans, LA.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

M.H. has equity interest in Doc Odds, LLC. The research presented is not related to the disclosed interests above. The remaining authors declare no conflict of interest.

Reprints: Michal Horný, PhD, MSc, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 101 Woodruff Circle, Woodruff Memorial Research Building, Room 1215A, Atlanta, GA 30322. E-mail:

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