Regional Variation of Computed Tomographic Imaging in the United States and the Risk of Nephrectomy

JAMA Intern Med. 2018 Feb 1;178(2):221-227. doi: 10.1001/jamainternmed.2017.7508.


Importance: While computed tomography (CT) represents a tremendous advance in diagnostic imaging, it also creates the problem of incidental detection-the identification of tumors unrelated to the clinical symptoms that initiate the test.

Objective: To determine the geographic variation in the United States in CT imaging and the corresponding association with one of the most consequential sequelae of incidental detection: nephrectomy.

Design, setting, and participants: This study is a cross-sectional analysis of age-, sex-, and race-adjusted Medicare data (January 2010-December 2014) from 306 hospital referral regions (HRRs) in the United States and includes information from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years.

Exposures: Regional CT risk (ie, the proportion of the population receiving either a chest or abdominal CT over 5 years).

Main outcomes and measures: Five-year risk of nephrectomy (partial or total).

Results: Data from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years were gathered and illustrate that 43% of Medicare beneficiaries age 65 to 85 years received either a chest or abdominal CT from January 2010 to December 2014. This risk varied across the HRRs, ranging from 31% in Santa Cruz, California, to 52% in Sun City, Arizona. Increased regional CT risk was associated with a higher nephrectomy risk (r = 0.38; 95% CI, 0.28-0.47), particularly among HRRs with more than 50 000 beneficiaries (r = 0.47; 95% CI, 0.31-0.61). After controlling for HRR adult smoking rates, imaging an additional 1000 beneficiaries was associated with 4 additional nephrectomies (95% CI, 3-5). Case-fatality rates for those who underwent nephrectomy were 2.1% at 30 days and 4.3% at 90 days.

Conclusions and relevance: Fee-for-service Medicare beneficiaries are commonly exposed to CT imaging. Those residing in high-scanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses. Additional surgery should be considered one of the risks of excessive CT imaging.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Fee-for-Service Plans / statistics & numerical data*
  • Female
  • Humans
  • Kidney Neoplasms / diagnosis*
  • Kidney Neoplasms / epidemiology
  • Kidney Neoplasms / surgery
  • Male
  • Medicare / statistics & numerical data*
  • Nephrectomy*
  • Referral and Consultation
  • SEER Program
  • Tomography, X-Ray Computed / economics
  • Tomography, X-Ray Computed / statistics & numerical data*
  • United States