State breast density notification laws increase follow-up breast ultrasound utilization

By Staff News Brief

What impact have state breast density notification laws had on supplemental imaging utilization?

The Harvey L. Neiman Health Policy Institute, a medical imaging socioeconomic research organization in Reston, VA, recently underwrote research to find the answer.

Breast density notification laws are meant to educate women about the increased risk of breast cancer associated with such breast tissue. However, legislation enacted in 31 states currently varies widely and is highly controversial.  

The research sponsored by the institute seeks to identify characteristics of state-level policies that are associated with increased supplemental breast ultrasound following screening mammograms. Principal investigator Michal Horný, PhD, assistant professor in the department of radiology and imaging sciences at Emory University School of Medicine in Atlanta, determined that follow-up breast ultrasound exams increased by about 1% in states with legislation, and that the cost for every 1% increase was approximately $95 million. Whether the cost of this additional screening is beneficial remains unknown.

The authors reviewed the characteristics of legislation enacted by 2014 in 20 states. They chose breast ultrasound because it is the exam most likely to be performed after screening mammography. Researchers looked at:

  • the target population to be educated;
  • the required means of improving awareness of breast tissue density;
  • whether the language used explicitly suggested that patients might benefit from supplemental testing; and,
  • whether health plans were required to cover supplemental imaging.

The authors sampled 13.5 million screening mammograms of 7.7 million women aged 40 to 64 performed between 2007 and 2014 to determine how many breast ultrasounds were performed within 30 days of the mammograms. Most women (63%) had preferred provider organization (PPO) health insurance,  while 13% who were enrolled in a health maintenance organization (HMO). The sample was extracted from the Truven Health MarketScan Commercial Claims and Encounters Database compiled from major employer-sponsored health plans in the United States.

Except for Connecticut (15%), New Jersey (15%), and New York (18%),  some 5% to 7% of women had follow-up ultrasound exams before legislation was implemented. Follow-up ultrasound within 30 days of mammography increased by 1% in states with a basic notification law requiring providers send notifications to women with heterogeneously dense or extremely dense breasts. These notifications did not have to mention the patient might benefit from supplemental imaging. It also did not require health plans to fully cover this imaging. In states requiring full coverage, utilization increased by 3.5 percentage points, the authors reported in the July 20 online article in Medical Care.

Illinois law differed from the other 19 states by requiring the state Department of Public Health to publish a summary about breast density, but it did not specify how the summary should be distributed or mandate healthcare providers to give it to patients. The authors stated that this approach was not as impactful with respect to increases in supplemental imaging as states with notification laws. They also noted that a relatively small effect also was identified in Utah, where notification of patients was suggested but not mandated. The more targeted letters specifically were to women with dense breasts and the more directly the language of the letter was addressed to them, the greater the increase in ultrasound follow-up examinations were.

Dr. Horný and his co-authors noted that the effect of state legislation was “relatively modest”, with follow-up imaging increasing no more than five percentage points, the financial implications could be considerable.

“Low-involvement approaches such as a passive provision of information may not have the impact desired by the interested stakeholders,” they wrote. “But, high-involvement approaches such as mandating certain behaviors of patients, providers or payers may intensify the impact, but carry with them considerable costs.” The authors said that the average payment for a breast ultrasound exam in their sample was $187.

The study did not include any analysis relating to the number of breast cancers identified by supplemental breast ultrasound examinations. Whether laws are clinically benefitting dense breasted women remains unknown.


  1. Horný M, Shwartz M, Duszak R Jr, et al. Characteristics of state polices impact health care delivery: An analysis of mammographic dense breast notification and insurance legislation. Med Care. Published online July 20, 2018. doi: 10.1097/MLR.0000000000000967.
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State breast density notification laws increase follow-up breast ultrasound utilization.  Appl Radiol. 

By Staff News Brief| August 29, 2018

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