The findings arrive at a moment when the clinical rationale for prebiopsy imaging has never been stronger. Multiple randomized trials have demonstrated that imaging the prostate before obtaining tissue, and then using those images to target suspicious lesions, detects more of the clinically significant, aggressive cancers that genuinely threaten a patient’s life, while reducing the detection of indolent tumors that might otherwise trigger unnecessary treatment. This evidence base has prompted professional guidelines to progressively strengthen their endorsement of MRI as a standard step before needles are placed. What had remained unknown until now, however, was whether that accumulating evidence had actually changed what happens in hospitals and clinics across the country.

To answer that question, the research team, including lead clinical research biostatistician Stephen Rhodes of the UH Urology Institute, turned to Epic Cosmos, a large-scale database built from electronic health records spanning many health systems nationwide. Unlike earlier studies that relied on insurance claims data, which often lag behind real-world practice and miss patients whose care crosses different payers, the electronic health record approach captures what actually happened to individual patients at the point of care. The scale of the dataset, encompassing more than half a million biopsies over nearly a decade, allowed the researchers to track utilization trends with unusual granularity, including how patterns differed by whether a man was undergoing his first biopsy or a repeat procedure after a previously negative result.

The trajectory was striking in both groups, but for slightly different reasons. Among men with a prior negative biopsy, where the evidence supporting MRI was established earliest and where the procedure has long been recommended to help explain persistent elevations in prostate-specific antigen, MRI use rose from 38 percent in 2017 to 67 percent by the first half of 2026. Among biopsy-naive men, the increase was even more dramatic in relative terms, nearly a fivefold rise over the study period. Rhodes described the pace of change as genuinely rapid, noting that the timing tracks closely with the publication of the major randomized trials and their successive adoption into clinical guidelines. In an era when many evidence-based practices take fifteen to twenty years to diffuse into routine care, a near-complete transformation of biopsy practice within less than a decade represents an unusually swift example of evidence translation.

Yet the study’s authors are careful to emphasize that the story is one of substantial progress coexisting with persistent gaps. A full third of men undergoing a first prostate biopsy are still not receiving an MRI beforehand, which means the procedure is being performed, in effect, blind. That matters because the decision to image first changes two things simultaneously: whether a biopsy is needed at all, and, if it is, exactly where the needles should go. A man whose MRI shows no suspicious lesions may be spared the procedure entirely, avoiding the discomfort, bleeding risk, infection risk, and potential overdiagnosis that accompany blind sampling. A man whose scan reveals a concerning lesion can undergo targeted biopsies that are far more likely to find an aggressive cancer if one is present. Skipping the scan forfeits both benefits at once.

The senior author of the study, Jonathan Shoag, MD, Chief of the Division of Urologic Oncology and Director of the Prostate Cancer Program at University Hospitals, framed the problem in terms of quality measurement and equity. He noted that the true scope of the shortfall had been difficult to pin down before this analysis, with the best prior data, derived from insurance claims through 2022, suggesting MRI was used in only about 30 percent of biopsies. The motivation for the new study, he explained, was to establish a current, national picture: how many men are getting an MRI before biopsy today, and whether everyone is benefiting equally. Shoag said he still regularly sees patients who were biopsied at other institutions without a preceding MRI, and he attributes part of the persistent gap to access barriers and issues with insurance coverage, a well-recognized national problem that the new data now illuminate more clearly.

The analysis also surfaced patterns that the researchers found worth examining rather than simply accepting. MRI use fell off in two specific groups: men with very high PSA levels and men over the age of 80. In some cases, the authors suggest, this may reflect reasonable clinical judgment, since a markedly elevated PSA in an older patient may prompt an urgent diagnostic pathway in which imaging is perceived as a delay, and life expectancy considerations may alter the calculus for men in their ninth decade. But the researchers caution that these patterns deserve scrutiny rather than assumption. If otherwise appropriate candidates for imaging are being sent directly to biopsy out of habit, expedience, or lack of access, a measurable quality gap exists that health systems can and should audit. The study’s practical message for institutions is direct: track your own MRI rates by patient group, compare them against the evidence, and act on what the audit reveals.

Even where MRI is used, quality is not uniform, and the authors flag this as an ongoing concern for the field. Prostate MRI is a technically demanding examination that depends on scanner capability, protocol design, radiologist expertise, and structured reporting standards. A poor-quality scan can miss a clinically significant lesion, giving false reassurance, or overcall suspicious findings, triggering unnecessary biopsies. Shoag described how University Hospitals has invested in rigorously tracking MRI quality and performance and how it relates to biopsy outcomes, establishing workflows that give patients access to the latest imaging and biopsy techniques, including the transperineal approach, which carries a lower infection risk than the traditional transrectal route. He noted that the institution participated in the clinical trials that established these techniques as standards and has built a program to offer targeted biopsy with sedation to all patients, while also being an early adopter that made MRI accessible across its patient population.

Beyond the numbers, the study highlights how the diagnostic journey itself is being restructured around advanced imaging. Shoag described a coordinated model in which patients with elevated PSA levels are navigated through evaluation and decision-making, supported by a point-of-service scheduling initiative that books imaging and follow-up appointments before patients leave the office. The goal is to compress the interval between an abnormal screening result and a definitive answer, reducing the anxiety and drop-off that can occur when patients must coordinate multiple appointments across weeks. The institution is currently involved in multiple studies testing new tools to further improve prostate cancer diagnosis, suggesting that the rapid diffusion documented in this paper may be followed by another wave of refinements in how men are evaluated for the disease.

For patients, the study’s most actionable conclusion may be the simplest: any man facing a prostate biopsy should be asking whether an MRI beforehand is appropriate for him. For clinicians and health systems, the paper provides both a benchmark and a warning, documenting extraordinary progress in translating randomized trial evidence into practice while quantifying the gap that remains. With two thirds of men now imaged before their first biopsy and more than two thirds before repeat procedures, prebiopsy MRI has decisively entered the mainstream of American prostate cancer care. The remaining task, the authors suggest, is to close the residual gaps in access, coverage, and quality so that the benefits of targeted, image-guided diagnosis extend to every patient who stands to gain from them, rather than to a fortunate majority.

Subject of Research: National trends in prebiopsy MRI utilization for prostate cancer detection in the United States

Article Title: University Hospitals researchers find major increase in the use of MRI before prostate biopsy

Article References: University Hospitals researchers find major increase in the use of MRI before prostate biopsy. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: prostate cancer, prebiopsy MRI, prostate biopsy, JAMA Oncology, University Hospitals, mpMRI imaging, targeted biopsy, transperineal biopsy, PSA screening, clinical guidelines, healthcare quality, Epic Cosmos

The research team, led by Mihir M. Shah and corresponding author Gordon H. Bae, performed a cross-sectional analysis of 632,916 encounters tied to atopic dermatitis within Epic Cosmos, one of the largest aggregated electronic health record networks in the world. Epic Cosmos pools de-identified data from hundreds of health systems that use Epic’s software, giving investigators a longitudinal, nationwide window into real-world care patterns that no single institution could provide. Because the dataset is de-identified and aggregated, the study constituted a secondary analysis of existing records rather than human subjects research, and institutional review board approval was not required. The sheer scale of the cohort matters: with over half a million encounters, the analysis can detect utilization differences and demographic patterns that smaller, single-center studies routinely miss.

The technical logic of a cross-sectional EHR design is straightforward but powerful. Rather than following patients forward in time, the investigators snapshot a defined period and classify each encounter by care setting, comparing emergency department visits with outpatient dermatology visits for the same diagnosis. By leveraging standardized diagnostic coding across participating institutions, the team could quantify the proportion of atopic dermatitis care delivered in emergency settings, characterize the patients who end up there, and contrast the clinical resources consumed in each environment. Emergency department care for a chronic inflammatory skin disease is, on its face, a mismatch: emergency physicians are trained to stabilize acute conditions, not to manage the long-term topology of a relapsing dermatologic disease that requires emollient regimens, topical anti-inflammatory therapy, phototherapy, and increasingly sophisticated systemic agents.

Why do patients with a chronic rash end up in the emergency department at all? The new study sits within a well-documented context of dermatologic access failure in the United States. Prior work has shown that dermatologist density varies dramatically between urban and rural counties, that appointment wait times and insurance acceptance differ across practice types, and that patients from racial and ethnic minority and underserved populations face disproportionate barriers to allergy and immunology care. When a patient’s eczema flares at two in the morning and the next dermatology appointment is months away, the emergency room becomes the only open door. Earlier research has also quantified the financial toll: emergency department visits for atopic dermatitis carry substantial costs to patients and the health system, costs that are arguably avoidable when disease is controlled in the outpatient setting.

The Cosmos findings give that national picture an unprecedented empirical foundation. With 632,916 encounters analyzed, the study provides one of the largest published snapshots of where atopic dermatitis care actually happens in American medicine. The comparison between settings is not merely descriptive bookkeeping. Emergency department encounters for a chronic skin condition signal a system-level failure of continuity: the patient arrives in crisis, receives episodic treatment, and is discharged without the longitudinal disease management that guidelines from the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology recommend. Those 2023 guidelines emphasize stepped-care management, trigger avoidance, skin barrier maintenance, and early escalation to systemic therapies for moderate to severe disease, all of which depend on an established outpatient relationship that emergency visits cannot supply.

The demographic dimension of the analysis is where the public health stakes become sharpest. Studies of allergic and immunologic disease have repeatedly documented that underserved racial and ethnic populations experience higher disease burden and lower access to specialty care, and atopic dermatitis is no exception. If the Cosmos data show that emergency departments absorb a disproportionate share of atopic dermatitis encounters among particular insurance categories, age groups, or communities, the implication is that the emergency room is functioning as a safety-net dermatology clinic of last resort. That substitution is clinically suboptimal and economically inefficient, because the emergency setting delivers the most expensive per-encounter care in the health system while offering the least continuity for a disease whose successful management is fundamentally longitudinal.

For dermatologists and health policy analysts, the study offers a measurable benchmark against which interventions can be judged. Teledermatology, for example, has been proposed as a way to extend specialty expertise into underserved regions and after-hours windows, potentially diverting flare-related visits away from emergency departments. Same-week urgent dermatology slots, integrated itch clinics, and pharmacist-guided topical therapy refills represent other structural responses. The value of a dataset like Epic Cosmos is that it establishes the baseline: how many encounters, in which settings, among which populations. Without that baseline, it is impossible to know whether an intervention actually moved the needle. With it, health systems can set concrete targets, such as reducing the fraction of atopic dermatitis care delivered in emergency settings year over year.

The study also showcases a methodological shift reshaping clinical research. Epic Cosmos aggregates billing, diagnostic, and demographic data across a vast consortium of health systems, allowing cross-sectional analyses at a scale that approaches population-level surveillance. Such datasets democratize research: a research letter from a dermatology department can now characterize national care patterns that once required multi-year, multi-center prospective registries costing millions of dollars. The trade-offs are real, however. EHR data reflect care that was documented, not care that was needed but never sought, and coding practices vary across institutions. Cross-sectional designs capture association, not causation, and cannot fully disentangle whether patients choose emergency care, are forced into it, or are triaged there by constrained outpatient capacity. The authors acknowledge these constraints by framing the work as a cross-sectional analysis rather than a causal study.

What emerges from the 632,916 encounters is ultimately a systems diagnosis rather than a laboratory finding. Atopic dermatitis is a controllable chronic disease with an expanding therapeutic arsenal, from topical calcineurin inhibitors to biologic and oral systemic agents. Yet when a substantial share of its care migrates into emergency departments, the message is that the routine, relationship-based infrastructure needed to deploy that arsenal is not reaching everyone. The Stanford-led team, which reported no conflicts of interest and no dedicated funding for the work, offers the analysis as a call to quantify and close the gap between where eczema care is delivered and where it should be. As electronic health record networks grow and therapeutic options multiply, studies of this scale will increasingly define the frontier of dermatologic health services research, turning the humble rash into a lens through which the inequities of American health care come into sharp focus.

Subject of Research: Emergency department versus outpatient dermatology care utilization for atopic dermatitis analyzed across 632,916 encounters in the Epic Cosmos electronic health record database.

Article Title: Emergency department vs. outpatient dermatology care for atopic dermatitis: a cross-sectional analysis of 632,916 encounters in epic cosmos

Article References: Shah, M. M., Pour Mohammad, A., Bhatt, M., Ko, J. M., & Bae, G. H. (2026). Emergency department vs. outpatient dermatology care for atopic dermatitis: a cross-sectional analysis of 632,916 encounters in epic cosmos. Archives of Dermatological Research, 318(1), Article 454. https://doi.org/10.1007/s00403-026-04957-1

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04957-1

Keywords: atopic dermatitis, eczema, emergency department, outpatient dermatology, Epic Cosmos, electronic health records, health care utilization, dermatologist access, health disparities, cross-sectional analysis, Emergency, department