JAMA: An association of high rates of inappropriate imaging for prostate
cancer and breast cancer identified in a study of Medicare beneficiaries
suggests that, at the regional level, regional culture and
infrastructure could contribute to inappropriate imaging, something
policymakers should want to consider as they seek to improve the quality
of care and reduce health care spending, according to a study published
online by JAMA Oncology.
Researchers have estimated that 30 percent of resources spent on
health care in the United States does not improve the health of
patients. Choosing Wisely is a national effort to encourage the
appropriate use of health care resources. As part of that effort, the
American Society of Clinical Oncology released a Top 5 list of tests and
procedures that could be used less without compromising care and among
them were decreasing imaging to stage patients with low-risk prostate
and breast cancers, according to background information in the study.
Danil V. Makarov, M.D., M.H.S., of the New York University School of
Medicine, and coauthors used a Surveillance, Epidemiology and End
Results (SEER)-Medicare linked database to identify patients with
low-risk prostate or breast cancer based on Choosing Wisely
definitions. Because prostate and breast cancers affect different
patient populations and are often treated by different specialists,
there should not be an association between their imaging. But a
correlation between regional rates of prostate and breast cancer imaging
suggests that regional imaging behaviors share common determinants,
according to the authors.
The authors identified 9,219 men with prostate cancer and 30,398
women with breast cancer living in 84 hospital referral regions (HRRs).
They found high rates of inappropriate imaging for both prostate cancer
(44.4 percent) and breast cancer (41.8 percent). At the HRR-level,
inappropriate prostate cancer imaging rates were associated with
inappropriate breast cancer imaging rates, according to the results. At
the patient level, for example, a man with low-risk prostate cancer had
higher odds of undergoing inappropriate imaging if he lived in an HRR
with higher inappropriate breast cancer imaging.
“Our findings suggest that practice patterns may be a function of
local propensities for health care utilization. This is a novel finding
with great relevance to cancer policy. As patients with prostate cancer
and breast cancer are a nonoverlapping cohort treated by nonoverlapping
specialists, an association of inappropriate imaging between them
suggests that regional culture and infrastructure contribute to health
care utilization patterns across disease. … Further research should be
conducted to determine the causes of regional patterns of inappropriate
imaging. Such research, including an evaluation of the clinicians and
institutions performing these tests, might help optimize policy
interventions aimed at improving the quality and lowering the cost of
health care without decreasing access to care for those who need it,”
the study concludes.
(JAMA Oncol. Published online March 12, 2015. doi:10.1001/jamaoncol.2015.37. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note: The
authors made conflict of interest and funding/support disclosures.
Please see the article for additional information, including other
authors, author contributions and affiliations, financial disclosures,
funding and support, etc.
Commentary: Diagnostic Imaging Use for Patients with Cancer
In a related editorial, Samuel Swisher-McClure, M.D., M.S.H.P., and
Justin Bekelman, M.D., of the University of Pennsylvania, Philadelphia,
write: “As our understanding of explanatory factors driving regional
patterns of health care continues to evolve, interventions designed to
educate, enhance awareness, and support shared medical decision-making
between patients and physicians are most appropriate. The Choosing Wisely
campaign is a laudable example, and it will be critical for continued
research to examine temporal trends in patterns of care following its
implementation to assess the potential effects. Payment policies that
reward high-value care and discourage low-value care are also promising.
However, as concluded by the recent IOM [Institute of Medicine] report,
smaller-level variation exists within individual HRRs, and so payment
policies applied uniformly across geographic regions may be unjust and
risk adversely affecting patient outcomes by reducing overall care
utilization regardless of appropriateness.”
(JAMA Oncol. Published online March 12, 2015. doi:10.1001/jamaoncol.2015.31. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note:
Please see the article for additional information, including other
authors, author contributions and affiliations, financial disclosures,
funding and support, etc.