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Sundaresan V, Lokeshwar S, Sutherland R, Sohoni N, Golos A, Ajjawi I, Leapman M. Sociodemographic disparities in prostate cancer imaging. Abdom Radiol (NY) 2024:10.1007/s00261-024-04603-2. [PMID: 39325212 DOI: 10.1007/s00261-024-04603-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 09/15/2024] [Accepted: 09/17/2024] [Indexed: 09/27/2024]
Abstract
Imaging is central to the diagnosis, staging, treatment planning, and monitoring of prostate cancer (PCa). Unequal access to new imaging techniques may directly contribute to gaps in PCa treatment and outcome. Thus, identifying disparities in PCa diagnosis and treatment are centrla to informing strategies to promote equitable cancer care. This review examines the existing evidence regarding clinical and sociodemographic factors associated with disparities in imaging utilization and treatment for PCa. Major areas of disparities identified include healthcare and research access. Sociodemographic disparities are present in screening and diagnosis; Black patients are consistently less likely to receive both prostate multiparametric MRI and timely molecular imaging used to evaluate for biochemical recurrence. Regional variation in appropriate and inappropriate diagnostic imaging also contributes to corresponding differences in outcomes, especially between urban and rural settings. Delays in PCa imaging and diagnosis also delay definitive treatment or placement on active surveillance, with prominent differences by race and measures of social advantage Recognition of these disparities in PCa imaging and treatment can reinforce actions to improve equitable access to patients affected by PCa. Identifying modifiable steps in the PCa diagnosis, staging, and treatment workflow may inform interventions to bridge gaps in cancer outcome.
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Lange SM, Choudry MM, Hunt TC, Ambrose JP, Haaland BA, Lowrance WT, Hanson HA, O’Neil BB. Impact of choosing wisely on imaging in men with newly diagnosed prostate cancer. Urol Oncol 2023; 41:48.e19-48.e26. [PMID: 36307366 PMCID: PMC9808817 DOI: 10.1016/j.urolonc.2022.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Encouraging the appropriate use of staging imaging in patients with newly diagnosed prostate cancer remains a challenge. Assessing the effects of national efforts may help guide future initiatives in curtailing low-value care. The purpose of this study was to determine the impact of the Choosing Wisely campaign on imaging utilization among men with prostate cancer. METHODS Surveillance, Epidemiology, and End Results - Medicare data were used to complete a longitudinal population-based study of men diagnosed with prostate cancer from 2007 to 2015. An interrupted time series analysis evaluated the impact of the Choosing Wisely campaign on trends of imaging utilization. RESULTS From 2007 to 2015 imaging utilization in low-risk patients decreased, with computed tomography (CT) usage declining from 45.0% to 34.4% (P<0.001) and nuclear medicine bone scan (NMBS) from 27.8% to 11.7% (P<0.001). Choosing Wisely likely contributed to an absolute reduction of 2.9% (P=0.03) in utilization of NMBS in the low-risk population. Imaging usage for all modalities increased in the high-risk population, but with 32.8% continuing to not receive guideline-supported imaging. CONCLUSIONS In 2012, the Choosing Wisely campaign sought to decrease inappropriate staging imaging for men with low-risk prostate cancer and encourage stewardship of medical resources. Overall decreases in staging imaging trends suggest a move towards higher value care. However, this study found that the Choosing Wisely recommendations had a modest impact on utilization of NMBS, but not CT or PET scans. These results may help inform future efforts to promote guideline concordant imaging.
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Affiliation(s)
- Suzanne M. Lange
- Division of Urology, University of Utah, Salt Lake City, Utah, USA
| | - Mouneeb M. Choudry
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Trevor C. Hunt
- Department of Urology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacob P. Ambrose
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Benjamin A. Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | | | - Heidi A. Hanson
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Brock B. O’Neil
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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3
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Leapman MS, Dinan M, Pasha S, Long J, Washington SL, Ma X, Gross CP. Mediators of Racial Disparity in the Use of Prostate Magnetic Resonance Imaging Among Patients With Prostate Cancer. JAMA Oncol 2022; 8:687-696. [PMID: 35238879 PMCID: PMC8895315 DOI: 10.1001/jamaoncol.2021.8116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Racial disparity in the use of prostate magnetic resonance imaging (MRI) presents obstacles to closing gaps in prostate cancer diagnosis, treatment, and outcome. Objective To identify clinical, sociodemographic, and structural processes underlying racial disparity in the use of prostate MRI among men with a new diagnosis of prostate cancer. Design, Setting, and Participants This population-based cohort study used mediation analysis to assess claims in the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database for prostate MRI among 39 534 patients with a diagnosis of localized prostate cancer from January 1, 2011, to December 31, 2015. Statistical analysis was performed from April 1, 2020, to September 1, 2021. Exposure Diagnosis of prostate cancer. Main Outcomes and Measures Claims for prostate MRI within 6 months before or after diagnosis of prostate cancer were assessed. Candidate clinical and sociodemographic meditators were identified based on their association with both race and prostate MRI, including the Index of Concentration at the Extremes (ICE), as specified to measure racialized residential segregation. Mediation analysis was performed using nonlinear multiple additive regression trees models to estimate the direct and indirect effects of mediators. Results A total of 39 534 eligible male patients (3979 Black patients [10.1%] and 32 585 White patients [82.4%]; mean [SD] age, 72.8 [5.3] years) were identified. Black patients with prostate cancer were less likely than White patients to receive a prostate MRI (6.3% vs 9.9%; unadjusted odds ratio, 0.62, 95% CI, 0.54-0.70). Approximately 24% (95% CI, 14%-32%) of the racial disparity in prostate MRI use between Black and White patients was attributable to geographic differences (SEER registry), 19% (95% CI, 11%-28%) was attributable to neighborhood-level socioeconomic status (residence in a high-poverty area), 19% (95% CI, 10%-29%) was attributable to racialized residential segregation (ICE quintile), and 11% (95% CI, 7%-16%) was attributable to a marker of individual-level socioeconomic status (dual eligibility for Medicare and Medicaid). Clinical and pathologic factors were not significant mediators. In this model, the identified mediators accounted for 81% (95% CI, 64%-98%) of the observed racial disparity in prostate MRI use between Black and White patients. Conclusions and Relevance In this this population-based cohort study of US adults, mediation analysis revealed that sociodemographic factors and manifestations of structural racism, including poverty and residential segregation, explained most of the racial disparity in the use of prostate MRI among older Black and White men with prostate cancer. These findings can be applied to develop targeted strategies to improve cancer care equity.
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Affiliation(s)
- Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Michaela Dinan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Saamir Pasha
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Jessica Long
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Samuel L. Washington
- Department of Urology, University of California, San Francisco, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Lesley J J Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fiona M Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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Lunn Y, Patel R, Sokphat TS, Bourn L, Fields K, Fitzgerald A, Sundaresan V, Thomas G, Korvink M, Gunn LH. Assessing Hospital Resource Utilization with Application to Imaging for Patients Diagnosed with Prostate Cancer. Healthcare (Basel) 2022; 10:healthcare10020248. [PMID: 35206863 PMCID: PMC8872431 DOI: 10.3390/healthcare10020248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Resource utilization measures are typically modeled by relying on clinical characteristics. However, in some settings, those clinical markers are not available, and hospitals are unable to explore potential inefficiencies or resource misutilization. We propose a novel approach to exploring misutilization that solely relies on administrative data in the form of patient characteristics and competing resource utilization, with the latter being a novel addition. We demonstrate this approach in a 2019 patient cohort diagnosed with prostate cancer (n = 51,111) across 1056 U.S. healthcare facilities using Premier, Inc.’s (Charlotte, NC, USA) all payor databases. A multivariate logistic regression model was fitted using administrative information and competing resources utilization. A decision curve analysis informed by industry average standards of utilization allows for a definition of misutilization with regards to these industry standards. Odds ratios were extracted at the patient level to demonstrate differences in misutilization by patient characteristics, such as race; Black individuals experienced higher under-utilization compared to White individuals (p < 0.0001). Volume-adjusted Poisson rate regression models allow for the identification and ranking of facilities with large departures in utilization. The proposed approach is scalable and easily generalizable to other diseases and resources and can be complemented with clinical information from electronic health record information, when available.
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Affiliation(s)
- Yazmine Lunn
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
| | - Rudra Patel
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
| | - Timothy S. Sokphat
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | - Laura Bourn
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | - Khalil Fields
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | - Anna Fitzgerald
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | - Vandana Sundaresan
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | - Greeshma Thomas
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
| | | | - Laura H. Gunn
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (Y.L.); (R.P.); (T.S.S.); (L.B.); (K.F.); (A.F.); (V.S.)
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA;
- Faculty of Medicine, School of Public Health, Imperial College London, London W6 8RP, UK
- Correspondence:
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6
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Leapman MS, Wang R, Park HS, Yu JB, Sprenkle PC, Dinan MA, Ma X, Gross CP. Adoption of New Risk Stratification Technologies Within US Hospital Referral Regions and Association With Prostate Cancer Management. JAMA Netw Open 2021; 4:e2128646. [PMID: 34623406 PMCID: PMC8501394 DOI: 10.1001/jamanetworkopen.2021.28646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE The clinical decisions that arise from prostate magnetic resonance imaging (MRI) and genomic testing in patients with prostate cancer are not well understood. OBJECTIVE To evaluate the association between regional uptake of prostate MRI and genomic testing and observation vs treatment for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of commercial insurance claims for prostate MRI and genomic testing included 65 530 patients 40 to 89 years of age newly diagnosed with prostate cancer from July 1, 2012, through June 30, 2019. EXPOSURES Patient- and regional-level use of prostate MRI and genomic testing. MAIN OUTCOMES AND MEASURES Observation vs definitive treatment for prostate cancer. Patient-level analyses examined the association between receipt of testing or residing in a hospital referral region (HRR) that adopted testing and observation. In regional-level analyses, the dependent variable was the change in the proportion of patients observed for prostate cancer at the HRR level between 2 periods: July 1, 2012, to June 30, 2014, and July 1, 2017, to June 20, 2019. The independent study variables included HRR-level changes in the proportion of men undergoing prostate MRI and genomic testing between these periods, and the models were adjusted for contextual factors associated with prostate cancer care and socioeconomic status. RESULTS This study identified 65 530 patients, including 27 679 in the early period (mean [SD] age, 58.0 [5.9] years) and 37 851 in the late period (mean [SD] age, 59.0 [5.7] years). Use of prostate MRI increased significantly from 7.2% (95% CI, 6.9%-7.5%) to 16.7% (95% CI, 16.3%-17.1%) from the early to late period. Use of genomic testing increased significantly from 1.3% (95% CI, 1.1%-1.4%) to 12.7% (95% CI, 12.3%-13.0%) from the early to late period. Compared with the lowest, the highest HRR quartiles of prostate MRI and genomic testing uptake were associated with an adjusted 4.1% (SE, 1.1%; P < .001) and 2.5% (SE, 1.1%; P = .03) absolute increase in the proportion of patients receiving observation, respectively. CONCLUSIONS AND RELEVANCE In this cohort study, uptake of prostate MRI and genomic testing was associated with increased use of initial observation vs treatment for prostate cancer. Marked geographic variation supports the need for further patient-level research to optimize the dissemination and outcome of testing.
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Affiliation(s)
- Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Henry S. Park
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James B. Yu
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | | | - Michaela A. Dinan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Winn AN, Kelly M, Ciprut S, Walter D, Gold HT, Zeliadt SB, Sherman SE, Makarov DV. The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer. Cancer Rep (Hoboken) 2021; 5:e1468. [PMID: 34137520 PMCID: PMC8842701 DOI: 10.1002/cnr2.1468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent. Aim To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases. Methods To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis. Results When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective. Conclusion This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.
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Affiliation(s)
- Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
| | - Steven B Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Scott E Sherman
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
| | - Danil V Makarov
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
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8
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Rodin D, Glicksman RM, Clark K, Kakani P, Cheung MC, Singh S, Rosenthal M, Sinaiko AD. Mammographic Surveillance in Older Women With Breast Cancer in Canada and the United States: Are We Choosing Wisely? Pract Radiat Oncol 2021; 11:e384-e394. [PMID: 33753302 DOI: 10.1016/j.prro.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/06/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Guidelines on mammographic surveillance after breast cancer treatment have been disseminated internationally and incorporated into Choosing Wisely recommendations to reduce low-value care. However, adherence within different countries before their publication is unknown. METHODS AND MATERIALS Low-value mammography, defined as "short-interval" (within 6 months of radiation) or "high-frequency" (>1 within 12 months of radiation), was compared in Medicare fee-for-service in the United States and Ontario, Canada. Women ≥65 years diagnosed with breast cancer who underwent breast-conserving therapy with a minimum of 24 months of follow-up were included (n = 19,715 United States; 6479 Ontario). Secondary outcomes were patient and physician characteristics associated with discordance. RESULTS Short-interval mammography was higher in the United States than in Ontario (55.9% vs 38.0%, P < .001), as was high-frequency (39.6% vs 7.9%, P < .001). In Ontario, younger age (42% ≥85 vs 58% <74 years, P < .001) and chemotherapy (69% vs 51%, P < .001) were associated with short-interval mammography; in the United States, age, earlier diagnosis year, stage, chemotherapy, rurality, and academic center treatment were associated with greater use. Chemotherapy was associated with high-frequency mammography in both countries (13% vs 7% in Ontario, P < .001; 69% vs 51% in United States, P = .02); younger age, earlier diagnosis year, stage, and nonacademic center treatment were associated in the United States. In both countries, radiation oncologists had the highest proportion of providers ordering low-value mammograms. CONCLUSIONS Despite significant evidence guiding surveillance mammography recommendations, there are high rates of short-interval mammography in both the United States and Ontario, and high rates of high-frequency mammography in the United States. Further international efforts, such as Choosing Wisely, are needed to reduce low-value mammography.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
| | - Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn Clark
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Pragya Kakani
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Simron Singh
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Meredith Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Anna D Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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9
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Leapman MS, Wang R, Ma S, Gross CP, Ma X. Regional Adoption of Commercial Gene Expression Testing for Prostate Cancer. JAMA Oncol 2021; 7:52-58. [PMID: 33237277 DOI: 10.1001/jamaoncol.2020.6086] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Although tissue-based genomic tests can aid in treatment decision-making for patients with prostate cancer, little is known about their clinical adoption. Objective To evaluate regional adoption of genomic testing for prostate cancer and understand common trajectories of uptake shared by regions. Design, Setting, and Participants This dynamic cohort study of patients diagnosed with prostate cancer used administrative claims from Blue Cross Blue Shield Axis, the largest source of commercial health insurance in the US, to characterize temporal trends in the use of commercial, tissue-based genomic testing and calculate the proportion of tested patients at the hospital referral region (HRR) level. Eligible patients from July 1, 2012, through June 30, 2018, were those aged 40 to 89 years with prostate cancer diagnosed from July 1, 2012, through June 30, 2018. Main Outcomes and Measures Group-based trajectory modeling was used to classify regions according to discrete trajectories of adoption of commercial, tissue-based genomic testing for prostate cancer. Across regions with distinct trajectories, HRR-level sociodemographic and health care contextual characteristics were compared, using data previously calculated among Medicare beneficiaries. Results A total of 92 418 men with prostate cancer who met inclusion criteria were identified; the median (interquartile range) age at diagnosis was 60 (56-63) years. Overall, the proportion of patients who received genomic testing increased from 0.8% in July 2012 to June 2013 to 11.3% in July 2017 to June 2018. Trajectory modeling identified 5 distinct regional trajectories of genomic testing adoption. Although less than 1% of patients in each group were tested at baseline, group 1 (lowest adoption) increased to 4.0%. Groups 2 (7.8%), 3 (14.6%), and 4 (17.3%) experienced more modest growth, while in group 5 (highest adoption), use increased to 33.8% of patients tested from June 2017 to July 2018. Compared with regions that more slowly adopted testing, HRRs with the highest rate of adoption (group 5) had higher HRR-level education measures (percentage [SD] with college education: group 1, 25.6% [4.8%]; vs group 2, 27.5% [7.3%]; vs group 3, 30.3% [9.1%]; vs group 4, 29.8% [8.2%]; vs group 5, 30.4% [11.4%]; P for trend = .03), median (SD) household income (group 1, $50 412.8 [$6907.4]; vs group 2, $54 419.6 [$11 324.5]; vs group 3, $61 424.0 [$17 723.8]; vs group 4, $58 508.3 [$15 174.6]; vs group 5, $58 367.0 [$13 180.5]; P for trend = .005), and prostate cancer resources, including clinician density (No. [SD] of clinicians per 100 000: group 1, 2.5 [0.3]; vs group 2, 2.5 [0.5]; vs group 3, 2.6 [0.5]; vs group 4, 2.7 [0.7]; vs group 5, 2.6 [0.5]; P for trend = .04) and prostate cancer screening (percentage [SD] of prostate-specific antigen testing among patients aged 68-74 y: group 1, 29.4% [11.8%]; vs group 2, 32.4% [11.2%]; vs group 3, 33.1% [12.7%]; vs group 4, 36.1% [9.7%]; vs group 5, 28.8% [11.8%]; P for trend = .05). Conclusions and Relevance In this cohort study of patients with prostate cancer, the adoption of commercial tissue-based genomic testing for prostate cancer was highly variable in the US at the regional level and may be associated with contextual measures related to socioeconomic status and patterns of prostate cancer care. These findings highlight factors underlying differential adoption of prognostic technologies for patients with cancer.
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Affiliation(s)
- Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Shuangge Ma
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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11
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Shah H, Surujballi J, Awan AA, Hutton B, Arnaout A, Shorr R, Vandermeer L, Alzahrani MJ, Clemons M. A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management. Breast Cancer Res Treat 2020; 185:533-547. [PMID: 33156490 DOI: 10.1007/s10549-020-06009-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Choosing Wisely (CW)® was created by the American Board of Internal Medicine (ABIM) to promote patient-physician conversations about unnecessary medical interventions. Similarly, other countries created their own panels of experts called "CW® campaigns" which review recommendations submitted by that country's oncology societies. We performed a scoping review to consolidate CW® recommendations from different groups with respect to breast cancer care. METHODS A systematic search of Medline and Embase was designed by an information specialist for publications presenting CW® recommendations for breast cancer care practices from 2011-2020. We also reviewed the websites of all CW® campaigns and reference sections of each CW® recommendation. Two reviewers independently screened studies for inclusion and performed data extraction. Findings were summarized narratively. RESULTS Review of ABIM CW® recommendations showed 19 breast cancer-related recommendations pertaining to; screening (n = 4), radiological staging (n = 2), treatment (n = 10), surveillance (n = 2), and miscellaneous (genetic testing; n = 1). Of 22 countries with CW® campaigns, 10 published recommendations for breast cancer. Over half (57%) of recommendations were supported by more than one country. No recommendations were refuted between campaigns. Two campaigns developed 3 novel recommendations on new topics, including chemotherapy in ductal carcinoma in situ (Italy) and comparison of screening imaging modalities (Portugal). CONCLUSIONS CW® recommendations focus on reducing overutilization of investigations and treatments. There was a high rate of consensus between different CW® campaigns. As health care systems globally move attention to reduce low-value care, further studies are required to address adherence to these current recommendations and develop new recommendations.
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Affiliation(s)
- Hely Shah
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Julian Surujballi
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON, Canada
| | - Arif Ali Awan
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON, Canada
| | - Brian Hutton
- The University of Ottawa, School of Epidemiology and Public Health, and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Angel Arnaout
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | | | - Mashari Jemaan Alzahrani
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON, Canada
| | - Mark Clemons
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada. .,Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON, Canada. .,The University of Ottawa, School of Epidemiology and Public Health, and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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12
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Miles RC, Lee CI, Sun Q, Bansal A, Lyman GH, Specht JM, Fedorenko CR, Greenwood-Hickman MA, Ramsey SD, Lee JM. Patterns of Surveillance Advanced Imaging and Serum Tumor Biomarker Testing Following Launch of the Choosing Wisely Initiative. J Natl Compr Canc Netw 2020; 17:813-820. [PMID: 31319393 DOI: 10.6004/jnccn.2018.7281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/06/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to assess advanced imaging (bone scan, CT, or PET/CT) and serum tumor biomarker use in asymptomatic breast cancer survivors during the surveillance period. PATIENTS AND METHODS Cancer registry records for 2,923 women diagnosed with primary breast cancer in Washington State between January 1, 2007, and December 31, 2014, were linked with claims data from 2 regional commercial insurance plans. Clinical data including demographic and tumor characteristics were collected. Evaluation and management codes from claims data were used to determine advanced imaging and serum tumor biomarker testing during the peridiagnostic and surveillance phases of care. Multivariable logistic regression models were used to identify clinical factors and patterns of peridiagnostic imaging and biomarker testing associated with surveillance advanced imaging. RESULTS Of 2,923 eligible women, 16.5% (n=480) underwent surveillance advanced imaging and 31.8% (n=930) received surveillance serum tumor biomarker testing. Compared with women diagnosed before the launch of the Choosing Wisely campaign in 2012, later diagnosis was associated with lower use of surveillance advanced imaging (odds ratio [OR], 0.68; 95% CI, 0.52-0.89). Factors significantly associated with use of surveillance advanced imaging included increasing disease stage (stage III: OR, 3.65; 95% CI, 2.48-5.38), peridiagnostic advanced imaging use (OR, 1.76; 95% CI, 1.33-2.31), and peridiagnostic serum tumor biomarker testing (OR, 1.35; 95% CI, 1.01-1.80). CONCLUSIONS Although use of surveillance advanced imaging in asymptomatic breast cancer survivors has declined since the launch of the Choosing Wisely campaign, frequent use of surveillance serum tumor biomarker testing remains prevalent, representing a potential target for further efforts to reduce low-value practices.
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Affiliation(s)
- Randy C Miles
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Christoph I Lee
- Department of Radiology, University of Washington Medical Center
| | - Qin Sun
- Fred Hutchinson Cancer Research Center
| | | | | | - Jennifer M Specht
- Department of Oncology, University of Washington Medical Center, and
| | | | | | | | - Janie M Lee
- Department of Radiology, University of Washington Medical Center
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13
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Carpenter CP, Johnston D, Tourville E, Sharadin C, Alzubaidi AN, Giel DW. Inappropriate imaging for management of cryptorchidism: Has the choosing Wisely® recommendation reduced occurrence? J Pediatr Urol 2020; 16:462.e1-462.e6. [PMID: 32674979 DOI: 10.1016/j.jpurol.2020.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/06/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral. OBJECTIVE The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR. STUDY DESIGN We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05. RESULTS 1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p < 0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p = 0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p = 0.61). CONCLUSION Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.
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Affiliation(s)
- Christina P Carpenter
- Department of Urology, Division of Pediatric Urology, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA; Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | | | - Elizabeth Tourville
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia Sharadin
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ahmad N Alzubaidi
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dana W Giel
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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Lupichuk S, Tilley D, Surgeoner B, King K, Joy AA. Unwarranted imaging for distant metastases in patients with newly diagnosed ductal carcinoma in situ and stage I and II breast cancer. Can J Surg 2020; 63:E100-E109. [PMID: 32109016 DOI: 10.1503/cjs.003519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background In 2012, the American Society of Clinical Oncology (ASCO) released a Choosing Wisely Top Five list that included a recommendation against ordering advanced imaging tests to screen for metastases among asymptomatic patients with early breast cancer. Our provincial breast cancer staging guideline was subsequently updated. We report on the use of unwarranted bone scanning (BS), computed tomography (CT), nonbreast magnetic resonance imaging (MRI) and positron emission tomography (PET) among women diagnosed with stage 0–II breast cancer in Alberta in 2011–2015. Methods The cohort was retrospectively ascertained from the Alberta Cancer Registry. We used additional provincial data sources to obtain information about diagnostic imaging tests completed from biopsy to surgical date plus 4 months. The reason for each BS, CT, MRI and PET was abstracted. We calculated the frequency of advanced imaging tests completed for routine metastatic screening. Results Of 10 142 patients included, 2887 (28.5%) had at least 1 advanced imaging test completed for routine metastatic screening. Of these 2887 patients, 438 (15.2%) had a follow-up BS, CT, MRI or PET, and 28 patients (1.0%) had a nonbreast imageguided biopsy. Use of routine advanced imaging tests did not change clearly over time. Conclusion Our results demonstrate persistent use of advanced imaging tests for routine metastatic screening among patients with stage 0–II breast cancer despite the release of the ASCO Choosing Wisely recommendations and the update of our provincial breast cancer staging guideline. Investigation of strategies for guideline translation to improve upon value-based care of patients with early breast cancer is warranted.
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Affiliation(s)
- Sasha Lupichuk
- From the Tom Baker Cancer Centre, Calgary, Alta. (Lupichuk); CancerControl Alberta, Alberta Health Services, Calgary, Alta. (Tilley, Surgeoner); and the Cross Cancer Institute, Edmonton, Alta. (King, Joy)
| | - Derek Tilley
- From the Tom Baker Cancer Centre, Calgary, Alta. (Lupichuk); CancerControl Alberta, Alberta Health Services, Calgary, Alta. (Tilley, Surgeoner); and the Cross Cancer Institute, Edmonton, Alta. (King, Joy)
| | - Brae Surgeoner
- From the Tom Baker Cancer Centre, Calgary, Alta. (Lupichuk); CancerControl Alberta, Alberta Health Services, Calgary, Alta. (Tilley, Surgeoner); and the Cross Cancer Institute, Edmonton, Alta. (King, Joy)
| | - Karen King
- From the Tom Baker Cancer Centre, Calgary, Alta. (Lupichuk); CancerControl Alberta, Alberta Health Services, Calgary, Alta. (Tilley, Surgeoner); and the Cross Cancer Institute, Edmonton, Alta. (King, Joy)
| | - Anil Abraham Joy
- From the Tom Baker Cancer Centre, Calgary, Alta. (Lupichuk); CancerControl Alberta, Alberta Health Services, Calgary, Alta. (Tilley, Surgeoner); and the Cross Cancer Institute, Edmonton, Alta. (King, Joy)
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15
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Laviana AA, Luckenbaugh AN, Resnick MJ. Trends in the Cost of Cancer Care: Beyond Drugs. J Clin Oncol 2020; 38:316-322. [PMID: 31804864 PMCID: PMC6994251 DOI: 10.1200/jco.19.01963] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 01/10/2023] Open
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Highlighting a Common Quality of Care Delivery Problem: Overuse of Low-value Healthcare Services. J Healthc Qual 2019; 40:201-208. [PMID: 28846551 DOI: 10.1097/jhq.0000000000000095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-value healthcare services (LVHS) are defined as procedures delivered that provide little or no clinical benefit. Overuse of LVHS, or delivery when the risks exceed the benefits, contributes to excessive spending without improved outcomes. Furthermore, overuse contributes to healthcare waste. PURPOSE The primary purpose of this commentary is to (1) examine the problem of LVHS overuse and its impacts on quality care delivery and (2) propose factors to consider in developing quality measures to help reduce overuse and waste and thus improve patient outcomes. METHODS To inform and support this commentary, we conducted a limited review of the literature related to LVHS overuse, its consequences, and suggested solutions. Online search engines were used to identify research related to our primary areas of interest. RESULTS This commentary demonstrates that overuse and associated healthcare waste is growing among selected LVHS. The factors of overuse are multidimensional and poorly understood. Meanwhile, overuse of LVHS has financial consequences and impacts quality of care and outcomes. CONCLUSIONS Overuse of LVHS is common in the United States, leading to waste and suboptimal patient outcomes. Thus a need exists to address overuse and develop measures to capture a larger scope of services.
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Chimonas S, Fortier E, Li DG, Lipitz-Snyderman A. Facts and Fears in Public Reporting: Patients' Information Needs and Priorities When Selecting a Hospital for Cancer Care. Med Decis Making 2019; 39:632-641. [PMID: 31226909 DOI: 10.1177/0272989x19855050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. Public reporting on the quality of provider care has the potential to empower patients to make evidence-based decisions. Yet patients seldom consult resources such as provider report cards in part because they perceive the information as irrelevant. To inform more effective public reporting, we investigated patients' information priorities when selecting a hospital for cancer treatment. We hypothesized that patients would be most interested in data on clinical outcomes. Methods. An experienced moderator led a series of focus groups using a semistructured discussion guide. Separate sessions were held with patients aged 18 to 54 years and those older than 54 years in Philadelphia, Pennsylvania; Phoenix, Arizona; and Indianapolis, Indiana, in 2017. All 38 participants had received treatment for cancer within the past 2 years and had a choice of hospitals. Results. In selecting hospitals for cancer treatment, many participants reported that they considered factors such as reputation, quality of the facilities, and experiences of other patients. For most, however, decisions were guided by trusted advisors, with the majority agreeing that a physician's opinion would sway them to disregard objective data about hospital quality. Nonetheless, nearly all expressed interest in having comparative data. Participants varied in selecting from a hypothetical list, "the top 3 things you would want to know when choosing a hospital for cancer care." The most commonly preferred items were overall care quality, timeliness, and patient satisfaction. Contrary to our hypothesis, many preferred to avoid viewing comparative clinical outcomes, particularly survival. Conclusions. Patients' information preferences are diverse. Fear or other emotional responses might deter patients from viewing outcomes data such as survival. Additional research should explore optimal ways to help patients incorporate comparative data on the components of quality they value into decision making.
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Affiliation(s)
- Susan Chimonas
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elizabeth Fortier
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diane G Li
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Allison Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Comparing Prognostic Utility of a Single-marker Immunohistochemistry Approach with Commercial Gene Expression Profiling Following Radical Prostatectomy. Eur Urol 2018; 74:668-675. [DOI: 10.1016/j.eururo.2018.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/13/2018] [Indexed: 11/18/2022]
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Bouck Z, Ferguson J, Ivers NM, Kerr EA, Shojania KG, Kim M, Cram P, Pendrith C, Mecredy GC, Glazier RH, Tepper J, Austin PC, Martin D, Levinson W, Bhatia RS. Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care. JAMA Netw Open 2018; 1:e183506. [PMID: 30646242 PMCID: PMC6324437 DOI: 10.1001/jamanetworkopen.2018.3506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. OBJECTIVES To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. EXPOSURES Physician sex, years since medical school graduation, and primary care model. MAIN OUTCOMES AND MEASURES This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2). RESULTS The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. CONCLUSIONS AND RELEVANCE This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- currently a student at Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Noah M. Ivers
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A. Kerr
- Center for Clinical Management, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kaveh G. Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Min Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System and Health Network, Toronto, Ontario, Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Graham C. Mecredy
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Richard H. Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Tipton T, Edwards K, Simpson K, Prasad M, Stec A. Pathologic Specimens at Time of Pyeloplasty: Frequency and Practice Patterns. Urology 2018; 122:158-161. [PMID: 30195010 DOI: 10.1016/j.urology.2018.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess national and regional practice patterns and rates of pathologic specimen identification sent at time of pyeloplasty, as well as project associated costs, we used a national administrative database. The rate at which the excised ureteropelvic junction obstruction (UPJO) is sent for pathologic identification is variable, arguably without a clear clinical purpose. MATERIALS / METHODS Utilizing a national administrative database of privately insured patients, 1496 individual cases were identified using international classification of diseases (ICD) and Current Procedural Terminology (CPT) coding. Patients from 0-18 years of age were included whose pyeloplasty was performed during 2010-2014. Patients who were and were not billed for pathologic identification at time of surgery were identified. Regional practice patterns and associated costs were determined. RESULTS One thousand four hundred and ninety-six pyeloplasty cases were identified (68.2% males). Specimens were sent for pathologic identification in 827 cases (55%). Average age was 5.8 years for those without pathology and 4.6 years for those in whom a specimen was billed. Regionally, the Western United States was least likely to bill for surgical pathology (49%). The parental out-of-pocket payment for the encounter was on average $1518 for cases in which pathology was sent and $1398 for those cases for which no pathology bill was identified. CONCLUSION Pediatric pyeloplasty is a common surgical procedure for which a pathologic specimen is sent in as many as 55% of cases in this cohort. Regional differences exist across the country and there is an associated slightly higher out-of-pocket cost in cases for which pathologic specimens are sent at time of pyeloplasty.
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Affiliation(s)
| | | | - Kit Simpson
- MUSC Department of Healthcare Leadership and Management, Charleston, SC
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Schroeck FR, Lynch KE, Chang JW, MacKenzie TA, Seigne JD, Robertson DJ, Goodney PP, Sirovich B. Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer. JAMA Netw Open 2018; 1:e183442. [PMID: 30465041 PMCID: PMC6241521 DOI: 10.1001/jamanetworkopen.2018.3442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/12/2018] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Cancer care guidelines recommend aligning surveillance frequency with underlying cancer risk, ie, more frequent surveillance for patients at high vs low risk of cancer recurrence. OBJECTIVE To assess the extent to which such risk-aligned surveillance is practiced within US Department of Veterans Affairs facilities by classifying surveillance patterns for low- vs high-risk patients with early-stage bladder cancer. DESIGN SETTING AND PARTICIPANTS US national retrospective cohort study of a population-based sample of patients diagnosed with low-risk or high-risk early-stage bladder between January 1, 2005, and December 31, 2011, with follow-up through December 31, 2014. Analyses were performed March 2017 to April 2018. The study included all Veterans Affairs facilities (n = 85) where both low-and high-risk patients were treated. EXPOSURES Low-risk vs high-risk cancer status, based on definitions from the European Association of Urology risk stratification guidelines and on data extracted from diagnostic pathology reports via validated natural language processing algorithms. MAIN OUTCOMES AND MEASURES Adjusted cystoscopy frequency for low-risk and high-risk patients for each facility, estimated using multilevel modeling. RESULTS The study included 1278 low-risk and 2115 high-risk patients (median [interquartile range] age, 77 [71-82] years; 99% [3368 of 3393] male). Across facilities, the adjusted frequency of surveillance cystoscopy ranged from 3.7 to 6.2 (mean, 4.8) procedures over 2 years per patient for low-risk patients and from 4.6 to 6.0 (mean, 5.4) procedures over 2 years per patient for high-risk patients. In 70 of 85 facilities, surveillance was performed at a comparable frequency for low- and high-risk patients, differing by less than 1 cystoscopy over 2 years. Surveillance frequency among high-risk patients statistically significantly exceeded surveillance among low-risk patients at only 4 facilities. Across all facilities, surveillance frequencies for low- vs high-risk patients were moderately strongly correlated (r = 0.52; P < .001). CONCLUSIONS AND RELEVANCE Patients with early-stage bladder cancer undergo cystoscopic surveillance at comparable frequencies regardless of risk. This finding highlights the need to understand barriers to risk-aligned surveillance with the goal of making it easier for clinicians to deliver it in routine practice.
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Affiliation(s)
- Florian R. Schroeck
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Kristine E. Lynch
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Ji won Chang
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Todd A. MacKenzie
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - John D. Seigne
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Douglas J. Robertson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Philip P. Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Brenda Sirovich
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
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Filson CP. Quality of care and economic considerations of active surveillance of men with prostate cancer. Transl Androl Urol 2018; 7:203-213. [PMID: 29732278 PMCID: PMC5911536 DOI: 10.21037/tau.2017.08.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.
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Affiliation(s)
- Christopher P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta Veterans Administration Medical Center, Decatur, GA, USA
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Miller G, Rhyan C, Beaudin-Seiler B, Hughes-Cromwick P. A Framework for Measuring Low-Value Care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:375-379. [PMID: 29680091 DOI: 10.1016/j.jval.2017.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/11/2017] [Accepted: 10/23/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND It has been estimated that more than 30% of health care spending in the United States is wasteful, and that low-value care, which drives up costs unnecessarily while increasing patient risk, is a significant component of wasteful spending. OBJECTIVES To address the need for an ability to measure the magnitude of low-value care nationwide, identify the clinical services that are the greatest contributors to waste, and track progress toward eliminating low-value use of these services. Such an ability could provide valuable input to the efforts of policymakers and health systems to improve efficiency. METHODS AND RESULTS We reviewed existing methods that could contribute to measuring low-value care and developed an integrated framework that combines multiple methods to comprehensively estimate and track the magnitude and principal sources of clinical waste. We also identified a process and needed research for implementing the framework. CONCLUSIONS A comprehensive methodology for measuring and tracking low-value care in the United States would provide an important contribution toward reducing waste. Implementation of the framework described in this article appears feasible, and the proposed research program will allow moving incrementally toward full implementation while providing a near-term capability for measuring low-value care that can be enhanced over time.
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Affiliation(s)
- George Miller
- Altarum Center for Value in Health Care, Arbor, MI, USA.
| | - Corwin Rhyan
- Altarum Center for Value in Health Care, Arbor, MI, USA
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Welk B, Winick-Ng J, McClure JA, Lorenzo AJ, Kulkarni G, Ordon M. The Impact of the Choosing Wisely Campaign in Urology. Urology 2018; 116:81-86. [PMID: 29572056 DOI: 10.1016/j.urology.2018.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 02/28/2018] [Accepted: 03/08/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine if 3 of the Canadian Urological Association's Choosing Wisely recommendations (released in 2013-2014) related to urologic care altered physician and patient behavior. METHODS Administrative data from Ontario, Canada between 2008 and 2017 was used. We identified 3 cohorts: First, we determined how many men >66 years of age had a serum testosterone level before starting testosterone therapy. Second, we determined how many boys undergoing an orchiopexy underwent abdominal imaging before their surgery. Third, we determined how many men with low risk prostate cancer underwent a Bone Scan after diagnosis. Piece-wise linear regression was used to evaluate for a significant change after Choosing Wisely. RESULTS We identified 13,113 men who had their initial prescription for testosterone filled. Serum testosterone measurement increased over time, from approximately 43% to 68%. There were 9319 boys who underwent an orchiopexy. The use of pre-orchiopexy ultrasound was generally stable (approximately 55%). We identified 27,174 men with low risk prostate cancer. The use of bone scans after diagnosis decreased over time from approximately 24% to 20%. In all 3 of these groups, there was no significant change after Choosing Wisely (P = .74, P = .70, P = .72 respectively). CONCLUSION In Ontario, there was no evidence of a significant change in 3 practice patterns that were featured in Choosing Wisely Urology recommendations. Further thought may be needed on how to translate these and future recommendations into behavior change.
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Affiliation(s)
- Blayne Welk
- Department of Surgery, Western University, London, ON, Canada; Institute for Clinical Evaluative Sciences, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
| | | | | | - Armando J Lorenzo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Girish Kulkarni
- Institute for Clinical Evaluative Sciences, London, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Ordon
- Institute for Clinical Evaluative Sciences, London, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Choosing Wisely: Optimizing Routine Workup for the Newly Diagnosed Breast Cancer Patient. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0268-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Oakes AH, Sharma R, Jackson M, Segal JB. Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review. Urol Oncol 2017; 35:647-658. [PMID: 28943200 PMCID: PMC5659754 DOI: 10.1016/j.urolonc.2017.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The overuse of radiologic services, where imaging tests are provided in circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health care systems. Advanced imaging in the staging of low-risk prostate cancer is considered an overused procedure by many professional societies, yet the determinants that drive this phenomenon are not fully appreciated. METHODS We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that contain original data and describe determinants associated with the overuse of imaging in low-risk prostate cancer. Paired reviewers independently screened abstracts, assessed quality, and extracted data. We synthesized the identified determinants as patient-level, clinician-level, or system-level factors of overuse. RESULTS A total of 14 articles were included; the 13 empirical studies defined overuse as being the use of imaging that was discordant with clinical guidelines. Patient- and system-related factors were most commonly described as being associated with overuse; clinician-level determinants were examined infrequently. Older patient age (n = 5), more patient comorbidities (n = 7), and characteristics related to geography (n = 6), higher regional income (n = 6), and less education (n = 5) were the most consistently identified statistically significant determinants of overuse. Meaningful differences were detected between health care settings; large integrated health care systems provided less variable care and had lower rates of overuse. Clinical indicators related to prostate cancer were inconsistently associated with overuse. CONCLUSION Many patient- and system-related determinants were identified as contributing to the overuse of advanced imaging to stage low-risk prostate cancer. Overuse may be the consequence of systematized clinician behavior and be relatively invariant of patient characteristics. The identified system-level determinants suggest that payment models that are not tied to volume or that reward, enhanced care co-ordination may curb overuse. We propose further examination of physician-level determinants and implore researchers to rank the relative importance of the identified factors and to test their influence through experimental and quasi-experimental methods.
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Affiliation(s)
- Allison H Oakes
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Ritu Sharma
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Madeline Jackson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jodi B Segal
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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Rocque GB, Williams CP, Kenzik KM, Jackson BE, Halilova KI, Sullivan MM, Rocconi RP, Azuero A, Kvale EA, Huh WK, Partridge EE, Pisu M. Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models? J Oncol Pract 2017; 14:e375-e383. [PMID: 28981388 DOI: 10.1200/jop.2017.024935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients. METHODS This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service. RESULTS Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending. CONCLUSION Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.
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Affiliation(s)
- Gabrielle B Rocque
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Courtney P Williams
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Kelly M Kenzik
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Bradford E Jackson
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Karina I Halilova
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Margaret M Sullivan
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Rod P Rocconi
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Andres Azuero
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Elizabeth A Kvale
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Warner K Huh
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Edward E Partridge
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Maria Pisu
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
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Levin DC, Rao VM. Reducing Inappropriate Use of Diagnostic Imaging Through the Choosing Wisely Initiative. J Am Coll Radiol 2017; 14:1245-1252. [DOI: 10.1016/j.jacr.2017.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 01/09/2023]
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Rocque G, Blayney DW, Jahanzeb M, Knape A, Markham MJ, Pham T, Shelton J, Sudheendra P, Evans T. Choosing Wisely in Oncology: Are We Ready For Value-Based Care? J Oncol Pract 2017; 13:e935-e943. [PMID: 28783425 DOI: 10.1200/jop.2016.019281] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION In 2012, ASCO created the Top Five Choosing Wisely (CW) list of low-value tests and procedures for which there is little evidence of benefit. ASCO's Quality Oncology Practice Initiative, an oncologist-led practice-based quality assessment program, includes measures on the basis of these recommendations. METHODS CW test measures from spring and fall 2013, spring 2014, and spring 2015 were evaluated for concordance rates, change in the concordance over time, and variability by practice characteristics. Practice characteristics recorded included geographic location, academic affiliation, number of new cases, number of medical oncologists, and rounds of participation in Quality Oncology Practice Initiative. Medians, interquartile ranges, and percentages were calculated for concordance with recommendations and practice characteristics. Change in recommendation concordance over time was assessed using linear regression models. RESULTS From 2013 to 2015, 341 unique oncology practices abstracted the CW measures. Performance varied for specific recommendations. The median concordance was best for measure 1 (patients with low or undocumented performance status who received chemotherapy), where concordance ranged from 78.4% to 83.3%. The lowest concordance was for measure 3 (use of biomarkers or advanced imaging tests for surveillance in early breast cancer), where concordance ranged from 67.7% to 74.2%. Performance on CW measures varied markedly by individual practice. Variability over time and by practice characteristics was observed. CONCLUSION Performance on ASCO's CW demonstrates room for improvement. Concordance rates varied substantially by practice. Further education on CW measures is needed to improve patient care and enhance value.
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Affiliation(s)
- Gabrielle Rocque
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Douglas W Blayney
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Mohammad Jahanzeb
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - August Knape
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Merry Jennifer Markham
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Trang Pham
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Jeremy Shelton
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Preeti Sudheendra
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
| | - Tracey Evans
- University of Alabama at Birmingham, Birmingham, AL; Stanford University Cancer Institute, Stanford; UCLA/Veterans Affairs, Los Angeles, CA; University of Miami, Miami; University of Florida, Gainesville, FL; ASCO, Alexandria, VA; MD Anderson Cancer Center at Cooper, Voorhees Township, NJ; and University of Pennsylvania, Philadelphia, PA
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Abstract
BACKGROUND Overuse, the provision of health services for which harms outweigh the benefits, results in suboptimal patient care and may contribute to the rising costs of cancer care. We performed a systematic review of the evidence on overuse in oncology. METHODS We searched Medline, EMBASE, the Cochrane Library, Web of Science, SCOPUS databases, and 2 grey literature sources, for articles published between December 1, 2011 and March 10, 2017. We included publications from December 2011 to evaluate the literature since the inception of the ABIM Foundation's Choosing Wisely initiative in 2012. We included original research articles quantifying overuse of any medical service in patients with a cancer diagnosis when utilizing an acceptable standard to define care appropriateness, excluding studies of cancer screening. One of 4 investigator reviewed titles and abstracts and 2 of 4 reviewed each full-text article and extracted data. Methodology used PRISMA guidelines. RESULTS We identified 59 articles measuring overuse of 154 services related to imaging, procedures, and therapeutics in cancer management. The majority of studies addressed adult or geriatric patients (98%) and focused on US populations (76%); the most studied services were diagnostic imaging in low-risk prostate and breast cancer. Few studies evaluated active cancer therapeutics or interventions aimed at reducing overuse. Rates of overuse varied widely among services and among studies of the same service. CONCLUSIONS Despite recent attention to overuse in cancer, evidence identifying areas of overuse remains limited. Broader investigation, including assessment of active cancer treatment, is critical for identifying improvement targets to optimize value in cancer care.
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Initiative to reduce bone scans for low-risk prostate cancer patients: A quasi-experimental before-and-after study in a Veterans Affairs hospital. Adv Radiat Oncol 2017; 2:416-419. [PMID: 29114610 PMCID: PMC5605298 DOI: 10.1016/j.adro.2017.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/07/2017] [Indexed: 11/26/2022] Open
Abstract
Purpose Bone scans (BS) are a low-value test for asymptomatic men with low-risk prostate cancer. We performed a quality improvement intervention aimed at reducing BS for these patients. Methods and materials The intervention was a presentation that leveraged the behavioral science concepts of social comparison and normative appeals. Participants were multidisciplinary stakeholders from the Radiation Oncology and Urology services at a Veterans Affairs hospital. We determined the baseline rate of BS by retrospectively analyzing cases of asymptomatic men with newly diagnosed low-risk prostate cancer. For social comparison, we presented contemporary peer BS rates in the United States—including Veterans Affairs hospitals. For normative appeals, we reviewed guidelines from various professional groups. To analyze the effect of this intervention, we performed a quasi-experimental, uncontrolled, before-and-after study. Results During the 1-year period before the intervention, 32 of 37 patients with low-risk prostate cancer (86.5%) received a BS. The contemporary peer rate was approximately 30%. All reviewed guidelines recommended against BS. During the 1-year period after the intervention, the rate of BS was reduced to 65.5% (19 of 29 patients; P = .043 by one-sided Fisher's exact test). Conclusions We observed a modest reduction in guideline-discordant BS after the quality improvement intervention. BS rates might be influenced by initiatives that combine social comparisons with appeals to professional norms.
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Yasaitis L, Bekelman JE, Polsky D. Relation Between Narrow Networks and Providers of Cancer Care. J Clin Oncol 2017; 35:3131-3135. [PMID: 28678667 DOI: 10.1200/jco.2017.73.2040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Health insurers offer plans covering a narrow subset of providers in an attempt to lower premiums and compete for consumers. However, narrow networks may limit access to high-quality providers, particularly those caring for patients with cancer. Methods We examined provider networks offered on the 2014 individual health insurance exchanges, assessing oncologist supply and network participation in areas that do and do not contain one of 69 National Cancer Institute (NCI)-Designated Cancer Centers. We characterized a network's inclusion of oncologists affiliated with NCI-Designated Cancer Centers relative to oncologists excluded from the network within the same region and assessed the relationship between this relative inclusion and each network's breadth. We repeated these analyses among networks offered in the same regions as the subset of 27 NCI-Designated Cancer Centers identified as National Comprehensive Cancer Network (NCCN) Cancer Centers. Results In regions containing NCI-Designated Cancer Centers, there were 13.7 oncologists per 100,000 residents and 4.9 (standard deviation [SD], 2.8) networks covering a mean of 39.4% (SD, 26.2%) of those oncologists, compared with 8.8 oncologists per 100,000 residents and 3.2 (SD, 2.1) networks covering on average 49.9% (SD, 26.8%) of the area's oncologists ( P < .001 for all comparisons). There was a strongly significant correlation ( r = 0.4; P < .001) between a network's breadth and its relative inclusion of oncologists associated with NCI-Designated Cancer Centers; this relationship held when considering only affiliation with NCCN Cancer Centers. Conclusion Narrower provider networks are more likely to exclude oncologists affiliated with NCI-Designated or NCCN Cancer Centers. Health insurers, state regulators, and federal lawmakers should offer ways for consumers to learn whether providers of cancer care with particular affiliations are in or out of narrow provider networks.
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Affiliation(s)
- Laura Yasaitis
- All authors: University of Pennsylvania, Philadelphia, PA
| | | | - Daniel Polsky
- All authors: University of Pennsylvania, Philadelphia, PA
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Copeland TP, Franc BL. High-cost cancer imaging: Opportunities for utilization management. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Eberhardt SC, Shah SK. R-SCAN: Appropriate Imaging for Low-Risk Prostate Cancer. J Am Coll Radiol 2017; 14:790-792. [PMID: 28356199 DOI: 10.1016/j.jacr.2017.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 01/24/2017] [Accepted: 01/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Steven C Eberhardt
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico.
| | - Satyan K Shah
- Department of Surgery, Division of Urology, University of New Mexico, Albuquerque, New Mexico
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Henry NL, Braun TM, Breslin TM, Gorski DH, Silver SM, Griggs JJ. Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry. Cancer 2017; 123:2975-2983. [PMID: 28301680 DOI: 10.1002/cncr.30674] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/14/2017] [Accepted: 02/18/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care. METHODS Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record. RESULTS Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease. CONCLUSION Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.
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Affiliation(s)
- N Lynn Henry
- Huntsman Cancer Institute, Salt Lake City, Utah.,University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas M Braun
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - David H Gorski
- Wayne State University School of Medicine, Detroit, Michigan.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan
| | | | - Jennifer J Griggs
- University of Michigan School of Public Health, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
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Chockley K, Emanuel E. The End of Radiology? Three Threats to the Future Practice of Radiology. J Am Coll Radiol 2016; 13:1415-1420. [DOI: 10.1016/j.jacr.2016.07.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 12/18/2022]
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Hurley P, Dhir A, Gao Y, Drabik B, Lim K, Curry J, Womble PR, Linsell SM, Brachulis A, Sexton DW, Ghani KR, Denton BT, Miller DC, Montie JE. A Statewide Intervention Improves Appropriate Imaging in Localized Prostate Cancer. J Urol 2016; 197:1222-1228. [PMID: 27889418 DOI: 10.1016/j.juro.2016.11.098] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer. MATERIALS AND METHODS MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns. RESULTS A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p <0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p <0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods. CONCLUSIONS An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.
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Rocque GB, Williams CP, Jackson BE, Wallace AS, Halilova KI, Kenzik KM, Partridge EE, Pisu M. Choosing Wisely: Opportunities for Improving Value in Cancer Care Delivery? J Oncol Pract 2016; 13:e11-e21. [PMID: 27845867 DOI: 10.1200/jop.2016.015396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Patients, providers, and payers are striving to identify where value in cancer care can be increased. As part of the Choosing Wisely (CW) campaign, ASCO and the American Society for Therapeutic Radiology and Oncology have recommended against specific, yet commonly performed, treatments and procedures. METHODS We conducted a retrospective analysis of Medicare claims data to examine concordance with CW recommendations across 12 cancer centers in the southeastern United States. Variability for each measure was evaluated on the basis of patient characteristics and site of care. Hierarchical linear modeling was used to examine differences in average costs per patient by concordance status. Potential cost savings were estimated on the basis of a potential 95% adherence rate and average cost difference. RESULTS The analysis included 37,686 patients with cancer with Fee-for-Service Medicare insurance. Concordance varied by CW recommendation from 39% to 94%. Patient characteristics were similar for patients receiving concordant and nonconcordant care. Significant variability was noted across centers for all recommendations, with as much as an 89% difference. Nonconcordance was associated with higher costs for every measure. If concordance were to increase to 95% for all measures, we would estimate a $19 million difference in total cost of care per quarter. CONCLUSION These results demonstrate ample room for reduction of low-value care and corresponding costs associated with the CW recommendations. Because variability in concordance was driven primarily by site of care, rather than by patient factors, continued education about these low-value services is needed to improve the value of cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | - Maria Pisu
- University of Alabama at Birmingham, Birmingham, AL
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Lipitz-Snyderman A, Sima CS, Atoria CL, Elkin EB, Anderson C, Blinder V, Tsai CJ, Panageas KS, Bach PB. Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer. JAMA Intern Med 2016; 176:1541-1548. [PMID: 27533635 PMCID: PMC5363077 DOI: 10.1001/jamainternmed.2016.4426] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions. OBJECTIVE To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases. MAIN OUTCOME AND MEASURES To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use. RESULTS Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively). CONCLUSIONS AND RELEVANCE Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.
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Affiliation(s)
- Allison Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Camelia S Sima
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York3Genentech, California
| | - Coral L Atoria
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elena B Elkin
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher Anderson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York5Department of Urology, Columbia University, New York, New York
| | - Victoria Blinder
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York6Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
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Sethi RK, Kozin ED, Naunheim MR, Rosen M, Shrime MG, Sedaghat AR, Gray ST. Variable utilization patterns of computed tomography for rhinosinusitis in emergency departments. Laryngoscope 2016; 127:537-543. [DOI: 10.1002/lary.26217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/03/2016] [Accepted: 07/06/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Rosh K.V. Sethi
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Elliott D. Kozin
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Matthew R. Naunheim
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | | | - Mark G. Shrime
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Ahmad R. Sedaghat
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Stacey T. Gray
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts
- the Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
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Bychkovsky BL, Lin NU. Imaging in the evaluation and follow-up of early and advanced breast cancer: When, why, and how often? Breast 2016; 31:318-324. [PMID: 27422453 DOI: 10.1016/j.breast.2016.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/16/2016] [Indexed: 11/15/2022] Open
Abstract
Imaging in the evaluation and follow-up of patients with early or advanced breast cancer is an important aspect of cancer care. The role of imaging in breast cancer depends on the goal and should only be performed to guide clinical decisions. Imaging is valuable if a finding will change the course of treatment and improve outcomes, whether this is disease-free survival, overall survival or quality-of-life. In the last decade, imaging is often overused in oncology and contributes to rising healthcare costs. In this context, we review the data that supports the appropriate use of imaging for breast cancer patients. We will discuss: 1) the optimal use of staging imaging in both early (Stage 0-II) and locally advanced (Stage III) breast cancer, 2) the role of surveillance imaging to detect recurrent disease in Stage 0-III breast cancer and 3) how patients with metastatic breast cancer should be followed with advanced imaging.
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Affiliation(s)
- Brittany L Bychkovsky
- Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Nancy U Lin
- Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Landercasper J, Bailey L, Berry TS, Buras RR, Degnim AC, Fayanju OM, Froman J, Gass J, Greenberg C, Mautner SK, Krontiras H, Rao R, Sowden M, Tjoe JA, Wexelman B, Wilke L, Chen SL. Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely (®) Initiative. Ann Surg Oncol 2016; 23:3112-8. [PMID: 27334216 PMCID: PMC4999471 DOI: 10.1245/s10434-016-5327-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Current breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely (®) Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged. METHODS The Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely (®) Campaign. The resulting list of "appropriateness" measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below. RESULTS (1) Don't routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don't routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don't routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don't routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don't routinely perform a double mastectomy in patients who have a single breast with cancer. CONCLUSIONS The ASBrS list for the Choosing Wisely (®) campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.
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Affiliation(s)
| | - Lisa Bailey
- Bay Area Breast Surgeons, Inc., Oakland, CA, USA
| | | | | | | | | | | | | | - Caprice Greenberg
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | | | | | - Roshni Rao
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Lee Wilke
- University of Wisconsin of Madison, Madison, WI, USA
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Healy MA, Yin H, Reddy RM, Wong SL. Use of Positron Emission Tomography to Detect Recurrence and Associations With Survival in Patients With Lung and Esophageal Cancers. J Natl Cancer Inst 2016; 108:djv429. [PMID: 26903519 DOI: 10.1093/jnci/djv429] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/15/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Positron emission tomography (PET) scans are often used in cancer patients for staging, restaging, and monitoring for treatment response. These scans are also often used to detect recurrence in asymptomatic patients, despite a lack of evidence demonstrating improved survival. We sought to evaluate utilization of PET for this purpose and relationships with survival for patients with lung and esophageal cancers. METHODS Using national Surveillance, Epidemiology, and End Results (SEER) and Medicare-linked data, we identified incident patient cases from 2005 to 2009, with follow-up through 2011. We identified cohorts with primary lung (n = 97 152) and esophageal (n = 4446) cancers. Patient and tumor characteristics were used to calculate risk-adjusted two-year overall survival. Using Medicare claims, we examined PET utilization in person-years (to account for variable time in cohorts), excluding scans for staging and for follow-up of CT findings. We then stratified hospitals by quintiles of PET utilization for adjusted two-year survival analysis. All statistical tests were two-sided. RESULTS There was statistically significant variation in utilization of PET. Lowest vs highest utilizing hospitals performed .05 (SD = 0.04) vs 0.70 (SD = 0.44) scans per person-year for lung cancer and 0.12 (SD = 0.06) vs 0.97 (SD = 0.29) scans per person-year for esophageal cancer. Despite this, for those undergoing PET, lowest vs highest utilizing hospitals had an adjusted two-year survival of 29.0% (SD = 12.1%) vs 28.8% (SD = 7.2%) for lung cancer (P = .66) and 28.4% (SD = 7.2%) vs 30.3% (SD = 5.9%) for esophageal cancer (P = .55). CONCLUSIONS Despite statistically significant variation in use of PET to detect tumor recurrence, there was no association with improved two-year survival. These findings suggest possible overuse of PET for recurrence detection, which current Medicare policy would not appear to substantially affect.
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Affiliation(s)
- Mark A Healy
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Huiying Yin
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Rishindra M Reddy
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Sandra L Wong
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
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Ojerholm E, Halpern SD, Bekelman JE. Default Options: Opportunities to Improve Quality and Value in Oncology. J Clin Oncol 2016; 34:1844-7. [PMID: 26884581 DOI: 10.1200/jco.2015.64.8741] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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