Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review

Increased magnetic resonance imaging in prostate cancer management-What are the outcomes?

RATIONALE

Increased attention to cancer care has instigated altered systems for screening, diagnosis, and management of various types of cancer, such as in the prostate. While such systems very likely have improved the quality of cancer care, they also result in the altered use of specific services, such as magnetic resonance imaging (MRI).

AIMS AND OBJECTIVE

To study the change in the use of prostate MRI in the Norwegian health care system from 2013 to 2021 and to investigate some reasons for and potential implications of this change.

METHOD

Data from the Norwegian Health Economics Administration (HELFO), The Cancer Registry of Norway and Cause-of-death registry at the Norwegian Institute of public health and the health registry of Vestfold Hospital Trust were used for descriptive statistical analysis.

RESULTS

The number of MRIs of the prostate increased threefold from 2013 to 2021, representing an extra cost of 2 million USD in 2020. The incidence of prostate cancer was stable at about 5000 cases per year, corresponding to 178 per 100,000 men, indicating no increased overdiagnosis. However, the clinical staging has changed substantially during this period, indicating stage and grade migration. The number of negative biopsies was reduced, and there are three MRIs per reduced negative biopsy. The number of persons on active surveillance increased during the period. However, these changes are partly independent of the increase in the number of MRIs.

CONCLUSION

There was a substantial increase in the number of prostate MRIs and thus an increase in costs. This appears to have contributed to the reduction of negative biopsies, improved staging and increased active surveillance. However, as these effects are partly independent of the increase in MRIs, we need to document the outcomes for patients from prostate MRIs as their opportunity costs are substantial.

Assessing Hospital Resource Utilization with Application to Imaging for Patients Diagnosed with Prostate Cancer

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.

Factors Associated With Overuse of Health Care Within US Health Systems

Question

What features of health care systems in the US are associated with overuse of health care?

Findings

In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital.

Meaning

In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care.

Importance

Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.

Objective

To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.

Design, Setting, and Participants

In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

Exposures

We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.

Main Outcomes and Measures

Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.

Results

There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

Conclusions and Relevance

In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.

Induced Demand in Cancer Diagnosis

Context: Supplier-induced demand (SID) is an essential concept in health economics related to the diagnosis of different types of cancer and related expenditures. The current review considered studies on induced demand in cancer diagnosis. Evidence Acquisition: This systematic review investigated the induced diagnosis of cancer in four well-known databases (Scopus, Science Direct, Web of Science, and PubMed) from January 1980 to July 2019 using the keywords “induced demand,” “cancer,” and “diagnosis”. References of the studies found through the original search were also considered for analysis. Results: No studies focused on SID in cancer diagnosis could be found, thus indicating a significant deficiency in the discussion of SID in cancer diagnosis studies. Therefore, the terms most relevant to the concept of SID in cancer diagnosis were examined. Finally, 24 factors were categorized into three groups: economic, socio-cultural, and structural. The majority of evidence for the probability of SID in cancer diagnosis is related to overdiagnosis or early diagnosis caused by unnecessary screening (57.14% of reviewed articles) and the neglect of clinical practice guidelines (42.8% of reviewed articles), mainly by diagnostic imaging. Conclusions: Research focused explicitly on SID in cancer diagnosis is needed. Moreover, economic, social, and structural reforms related to the factors that connect overuse, overdiagnosis, and unnecessary services to cancer diagnosis are required to control costs and harm and provide the best benefits to patients.

Patient Perspectives on the Implementation of Risk-Aligned Bladder Cancer Surveillance: Systematic Evaluation Using the Tailored Implementation for Chronic Diseases Framework

PURPOSE

Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors.

PARTICIPANTS AND METHODS

Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories.

RESULTS

Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories.

CONCLUSION

Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.

Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients

Importance

Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare.

Objective

To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting.

Design, Setting, and Participants

This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018.

Exposures

Patient utilization of different health care delivery systems.

Main Outcomes and Measures

Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer.

Results

Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group.

Conclusions and Relevance

The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.