Increasing value by increasing volume: call for changes in US breast cancer screening practices

Temporal trends in healthcare utilization following primary melanoma diagnosis among Medicare beneficiaries

BACKGROUND

Little is known about the impact of primary melanoma diagnosis on healthcare utilization and changes in utilization over time.

OBJECTIVES

To evaluate population-based temporal trends in healthcare utilization following primary melanoma diagnosis.

METHODS

We conducted a before-and-after multiple time series study of Medicare beneficiaries aged ≥ 66 years with primary melanoma diagnoses between 2000 and 2009 using the Surveillance, Epidemiology, and End Results Medicare database. Primary exposure was time from primary melanoma diagnosis at 3-6 months and 6-24 months postdiagnosis. Covariates included tumour-, patient- and geographical-level characteristics and healthcare utilization in the 6 months before diagnosis. Poisson regression was used to estimate population-based risk-adjusted utilization rates for skin biopsies, benign skin excisions, internal medicine office visits and dermatology office visits.

RESULTS

The study population included 56 254 patients with first diagnoses of primary melanoma. Most patients were ≥ 75 years old (56·8%), male (62·1%), and had in situ melanoma (42·4%) or localized invasive melanoma (45·9%). From 2000 to 2009, risk-adjusted skin biopsy rates 24 months postdiagnosis increased from 358·3 to 541·3 per 1000 person-years (P < 0·001), and dermatology visits increased from 989·0 to 1535·6 per 1000 person-years (P < 0·001). Benign excisions and internal medicine visits remained stable. In 2000, risk-adjusted skin biopsy rates 6 months postdiagnosis increased by 208·5 relative to the 6 months before diagnosis (148·7 vs. 357·2) compared with an observed absolute increase of 272·5 (290·9 vs. 563·1) in 2009. Trends in dermatology visits were similar.

CONCLUSIONS

Utilization of skin biopsies and dermatology office visits following primary melanoma diagnosis has increased substantially over time. These results may inform optimization of care delivery for melanoma within the Medicare population.

Imaging-based screening: maximizing benefits and minimizing harms

Advanced imaging technologies play a central role in screening asymptomatic patients. However, the balance between imaging-based screening's potential benefits versus risks is sometimes unclear. Radiologists will have to address ongoing concerns, including high false-positive rates, incidental findings outside the organ of interest, overdiagnosis, and potential risks from radiation exposure. In this article, we provide a brief overview of these recurring controversies and suggest the following as areas that radiologists should focus on in order to tip the balance toward more benefits and less harms for patients undergoing imaging-based screening: interpretive variability, abnormal finding thresholds, and personalized, risk-based screening.