Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study

Utilization of CT and MRI scanning in Taiwan, 2000-2017

OBJECTIVES

This population-based study aimed to collect, analyze, and summarize the long-term trends in medical imaging use in Taiwan.

METHODS

A retrospective cohort population-based study of medical imaging usage for the individuals who received care under the National Health Insurance system from 2000 to 2017. CT and MRI utilization rates were determined overall as well as across certain variables including patient age, hospital type, health care type, hospital characteristics, and geographic area.

RESULTS

Individuals registered in our health insurance system have received 21,766,745 CT scans and 7,520,088 MRI scans from 2000 to 2017. Annual growth rates for both imaging types were positive over that period, though growth rates have slowed in recent years. The growth rate for CT use was greatest (9-12%) between 2001 and 2004, dropped to 2% in 2005, then generally rose thereafter, reaching 3% in 2017. Similarly, MRI use growth peaked at 24% between 2001 and 2003, dropped to 4% in 2005, then increased in a fluctuating manner, reaching 2% in 2017.

CONCLUSION

Over the past 2 decades, CT and MRI use in Taiwan has increased sharply, especially in the oldest age group (≥ 60 years old), but growth rates have slowed in recent years. Increases in imaging use have corresponded with improved clinical outcomes, including greater life expectancy and reduced mortality rates, though further assessment is required to demonstrate a direct link with imaging. Nevertheless, the better clinical outcomes are also predisposed by the comprehensive care covered by the NHI system.

Palliative care and imaging utilisation for patients with cancer

OBJECTIVE

This observational study explores the association between palliative care (PC) involvement and high-cost imaging utilisation for patients with cancer patients during the last 3 months of life.

METHODS

Adult patients with cancer who died between 1 January 2012 and 31 May 2015 were identified. Referral to PC, intensity of PC service use, and non-emergent oncological imaging utilisation were determined. Associations between PC utilisation and proportion of patients imaged and mean number of studies per patient (mean imaging intensity (MII)) were assessed for the last 3 months and the last month of life. Similar analyses were performed for randomly matched case-control pairs (n = 197). Finally, the association between intensity of PC involvement and imaging utilisation was assessed.

RESULTS

3784 patients were included, with 3523 (93%) never referred to PC and 261 (7%) seen by PC, largely before the last month of life (61%). Similar proportions of patients with and without PC referral were imaged during the last 3 months, while a greater proportion of patients with PC referral were imaged in the last month of life. PC involvement was not associated with significantly different MII during either time frame. In the matched-pairs analysis, a greater proportion of patients previously referred to PC received imaging in the period between the first PC encounter and death, and in the last month of life. MII remained similar between PC and non-PC groups. Finally, intensity of PC services was similar for imaged and non-imaged patients in the final 3 months and 1 month of life. During these time periods, increased PC intensity was not associated with decreased MII.

CONCLUSIONS

PC involvement in end-of-life oncological care was not associated with decreased use of non-emergent, high-cost imaging. The role of advanced imaging in the PC setting requires further investigation.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

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.

Identifying tests related to breast cancer care in claims data

To develop a method for calculating rates of testing for breast cancer recurrence in patients who have already undergone initial treatment for breast cancer, we calculated rates in a cohort of Medicare breast cancer patients and an age-matched noncancer cohort. We first used only tests with claims including diagnosis codes indicating invasive breast cancer and then used all tests regardless of diagnosis code. For each method, we calculated testing rates in the breast cancer cohort above the background rate in the noncancer population. The two methods provided similar estimates of testing prevalence and frequency, with exception of prevalence of CT.

Patterns of CT use in Japan, 2014: A nationwide cross-sectional study

OBJECTIVES

To describe CT usage in Japan by age, gender, and region and to clarify the relationship between aging and CT examination rate.

MATERIALS AND METHODS

We conducted a cross-sectional study using openly accessible data from the National Database, which includes all Japanese health insurance claim data from 2014. These data are anonymized and publicly available as spreadsheets. Therefore, this study did not require institutional review board approval. We calculated the rate of CT examinations per 1000 population by age, sex, and region with 99% confidence intervals. Pearson correlation coefficients were calculated between CT rate and aging in each region.

RESULTS

We analyzed 28.1 million CT scans, and the rate per 1000 population was 221.5 (99% CI, 221.4-221.6). By age, the corresponding rate for age 0-9 years was 28.9, that for age 10-9 years was 48.6, that for 20-29 years was 52.2, that for 30-39 years was 69.0, that for 40-49 years was 105.9, that for 50-59 years was 177.6, that for 60-69 years was 303.3, that for 70-79 years was 532.5 and that for ≥80 years was 801.5. The rate for male individuals was 233.6 and that for females was 210.0. The CT examination rate was 171.7 and 296.0 in the lowest- and highest-frequency regions, respectively. The average correlation coefficient between the aging rate in each region and the CT examination rate was 0.58 (0.35-0.74, p=0.00002).

CONCLUSION

In Japan, the CT examination rate per 1000 population was high (third highest in the world). Age may be a factor that increases CT use. Furthermore, because variation in CT examination rates by age, gender, and region were observed, it is necessary to standardize CT utilization.