The pen and the scalpel: effect of diffusion of information on nonclinical variations in surgical treatment

Thyroid Cancer Incidence Trends in the United States: Association with Changes in Professional Guideline Recommendations

Background: Overdiagnosis is the leading factor contributing to the rapid increase in thyroid cancer incidence of the last decades. During this period, however, thyroid cancer incidence has not been increasing at a constant pace. We hypothesized that changes in the slope of the incidence trends curve, called joinpoints, could be associated with changes in clinical practice guideline recommendations. Methods: Data were obtained from the initial nine registries of the Surveillance, Epidemiology, and End Results (SEER) Program. Thyroid cancer incidence was analyzed from 1975 to 2016. Joinpoints in thyroid cancer incidence trends and clinical variables were correlated with significant changes in clinical practice recommendations. Results: Incidence rate trends of medullary and anaplastic thyroid cancer were constant during the study period. Among papillary thyroid cancers (PTCs), three main joinpoints were identified, mainly driven by changes in incidence trends of smaller cancers. First, acceleration followed by two deceleration periods in thyroid cancer incidence coincident in time with the release of American Thyroid Association guidelines in 1996, 2009, and 2015. In 1996, the use of thyroid ultrasound and fine needle aspiration biopsy for the evaluation of thyroid nodules was described; and in 2009 and 2015, higher size thresholds for the biopsy of thyroid nodules were set. For the follicular variant of PTC, a joinpoint was observed around 1988, when the histological diagnosis of this entity was revised in the World Health Organization classification; and another one in 2015 coinciding with the proposal to remove the term carcinoma from noninvasive follicular-pattern tumors with papillary-like nuclear features which contributed to drive down the overall thyroid cancer incidence. Follicular thyroid cancer incidence was affected as well by changes in the guidelines, but to a lesser extent, and it was fairly stable during the study period. Conclusions: This study suggests that thyroid cancer incidence trends have been shaped, in large part, but not completely, by changes in professional guideline recommendations.

Geographic and Age-Based Variations in Medicare Reimbursement Among ASSH Members

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members' Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). "Hand-surgeons-per-capita" and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state's average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states' average reimbursement, reimbursement was not significantly correlated with the state's hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons' peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons.

Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

Background—

Clinical uncertainty is cited as a cause of geographic variation. However, little is known about the effect of comparative effectiveness research on variation. We examined whether geographic variation in the use of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) declined after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.

Methods and Results—

We examined changes in utilization and geographic variation in 67 hospital referral regions using the State Inpatient Databases. We compared age- and sex-adjusted rates of PCI for SIHD before (2006) and after (2008) publication of the COURAGE trial and compared those with contemporaneous changes in PCI volume for acute coronary syndrome. A total of 272 659 PCIs for SIHD from 526 hospitals were included in the analysis. After the publication of the COURAGE trial, PCI volume for SIHD declined by 25% ( P <0.001) and decreased by 12% for acute coronary syndrome ( P <0.001). This was predominantly attributable to changes in hospital referral regions with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile versus 18% in the lowest). As measured by the systematic component of variation, there was substantial geographic variation in the use of PCI for SIHD preceding the publication of the COURAGE trial. Variation declined by 28% (0.53 versus 0.40) after publication, but geographic variation remained higher for SIHD than acute coronary syndrome (0.40 versus 0.17).

Conclusions—

There was a substantial decline in the use of and geographic variation in PCI for SIHD after the publication of the COURAGE trial. However, geographic variation in the use of PCI for SIHD remained high.

Disease severity and radioactive iodine use for thyroid cancer

CONTEXT

Although variation in radioactive iodine (RAI) use for thyroid cancer has been demonstrated, the role of region and nonclinical correlates of use within risk groups has not been investigated.

OBJECTIVE

The objective of the study was to determine the correlates of RAI use within risk groups.

DESIGN/SETTING/PATIENTS

Use of RAI was evaluated across 9 US regions in 85 948 patients with well-differentiated thyroid cancer diagnosed between 2004 and 2008 at 986 hospitals associated with the US National Cancer Database. Cancers were then categorized as low risk (tumor size ≤ 1 cm and American Joint Committee on Cancer stage I disease), medium risk (neither low nor high-risk), and high risk (American Joint Committee on Cancer stage III or IV). Within each risk stratum, the role of region and nonclinical correlates of RAI use were evaluated using hierarchical logistic regression.

MAIN OUTCOME MEASURE

Use of RAI was measured.

RESULTS

Rates of RAI use varied across geographic regions from 49% to 66%. Regional differences persisted after controlling for patient and hospital characteristics and evaluating less vs more intensive regions within low-risk [odds ratio (OR) 0.36 (95% confidence interval [CI] 0.25-0.53)], medium-risk [OR 0.23 (95% CI 0.16-0.34)], and high-risk cancers [OR 0.30 (95% CI 0.19-0.49)]. Patterns of RAI use were similar in medium- and high-risk patients. The most nonclinical correlates of use were in low-risk patients.

CONCLUSION

Similar treatment patterns for the heterogeneous medium-risk thyroid cancer patients compared with the high-risk patients suggest more intensive management in patients with medium-risk disease. The large number of nonclinical correlates of RAI use, including region, imply controversy over indications for RAI.

Evaluative care guideline compliance is associated with provision of benign prostatic hyperplasia surgery

OBJECTIVE

To determine the impact of evaluative care guideline compliance on surgical intervention for benign prostatic hyperplasia (BPH).

METHODS

From Medicare claims data, we developed a cohort of men new to a urologist with a diagnosis of BPH. We determined urologists' compliance with guideline recommended care (3 months) and their time- and geography-standardized average monthly Medicare expenditures (1 year). At the level of the urologist, we assessed the impact of these measures on the use of surgical therapy within 1 year of the new patient visit.

RESULTS

Of 10 248 patients in the cohort, 675 received surgical intervention (6.7%). Guideline compliance (2% received surgery in highest quintile; 11% lowest quintile) was associated with surgical intervention. The results were robust to adjustment for patient and surgeon factors (Guideline Compliance, odds ratio = 0.09; 95% confidence interval = 0.06-0.15, highest to lowest adherence).

CONCLUSION

Urologists who tend to follow the AUA best practice guidelines for BPH evaluation perform surgical interventions on their BPH patients less frequently than urologists who do not follow these guidelines.

Use of radioactive iodine for thyroid cancer

CONTEXT

Substantial uncertainty persists about the indications for radioactive iodine for thyroid cancer. Use of radioactive iodine over time and the correlates of its use remain unknown.

OBJECTIVE

To determine practice patterns, the degree to which hospitals vary in their use of radioactive iodine, and factors that contribute to this variation.

DESIGN, SETTING, AND PATIENTS

Time trend analysis of radioactive iodine use in a cohort of 189,219 patients with well-differentiated thyroid cancer treated at 981 hospitals associated with the US National Cancer Database between 1990 and 2008. We used multilevel analysis to assess the correlates of patient and hospital characteristics on radioactive iodine use in the cohort treated from 2004 to 2008.

MAIN OUTCOME MEASURE

Use of radioactive iodine after total thyroidectomy.

RESULTS

Between 1990 and 2008, across all tumor sizes, there was a significant increase in the proportion of patients with well-differentiated thyroid cancer receiving radioactive iodine (1373/3397 [40.4%] vs 11,539/20,620 [56.0%]; P < .001). Multivariable analysis of patients treated from 2004 to 2008 found that there was a statistical difference in radioactive iodine use between American Joint Committee on Cancer stages I and IV (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.31-0.37) but not between stages II/III and IV (for stage II vs stage IV, OR, 0.97; 95% CI, 0.88-1.07 and for stage III vs stage IV, OR, 1.06; 95% CI, 0.95-1.17). In addition to patient and tumor characteristics, hospital volume was associated with radioactive iodine use. Wide variation in radioactive iodine use existed, and only 21.1% of this variation was accounted for by patient and tumor characteristics. Hospital type and case volume accounted for 17.1% of the variation. After adjusting for available patient, tumor, and hospital characteristics, 29.1% of the variance was attributable to unexplained hospital characteristics.

CONCLUSION

Among patients treated for well-differentiated thyroid cancer at hospitals in the National Cancer Database, there was an increase in the proportion receiving radioactive iodine between 1990 and 2008; much of the variation in use was associated with hospital characteristics.

Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required.

Sphincter preservation in rectal cancer is associated with patients' socioeconomic status

Background

Decision making regarding the choice of surgical procedure in rectal cancer is complex. It was hypothesized that, in addition to clinical factors, several aspects of patients' socioeconomic background influence this process.

Methods

Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995–2005 (16 713 patients) and analysed by logistic regression.

Results

Anterior resection (AR) was performed in 7433 patients (44·5 per cent), abdominoperineal resection (APR) in 3808 (22·8 per cent) and Hartmann's procedure in 1704 (10·2 per cent). Unmarried patients were least likely (odds ratio (OR) 0·76, 95 per cent confidence interval (c.i.) 0·64 to 0·88) and university-educated men were most likely (OR 1·30, 1·04 to 1·62) to have an AR. Patients with the highest income were more likely to undergo AR (OR 0·80, 0·85 and 0·86 respectively for first, second and third income quartiles). Socioeconomic differences in the use of AR were smallest among the youngest patients. Unmarried patients were more likely (OR 1·21, 95 per cent c.i. 1·00 to 1·48) and university-educated patients less likely (OR 0·78, 95 per cent c.i. 0·63 to 0·98) to have an APR.

Conclusion

The choice of surgical strategy in rectal cancer is not socioeconomically neutral. Confounding factors, such as co-morbidity or smoking, may explain some of the differences but inequality in treatment is also plausible.