Refining physician quality indicators for screening mammography in older women: distinguishing appropriate use from overuse

Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions

Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study

BACKGROUND

One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care.

OBJECTIVE

We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care.

METHODS

The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout).

RESULTS

This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021.

CONCLUSIONS

Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18673.

Mammography use among women aged 18-39 years in the United States

PURPOSE

Recommendations for breast cancer screening using mammography target asymptomatic women aged ≥ 40 years who are not at increased risk for breast cancer. Evidence is not available to demonstrate benefits of screening with mammography at younger ages, and little is known about mammography use among younger women. This study described mammography use among women aged 18-39 years.

METHODS

We analyzed data from the 2011-2015 National Survey of Family Growth, an in-person survey of a nationally representative sample of the U.S. household population. We estimated the prevalence of ever receiving a mammogram and examined reasons for the first mammograms among women aged 18-39 years without personal cancer history (n = 8324). We classified the first mammogram as a screening examination if it was performed either as part of a routine exam or because of family history of cancer.

RESULTS

Among women aged 18-39 years, 14.3% (95% CI 13.2-15.4) reported ever having a mammogram. Prevalence of mammography use was highest among women aged 35-39 years (31.0%, 95% CI 27.8-34.5), and was higher among non-Hispanic black women than in other race/ethnicity groups. Women with a family history of breast cancer reported a higher prevalence of mammography use than women without this family history. For both women with and without a family history of breast cancer, about half of all first mammograms were performed for screening reasons.

CONCLUSIONS

Among U.S. women aged 18-39 years with no personal cancer history, one in seven reported having received a mammogram. Women with no family history of breast cancer were as likely as those with a family history to initiate breast cancer screening with mammography before age 40. Our findings provide evidence that supports further research to examine factors that prompt young women to receive screening mammograms.

Receipt of Cancer Screening Is a Predictor of Life Expectancy

BACKGROUND

Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.

OBJECTIVE

To determine the association between receipt of screening mammography or PSA and overall survival.

DESIGN

Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001-2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.

PARTICIPANTS

A 5 % sample of Medicare beneficiaries aged 69-90 years as of 1/1/2003 (n = 906,723).

INTERVENTIONS

Receipt of screening mammography in 2001-2002 for women, or a screening PSA test in 2002 for men.

MAIN MEASURES

Survival from 1/1/2003 through 12/31/2012.

KEY RESULTS

Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR = 1.52; 95 % CI = 1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR = 1.23; 1.22, 1.25).

CONCLUSIONS

Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.

Coupling Financial Incentives With Direct Mail in Population-Based Practice

Financial incentives are being used increasingly to encourage a wide array of health behaviors because of their well-established efficacy. However, little is known about how to translate incentive-based strategies to public health practice geared toward improving population-level health, and a dearth of research exists on how individuals respond to incentives through public health communication strategies such as direct mail. This study reports results of a population-based randomized controlled trial testing a direct mail, incentive-based intervention for promoting mammography uptake. The study population was composed of a random sample of Minnesota women enrolled in Medicare fee-for-service and overdue for breast cancer screening. Participants ( N = 18,939) were randomized into three groups: (1) Direct Mail only, (2) Direct Mail plus Incentive, and (3) Control. Both direct mail groups received two mailers with a message about the importance of mammography; however, Mail plus Incentive mailers also offered a $25 incentive for getting a mammogram. Logistic regression analyses measured intervention effects. Results showed the odds for receiving mammography were significantly higher for the Direct Mail plus Incentive group compared with both Direct Mail only and Control groups. The use of incentives also proved to be cost-effective. Additionally, the Direct Mail only group was more likely to receive mammography than the Control group. Findings offer experimental evidence on how the population-based strategy of direct mail coupled with a financial incentive can encourage healthy behavior, as well as how incentive-based programs can be translated into health promotion practice aimed at achieving population-level impact.

Effect of a Financial Incentive for Colorectal Cancer Screening Adherence on the Appropriateness of Colonoscopy Orders

Performance incentives for preventive care may encourage inappropriate testing, such as cancer screening for patients with short life expectancies. Defining screening colonoscopies for patients with a >50% 4-year mortality risk as inappropriate, the authors performed a pre-post analysis assessing the effect of introducing a cancer screening incentive on the proportion of screening colonoscopy orders that were inappropriate. Among 2078 orders placed by 23 attending physicians in 4 academic general internal medicine practices, only 0.6% (n = 6/1057) of screening colonoscopy orders in the preintervention period and 0.6% (n = 6/1021) of screening colonoscopy orders in the postintervention period were deemed "inappropriate." This study found no evidence that the incentive led to an increase in inappropriate screening colonoscopy orders.

Is anyone listening? Variation in PSA screening among providers for men 75+ before and after United States Preventive Services Task Force recommendations against it: a retrospective cohort study

Background

In 2008, the United States Preventive Services Task Force recommended against prostate specific antigen (PSA) testing for cancer screening in men age 75+.

Purpose

To assess PSA screening by primary care physicians (PCPs) before and after recommendations.

Methods

In 2013, this retrospective cohort study analyzed PCPs in Texas with 20+ male patients aged 75+ in both 2007 and 2010, with Parts A and B Medicare. The main outcome was percent of PCP’s male patients 75+ who received PSA testing ordered by the PCP in 2007 and 2010, with no recent symptoms suggestive of prostate cancer.

Results

In both 2007 and 2010, 1,083 PCPs cared for at least 20 men aged 75 or older. The rate of PSA screening ordered by PCPs was 33.2% in 2007 and 30.6% in 2010. In multilevel analyses controlling for patient characteristics, the variation in PSA screening attributable to the PCP (intraclass correlation coefficient) increased from 23% in 2007 to 26% in 2010, p<0.001. Men with PCPs older than age 60 had 9% lower odds (95% CI, 1–17%) in 2010 compared to 2007 of receiving a PSA test, vs. a 4% increase (95% CI, 4% decrease to 12% increase) in men with PCPs aged 50 or younger. Patients with Board Certified PCPs had a 12% lower odds (95% CI, 8% to 16%) from 2007 to 2010, vs. 2% increase (95% CI 11% decrease to 18% increase) in men with PCPs without board certification.

Conclusions

The USPSTF recommendation did not increase consensus among PCPs regarding PSA screening of older men.

Potential overuse of screening mammography and its association with access to primary care

BACKGROUND

Cancer screening in individuals with limited life expectancy increases the risk of diagnosis and treatment of cancer that otherwise would not have become clinically apparent.

OBJECTIVE

To estimate screening mammography use in women with limited life expectancy, its geographic variation, and association with access to primary care and mammographic resources.

METHODS

We assessed screening mammography use in 2008-2009 in 106,737 women aged 66 years or older with an estimated life expectancy of <7 years using a 5% national sample of Medicare beneficiaries. Descriptive statistics were used to estimate the screening mammography utilization, by access to primary care.

RESULTS

Among women with a life expectancy of <7 years, 28.5% received screening mammography during 2008-2009. The screening rates were 34.6% versus 20.5% for women with and without an identifiable primary care physician, respectively. The screening rates were higher among women who saw >1 generalist physician and who had more visits to generalist physicians. There was substantial geographic variation across the United States, with an average rate of 39.5% in the hospital referral regions (HRRs) in the top decile of screening versus 19.5% in the HRRs in the bottom decile. The screening rates were higher among HRRs with more primary care physicians (r=0.14, P=0.02), mammography facilities (r=0.12, P=0.04), and radiologists (r=0.22, P<0.001).

CONCLUSIONS

Substantial proportions of women with limited life expectancy receive screening mammography. Results presented sound a cautionary note that greater access to primary care and mammographic resources is also associated with higher overuse.

Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies

BACKGROUND & AIMS

Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy.

METHODS

We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years.

RESULTS

Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34).

CONCLUSIONS

Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services.

Delivering high-quality and affordable care throughout the cancer care continuum

The national cost of cancer care is projected to reach $173 billion by 2020, increasing from $125 billion in 2010. This steep upward cost trajectory has placed enormous an financial burden on patients, their families, and society as a whole and raised major concern about the ability of the health care system to provide and sustain high-quality cancer care. To better understand the cost drivers of cancer care and explore approaches that will mitigate the problem, the National Cancer Policy Forum of the Institute of Medicine held a workshop entitled "Delivering Affordable Cancer Care in the 21st Century" in October 2012. Workshop participants included bioethicists, health economists, primary care physicians, and medical, surgical, and radiation oncologists, from both academic and community settings. All speakers expressed a sense of urgency about the affordability of cancer care resulting from the future demographic trend as well as the high cost of emerging cancer therapies and rapid diffusion of new technologies in the absence to evidence indicating improved outcomes for patients. This article is our summary of presentations at the workshop that highlighted the overuse and underuse of screening, treatments, and technologies throughout the cancer care continuum in oncology practice in the United States.

Practice-Changing Strategies to Deliver Affordable, High-Quality Cancer Care: Summary of an Institute of Medicine Workshop

The authors summarize presentations and discussion from the Delivering Affordable Cancer Care in the 21st Century workshop and focus on proposed strategies to improve the affordability of cancer care while maintaining or improving the quality of care.

Predicting life expectancy for community-dwelling older adults from Medicare claims data

Estimates of life expectancy are useful in assessing whether different prevention strategies are appropriate in different populations. We developed sex-specific Cox proportional-hazard models that use Medicare claims data to predict life expectancy and risk of death at up to 10 years for older adults. We identified a cohort of Medicare beneficiaries 66-90 years of age from the 5% Medicare claims data in 2000 (n = 1,137,311) and tracked each subject's vital status until December 31, 2009. Subjects were split randomly into training and validation samples. Models were developed from the training sample and validated by comparison of predicted to actual survival in the validation sample. The C statistics for the models including predictors of age and Elixhauser comorbidities were 0.76-0.79 for men and women for prediction of death at the 1-, 5-, 7-, and 10-year follow-up periods. More than 80% of subjects with <25% risk of death at 5, 7, and 10 years survived longer than the chosen cutoff years. More than 80% of subjects with ≥75% risk of death at 5, 7, and 10 years died by those cutoff years. The models overestimated the risk of death at 1 year for the high-risk groups. Sex-specific models that use age and Elixhauser comorbidities can accurately predict patient life expectancy and risk of death at 5-10 years.