Geographic variation and trends in carotid imaging among medicare beneficiaries, 2001 to 2006

Cost of Low-Value Imaging Worldwide: A Systematic Review

BACKGROUND AND OBJECTIVE

Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.

METHODS

This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.

RESULTS

Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.

CONCLUSIONS

This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

Trends in magnetic resonance and computed tomography angiography utilization among Medicare beneficiaries between 2013 and 2020

PURPOSE

To evaluate relative and absolute utilization trends and practice patterns in the United States for MRA and CTA.

METHODS

Using Medicare Part B physician payment databases (2013-2020), MRA and CTA interpreting physicians and exams were identified using the unique MRA and CTA Healthcare Common Procedure Coding System codes. The number of exams, physicians, demographics, use of contrast, and payments were summarized annually and analyzed to evaluate trends before and during the first year of the COVID-19 pandemic.

RESULTS

From 2013 to 2019, the annual number of MRA exams performed decreased by 17.9 %, while the number of CTA exams increased by 90.3 %. The number of physicians interpreting MRA decreased in both hospital (-17.2 %) and outpatient (-7.5 %) environments. The number of physicians interpreting CTA increased in both hospital (+29.4 %) and outpatient (+54.3 %) environments. During the first year of the COVID-19 pandemic, MRA utilization decreased across all imaging environments by 25.0 % whereas CTA only decreased by 5.5 %. Intracranial MRA studies were most often performed without contrast, while contrast use for neck MRA was performed at similar rates as non-contrast exams.

CONCLUSION

The overall utilization of MRA and the number of interpreting physicians are decreasing. On the other hand, CTA use and its number of interpreting physicians are increasing. During the first year of the COVID-19 pandemic, use of both MRA and CTA decreased, but the utilization of MRA decreased at five times the rate of CTA.

The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program

The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA) star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

Surgeon case volume and 30-day mortality after carotid endarterectomy among contemporary medicare beneficiaries: before and after national coverage determination for carotid artery stenting

BACKGROUND AND PURPOSE

After the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and carotid endarterectomy (CEA) decreased. We evaluated trends in surgeons' past-year CEA case-volume and 30-day mortality after CEA, and their association before and after the National Coverage Determination.

METHODS

In a retrospective cohort study of patients undergoing CEA (2001-2008) and CAS (2005-2008) using Medicare data, we described yearly trends of CEA and CAS rates, patient characteristics, and 30-day mortality after CEA. We used logistic regression adjusting for patient- and surgeon-level factors to assess the effect of surgeon case volume on 30-day mortality after CEA.

RESULTS

We identified 454 717 CEA and 27 943 CAS patients. Patients undergoing CEA in recent years were older and had more comorbidities than earlier years. CEA rates per 10 000 beneficiaries declined from 18.1 in 2002 to 12.7 in 2008, whereas median surgeon past-year case-volume declined from 27 to 21. The CAS rates peaked at 2.3 per 10 000 beneficiaries in 2006 but declined to 1.8 in 2008, resulting in declining overall revascularization procedure rates during 2005 to 2008. Thirty day post-CEA mortality was 1.40% (95% confidence interval, 1.34-1.47) in 2001 to 2002 and 1.17% (1.10-1.24) in 2007 to 2008. Surgeon's past-year case-volume of <10 was associated with higher 30-day mortality consistently during 2001 to 2008.

CONCLUSIONS

The rate of CEA procedures decreased substantially during 2001 to 2008, as did surgeon past-year case-volume. The postprocedural mortality in Medicare beneficiaries was high compared with trial patients but somewhat improved over time. Those operated by lower past-year case-volume surgeons had increased mortality.

Why is the management of asymptomatic carotid disease so controversial?

BACKGROUND

Despite level I evidence supporting a role for carotid endarterectomy (CEA) in the management of patients with asymptomatic carotid disease, there is surprisingly little international consensus regarding the optimal way to manage these patients.

METHODS

Review of current strategies for managing asymptomatic carotid disease

MAIN FINDINGS

Those favouring a pro-interventional approach argue that: (i) until new randomised trials demonstrate that best medical therapy (BMT) is better than CEA or carotid artery stenting (CAS) in preventing stroke, guidelines of practice should remain unchanged; (ii) strokes secondary to carotid thromboembolism harboured a potentially treatable asymptomatic lesion prior to the event. Because 80% of strokes are not preceded by a TIA/minor stroke, CEA/CAS is the only way of preventing these strokes; (iii) screening for carotid disease could identify patients with significant asymptomatic stenoses who could undergo prophylactic CEA/CAS in order to prevent avoidable stroke; (iv) international guidelines already advise that only 'highly-selected' patients should undergo CEA/CAS; (v) the 30-day risks of death/stroke after CEA/CAS are diminishing and this will increase long-term stroke prevention and (vi) the alleged decline in annualized stroke rates in medically treated patients is based upon flawed data.

CONCLUSIONS

The inescapable conclusion is that only a relatively small proportion of asymptomatic patients benefit from prophylactic CEA/CAS. The key question, therefore, remains; is society prepared to invest sufficient resources in identifying these 'high risk for stroke' patients so that they can benefit from aggressive BMT and CEA or CAS, leaving the majority of lower risk patients to be treated medically?

How to set up a departmental comparative effectiveness research unit: one department's experience

OBJECTIVE

Comparative effectiveness research (CER) is the comparison of clinical interventions in real-world settings. The purpose of this article is to discuss the experiences of a CER unit created within the radiology department of one medical institution to provide an example of how to pursue CER within the field of radiology.

CONCLUSION

Medical institutions would benefit from investing in CER by creating research groups specifically devoted to this evolving field.

Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease: results from U.S. Medicare 2000-2008

OBJECTIVES

This study sought to characterize temporal trends, patient-specific factors, and geographic variation associated with amputation in patients with lower-extremity peripheral artery disease (LE PAD) during the study period.

BACKGROUND

Amputation represents the end-stage failure for those with LE PAD, and little is known about the rates and geographic variation in the use of LE amputation.

METHODS

By using data from the Centers for Medicare & Medicaid Services (CMS) from January 1, 2000, to December 31, 2008, we examined national patterns of LE amputation among patients age 65 years or more with PAD. Multivariable logistic regression was used to adjust regional results for other patient demographic and clinical factors.

RESULTS

Among 2,730,742 older patients with identified PAD, the overall rate of LE amputation decreased from 7,258 per 100,000 patients with PAD to 5,790 per 100,000 (p < 0.001 for trend). Male sex, black race, diabetes mellitus, and renal disease were all independent predictors of LE amputation. The adjusted odds ratio of LE amputation per year between 2000 and 2008 was 0.95 (95% CI: 0.95-0.95, p < 0.001).

CONCLUSIONS

From 2000 to 2008, LE amputation rates decreased significantly among patients with PAD. However, there remains significant patient and geographic variation in amputation rates across the United States.