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Inappropriate breast, prostate cancer imaging linked to regional, culture infrastructure
High rates of inappropriate imaging for prostate cancer in hospital referral regions were associated with similarly inappropriate rates for breast cancer imaging within the same region, according to results of a SEER analysis.
This link suggests a regional-level propensity for inappropriate imaging utilization may exist, researchers wrote.
Danil V. Makarov, MD, MHS, assistant professor of urology, population health and health policy at NYU Langone Medical Center and a member of the Perlmutter Cancer Center, and colleagues sought to evaluate regional rates for low-risk prostate and breast cancer imaging, highlighted in ASCO’s Choosing Wisely campaign as a potentially inappropriate use of health care resources.
Researchers evaluated data collected from the SEER–Medicare database on 84 hospital referral regions. The retrospective cohort included 9,219 men with low-risk prostate cancer and 30,398 women with low-risk breast cancer.
Makarov and colleagues observed high rates for low-risk prostate cancer imaging (44.4%) and breast cancer imaging (41.8%).
Rates for inappropriate breast cancer imaging were associated with race (44% for black women vs. 41.7% for white women), diagnosis year (43.5% for 2007 vs. 40.1% for 2004), median household income (42.8% for $50,000-$63,000 per year vs. 39.6% for $33,000-40,000 per year), and marital status (42.1% among married women vs. 41.8% among unmarried women).
Prostate cancer imaging was more common in older men (48.9% for ages 80-84 years vs. 42.3% for ages 67-69 years), black men (45.9% for black vs. 44.2% for white), those with a later year of diagnosis (44.7% for 2007 vs. 43.8% for 2004), and those with higher median household income (46.3% for >$63,000 per year vs. 42.2% for <$33,000 per year).
Researchers categorized the hospital referral regions from the lowest quartile of inappropriate imaging rates to the highest. Rates for inappropriate prostate cancer imaging corresponded with the quartiles for inappropriate breast cancer imaging (lowest breast cancer quartile, 34.2% prostate cancer imaging rate; highest quartile, 56.4%). Rates for inappropriate breast cancer imaging increased from 38.1% in the lowest prostate cancer quartile to 45.7% in the highest.
Analyses adjusted for age, comorbidity and regional number of hospital beds indicated men with low-risk prostate cancer were significantly more likely to undergo imaging if they lived in the fourth (OR = 1.72; 95% CI, 1.12-2.65), third (OR = 1.19; 95% CI, 0.78-1.81) or second (OR = 1.76; 95% CI, 1.15-2.7) quartiles vs. the first quartile of breast cancer imaging.
An association, although insignificant, also existed between inappropriate breast cancer imaging as a function of hospital referral region-inappropriate prostate cancer imaging.
“These findings challenge us to move in a different direction than focusing exclusively on individual patient–doctor decision-making,” Makarov said in a press release. “Policy makers and researchers need to target high-utilization regions and promote incentives for appropriate care. Such a focus would enhance efforts to cut excessive health spending and build value-based strategies into health care practice.”
A 2013 Institute of Medicine (IOM) panel also identified geographical variation in health care spending at the hospital referral region level, Samuel Swisher-McClure, MD, MSHP, and Justin Bekelman, MD, both of the department of radiation oncology at the University of Pennsylvania Perelman School of Medicine, wrote in an accompanying editorial.
However, the panel found expenditure variation existed at every level of geography, and therefore it recommended against a geographically targeted value index.
“As our understanding of explanatory factors driving regional patterns of health care continues to evolve, interventions designed to educate, enhance awareness and support shared medical decision-making between patients and physicians are most appropriate,” Swisher-McClure and Bekelman wrote. “The Choosing Wisely campaign is a laudable example, and it will be critical for continued research to examine temporal trends in patterns of care following its implementation to assess the potential effects.
“Payment policies that reward high-value care and discourage low-value care are also promising,” they wrote. “However, as concluded by the recent IOM report, smaller-level variation exists within individual hospital referral regions, and so payment policies applied uniformly across geographic regions may be unjust and risk adversely affecting patient outcomes by reducing overall care utilization regardless of appropriateness.” – by Cameron Kelsall
Disclosure: Makarov reports consultant roles with Castlight Health and the FDA. Other researchers report research funding from or consultant roles with Johnson & Johnson, Medtronic and 21st Century Oncology. Swisher-McClure and Bekelman report no relevant financial disclosures.