Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review

Abstract

Background The overuse of radiologic services, where imaging tests are provided in circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health care systems. Advanced imaging in the staging of low-risk prostate cancer is considered an overused procedure by many professional societies, yet the determinants that drive this phenomenon are not fully appreciated. Methods We systematically searched published literature within MEDLINE® and Embase® from January 1998 to March 2017. We searched for studies conducted in the United States that contain original data and describe determinants associated with the overuse of imaging in low-risk prostate cancer. Paired reviewers independently screened abstracts, assessed quality, and extracted data. We synthesized the identified determinants as a patient-level, clinician-level, or system-level factors of overuse. Results Fourteen articles were included; the 13 empirical studies defined overuse as being the use of imaging that was discordant with clinical guidelines. Patient- and system-related factors were most commonly described as being associated with overuse; clinician-level determinants were examined infrequently. Older patient age (n=5), more patient comorbidities (n=7), and characteristics related to geography (n=6), higher regional income (n=6) and less education (n=5) were the most consistently identified statistically significant determinants of overuse. Meaningful differences were detected between health care settings; large integrated health care systems provided less variable care and had lower rates of overuse. Clinical indicators related to prostate cancer were inconsistently associated with overuse. Conclusion Many patient- and system-related determinants were identified as contributing to the overuse of advanced imaging to stage low-risk prostate cancer. Overuse may be the consequence of systematized clinician behavior and be relatively invariant of patient characteristics. The identified system-level determinants suggest that payment models that are not tied to volume or enhanced care coordination may curb overuse. We propose further examination of physician-level determinants and implore researchers to rank the relative importance of the identified factors and to test their influence through experimental and quasi-experimental methods.

Induced Demand in Cancer Diagnosis

“…The review revealed that physicians' personal benefits and financial incentives are the main drivers of unnecessary imaging and the overuse in cancer diagnosis (15,16). Other noteworthy factors are financial relationships between physicians and other health care providers (17) and physicians' full or partial ownership of imaging equipment (18). These factors significantly increase the probability of overuse through the increased utilization of diagnostic services.…”

“…These factors significantly increase the probability of overuse through the increased utilization of diagnostic services. Furthermore, the overuse of services for diagnosing early-stage cancer is related to a patient's geographical location (which affects their access to such services), income (and, thus, their ability to pay for these services), and education (18,19).…”

Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients

“…A 2017 systematic review identified 14 articles on overuse of imaging among patients with low-risk prostate cancer, representing data from 2004 to 2012. 32 In the previous 10 years, there were several published efforts to curb guideline-discordant imaging, some of which have been successful, like the Michigan Urological Surgery Improvement Collaborative, 33 and others which have been less so. 34 Guideline-discordant staging imaging for low-risk prostate cancer continues to be regarded as a Choosing Wisely priority.…”

Assessing Hospital Resource Utilization with Application to Imaging for Patients Diagnosed with Prostate Cancer

“…Such models would both provide a standard for resource utilization to practitioners and also identify potential over-/under-utilization of hospital resources during in-patient hospital stays. When developing models to detect resource over-utilization, researchers have identified patient, clinical, and system-level factors as variables of interest [ 4 ]. However, certain clinical factors may not be available for some users, such as those with administrative information and limited access to electronic health records (EHR), rendering some of the available models less generalizable.…”