Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers

Abstract

IMPORTANCE The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures. OBJECTIVE To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using the the Surveillance, Epidemiology, and End Results–Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions. MAIN OUTCOMES AND MEASURES In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa. RESULTS We identified 9219 men with prostate cancer and 30 398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12–2.65), 1.19 (0.78–1.81), or 1.76 (1.15–2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile. CONCLUSIONS AND RELEVANCE At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer

“…This suggests that nonpatient factors influence physician ordering behavior. 9 As described in the recent Institute of Medicine report 11 on variation in health care spending, there is likely to be considerable variation within the geographic region. Studies 11 have found variation by practice setting and even between individual physicians in the same practice.…”

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

“…17-20,22,24,26 The studies reporting a positive association measured comorbidity using the National Cancer Institute comorbidity index, 20,22 the Deyo adaptation of the Charlson comorbidity index, 17 or a simple count. 18,19,24,26 In contrast, the three studies that relied upon the original Charlson comorbidity index 14,23 or the Klabunde-Charlson comorbidity score 15 did not find a significant association between comorbidity and overuse.…”

“…All thirteen empirical studies evaluated the overuse of bone scan as an outcome. While two studies focused exclusively on bone scans, the remaining eleven studies considered bone scan in combination with up to three other imaging modalities; eleven studies examined computed tomography (CT), 15-21,23-26 eight studies examined magnetic resonance imaging (MRI), 15-17,20,21,24-26 five studies examined positron emission tomography (PET) 18,19,21,24,26 and one study examined ultrasonography. 15 (Table I) For example, an outcome may be defined as receipt of any imaging (bone scan, MRI, or PET) in an individual with early stage prostate cancer.…”

“…Moreover, the relationship between the identified factors and overutilization is complex; overutilization can be correlated with rates of appropriate utilization within the same disease, 25 rates of overutilization in other diseases, 19 and with low volume of overall service delivery. 24 Researchers should aim to understand the relative importance of these factors through experimental and quasi-experimental methods that assess changes in overuse in response to new policies or guidelines.…”

“…Three studies examined the relationship between the overuse of imaging in low-risk prostate cancer and other measures of utilization or resource supply; 19,24,25 overuse was positively associated with appropriate imaging in high-risk prostate cancer, 25 inappropriate imaging in low-risk breast cancer, 19 low overall hospital volume, 24 and hospital bed count per 1000 regional residents. 19 …”