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Frequency of unnecessary imaging prior to Choosing Wisely among Veterans diagnosed with low-risk cancer

Zeliadt SB, Makarov D, Au DH, Backhus LM, Zhou XA. Frequency of unnecessary imaging prior to Choosing Wisely among Veterans diagnosed with low-risk cancer. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 6; San Diego, CA.

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Research Objective: Choosing Wisely is an effort to encourage stewardship of healthcare resources by fostering a conversation between patients and physicians to reduce unnecessary medical procedures. In order to evaluate the success of Choosing Wisely it is important to closely monitor changes in utilization of targeted procedures. We describe the use of administrative data to assess baseline overuse of imaging procedures among Veterans newly diagnosed with two common cancers. Study Design: A retrospective cohort study focused on assessing two Choosing Wisely targets: "Don't perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis"; and "Patients with suspected or biopsy proven stage I non-small cell lung cancer do not require brain imaging prior to definitive care in the absence of neurologic symptoms." Population Studied: Veterans newly diagnosed with cancer between 2004-2008 were identified from the VHA Central Cancer Registry and linked with VHA and Medicare records. For prostate cancer, low-risk was defined as Gleason score under 8, PSA level under 20 and clinical T stage I or II. For lung cancer, low-risk was defined as stage I adenocardinoma or squamous non-small cell histology. Patients who died within 6 months of diagnosis were excluded, as were patients with specific indications of bone pain or neurologic symptoms. Principal Findings: We identified 29,951 Veterans (mean age 65.6) meeting the Choosing Wisely criteria for low-risk prostate cancer and 2,849 Veterans (mean age 68.6) meeting the criteria for low-risk lung cancer. Over 30% of the prostate cancer cohort and 39% of the lung cancer cohort had used Medicare-reimbursed services in the 12 month period prior to diagnosis. Using only VHA records, we observed that 44.5% of prostate cancer patients and 53.2% of lung cancer patients received unnecessary imaging in the peri-diagnostic period. When Medicare records were added, the use of unnecessary imaging increased to 47.5% of prostate cancer patients and 59.6% of lung cancer patients. Duplicative imaging procedures performed in both VHA and Medicare settings were identified among 150 prostate cancer patients ( < 1%) and 182 lung cancer patients (6.4%). Conclusions: The historical utilization of unnecessary imaging among Veterans diagnosed with low-risk prostate and lung cancer is substantial and expensive. Implications for Policy and Practice: Using administrative and electronic medical record data to determine whether targeted procedures identified in Choosing Wisely are being overused is challenging because there is often a lack of data to determine an accurate denominator of patients who should be receiving the procedures. The availability of cancer registry staging information is an important opportunity to study the effects of Choosing Wisely both because cancer registries allow for the identification of the denominator of all cancer patients and because overuse of imaging among cancer patients is so widespread. Although many Veterans are dually-eligible for Medicare and VHA healthcare coverage, those who are diagnosed with cancer at a VHA facility receive the majority of their care related to initial staging and treatment within the VHA setting. However, assessments of the quality of care among dually-eligible Veterans will be modestly biased if care reimbursed by Medicare is not included.

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