HA: Dialing back on inappropriate imaging may deter appropriate exams

In the effort to control healthcare costs in the U.S., policymakers have made reduction of inappropriate imaging a goal in regions of high utilization. However, a cross-sectional study of prostate cancer patients has found that regions of low inappropriate imaging also had low rates of appropriate imaging, a correlation which could indicate that imprudent efforts to decrease unnecessary utilization may inadvertently cut appropriate imaging as well, according to a study published in the April 2012 issue of Health Affairs.

The study, authored by Danil V. Makarov, MD, MHS, of New York University School of Medicine in New York City, and colleagues, found that men with high-risk prostate cancer were more likely to receive appropriate imaging if they lived in areas with high rates of inappropriate imaging. Imaging rates, both inappropriate and appropriate, are determined more by overall healthcare resource use, and reductions to one type of imaging correlate with the other, as if overall utilization was set by thermostat.

“This ‘thermostat model’ of regional healthcare utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients,” wrote the authors.

Makarov et al conducted the study with data on nearly 30,000 male prostate cancer patients ages 66 to 85 obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. All patients in the study cohort were diagnosed with prostate cancer in 2004 or 2005.

Results showed that fitted probabilities of inappropriate and appropriate imaging varied significantly from one SEER region to another. For instance, a patient in New Jersey had a 62 percent chance of receiving inappropriate imaging, the highest rate of any region, compared with a 22 percent chance in the Utah region, the lowest rate of all studied regions.

Despite the regional variability, areas with high probabilities of inappropriate imaging also tended to have higher probabilities of appropriate imaging. New Jersey again led the way with a 78 percent chance of patients receiving appropriate imaging.

The researchers also found poor adherence to National Comprehensive Cancer Network guidelines for imaging prostate cancer patients in the Medicare population as only two-thirds of men with high-risk disease received appropriate imaging. More than 45 percent of men with low-risk prostate cancer underwent inappropriate imaging.

“Our data support the proposed thermostat model because appropriate and inappropriate healthcare utilization patterns appear correlated at a regional level,” wrote the authors. “Better judgment or a stricter adherence to guidelines do not seem to affect resource use in low-use regions. Therefore, policy interventions should not solely target regional utilization patterns.”

Makarov and colleagues cautioned that as accountable care organizations, spurred by the Patient Protection and Affordable Care Act, begin to implement policies to reduce inappropriate healthcare utilization, the thermostat model must be kept in mind. Providers need to clearly define metrics and use multifaceted policies to break down the relationship between appropriate and inappropriate utilization and ensure that controlling costs does not limit quality care.