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Original Research |

Geographic Variation in Cancer-Related Imaging: Veterans Affairs Health Care System Versus MedicareCancer-Related Imaging in the VA Health Care System Versus Medicare

J. Michael McWilliams, MD, PhD; Jesse B. Dalton, MA; Mary Beth Landrum, PhD; Austin B. Frakt, PhD; Steven D. Pizer, PhD; and Nancy L. Keating, MD, MPH
[+] Article, Author, and Disclosure Information

From Harvard Medical School, Brigham and Women's Hospital, Boston University School of Medicine, and Northeastern University, Boston, and Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.

Disclaimer: This study used the linked SEER–Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The ideas and opinions expressed herein are those of the authors and endorsement by the California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their contractors and subcontractors is not intended nor should be inferred. The views reflect those of the authors and not the Department of Veterans Affairs.

Acknowledgment: The authors thank Pasha Hamed, MA, and Jeffrey Souza (Department of Health Care Policy, Harvard Medical School) for statistical programming support; their contributions were supported by the same funding sources as the authors. The authors also thank Samuel R. Bozeman, MPH; Barbara J. McNeil, MD, PhD; and Elizabeth B. Lamont, MD, MS, for their prior contributions to obtaining data and creating the cancer cohorts. The authors acknowledge the efforts of the Applied Research Program (National Cancer Institute [NCI]); the Office of Research, Development, and Information (Centers for Medicare & Medicaid Services [CMS]); Information Management Services (IMS); and the SEER program tumor registries in the creation of the SEER–Medicare database. The authors received helpful feedback as part of a larger evaluation of cancer care in the VA from members of the VA Oncology Program Evaluation Team, including persons from the Veterans Health Administration, VA Health Services Research and Delivery, and VA Office of Policy and Planning.

Grant Support: By the Doris Duke Charitable Foundation (Clinical Scientist Development Award 2010053; Dr. McWilliams), Beeson Career Development Award Program (National Institute on Aging K08 AG038354 and the American Federation for Aging Research; Dr. McWilliams), VA Health Services Research and Development (IAD 06-112; Drs. Frakt and Pizer), and the VA Office of Policy and Planning (as part of a larger evaluation of the quality of cancer care in the VA; Drs. Landrum and Keating). The collection of the cancer incidence data from California used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the NCI SEER program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention's National Program of Cancer Registries under agreement U55/CCR921930-02 awarded to the Public Health Institute.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0650.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. McWilliams (e-mail, mcwilliams@hcp.med.harvard.edu). Data set: Not publicly available and cannot be shared under the terms of the investigators' data use agreement.

Requests for Single Reprints: J. Michael McWilliams, MD, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, mcwilliams@hcp.med.harvard.edu.

Current Author Addresses: Drs. McWilliams, Landrum, and Keating and Mr. Dalton: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.

Dr. Frakt: Veterans Affairs Boston Healthcare System, 150 South Huntington Avenue (152H), Jamaica Plain, MA 02130.

Author Contributions: Conception and design: J.M. McWilliams, M.B. Landrum, A.B. Frakt, S.D. Pizer, N.L. Keating.

Analysis and interpretation of the data: J.M. McWilliams, J.B. Dalton, M.B. Landrum, A.B. Frakt, S.D. Pizer, N.L. Keating.

Drafting of the article: J.M. McWilliams.

Critical revision of the article for important intellectual content: J.M. McWilliams, M.B. Landrum, A.B. Frakt, S.D. Pizer, N.L. Keating.

Final approval of the article: J.M. McWilliams, M.B. Landrum, S.D. Pizer, N.L. Keating.

Statistical expertise: J.M. McWilliams, M.B. Landrum, A.B. Frakt, S.D. Pizer.

Obtaining of funding: J.M. McWilliams, S.D. Pizer, N.L. Keating.

Administrative, technical, or logistic support: S.D. Pizer.

Collection and assembly of data: J.M. McWilliams, J.B. Dalton, M.B. Landrum, N.L. Keating.


Ann Intern Med. 2014;161(11):794-802. doi:10.7326/M14-0650
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Background: Geographic variations in use of medical services have been interpreted as indirect evidence of wasteful care. Less overuse of services, however, may not be reliably associated with less geographic variation.

Objective: To compare average use and geographic variation in use of cancer-related imaging between fee-for-service Medicare and the Department of Veterans Affairs (VA) health care system.

Design: Observational analysis of cancer-related imaging from 2003 to 2005 using Medicare and VA utilization data linked to cancer registry data. Multilevel models, adjusted for sociodemographic and tumor characteristics, were used to estimate mean differences in annual imaging use between cohorts of Medicare and VA patients within geographic areas and variation in use across areas for each cohort.

Setting: 40 hospital referral regions.

Patients: Older men with lung, colorectal, or prostate cancer, including 34 475 traditional Medicare beneficiaries (Medicare cohort) and 6835 VA patients (VA cohort).

Measurements: Per-patient count of imaging studies for which lung, colorectal, or prostate cancer was the primary diagnosis (each study weighted by a standardized price), and a direct measure of overuse—advanced imaging for prostate cancer at low risk for metastasis.

Results: Adjusted annual use of cancer-related imaging was lower in the VA cohort than in the Medicare cohort (price-weighted count, $197 vs. $379 per patient; P < 0.001), as was annual use of advanced imaging for prostate cancer at low risk for metastasis ($41 vs. $117 per patient; P < 0.001). Geographic variation in cancer-related imaging use was similar in magnitude in the VA and Medicare cohorts.

Limitation: Observational study design.

Conclusion: Use of cancer-related imaging was lower in the VA health care system than in fee-for-service Medicare, but lower use was not associated with less geographic variation. Geographic variation in service use may not be a reliable indicator of the extent of overuse.

Primary Funding Source: Doris Duke Charitable Foundation and Department of Veterans Affairs Office of Policy and Planning.

Figures

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Figure 1.

Differences in use of cancer-related imaging between Medicare and VA cohorts, by imaging method.

Within-region differences in adjusted imaging use between Medicare and VA cohorts are displayed by imaging method. Error bars indicate 95% CIs. CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography; VA = Veterans Affairs.

* Price-weighted count.

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Figure 2.

Geographic variation in cancer-related imaging use for Medicare versus VA cohort, by HRR.

For each cohort, adjusted mean use of cancer-related imaging (mean price-weighted count expressed in dollars per patient) is displayed by HRR, with HRRs ranked separately for each cohort. Error bars indicate 95% CIs. In a sensitivity analysis, exclusion of the HRR with the highest level of use in the VA cohort did not alter conclusions. HRR = hospital referral region; VA = Veterans Affairs.

* Price-weighted count.

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Appendix Figure.

Geographic variation in cancer-related imaging use for Medicare versus VA cohort, by HRR quintiles.

For each cohort, adjusted mean use of cancer-related imaging is displayed by quintile of HRRs in the cohort's HRR-level ranking of mean adjusted use. (HRRs were ranked separately for each cohort.) In the Medicare cohort, adjusted annual use of cancer-related imaging was $141 (47%) higher per patient in HRRs in the highest quintile of use than in HRRs in the lowest quintile. In the VA cohort, adjusted annual use of cancer-related imaging was $237 (240%) higher per patient in HRRs in the highest quintile of use than in HRRs in the lowest quintile. Error bars indicate 95% CIs. HRR = hospital referral region; VA = Veterans Affairs.

* Price-weighted count.

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