High-Cost Imaging in Elderly Patients With Stage IV Cancer
High-Cost Imaging in Elderly Patients With Stage IV Cancer
Background Medicare expenditures for high-cost diagnostic imaging have risen faster than those for total cancer care and have been targeted for potential cost reduction. We sought to determine recent and long-term patterns in high-cost diagnostic imaging use among elderly (aged ≥65 years) patients with stage IV cancer.
Methods We identified claims within the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with computed tomography, magnetic resonance imaging, positron emission tomography, and nuclear medicine scans between January 1994 and December 2009 for patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer between January 1995 and December 2006 (N = 100 594 patients). The proportion of these patients imaged and rate of imaging per-patient per-month of survival were calculated for each phase of care in patients diagnosed between January 2002 and December 2006 (N = 55 253 patients). Logistic regression was used to estimate trends in imaging use in stage IV patients diagnosed between January 1995 and December 2006, which were compared with trends in imaging use in early-stage (stages I and II) patients with the same tumor types during the same period (N = 192 429 patients).
Results Among the stage IV patients diagnosed between January 2002 and December 2006, 95.9% underwent a high-cost diagnostic imaging procedure, with a mean number of 9.79 (SD = 9.77) scans per patient and 1.38 (SD = 1.24) scans per-patient per-month of survival. After the diagnostic phase, 75.3% were scanned again; 34.3% of patients were scanned in the last month of life. Between January 1995 and December 2006, the proportion of stage IV cancer patients imaged increased (relative increase = 4.6%, 95% confidence interval [CI] = 3.7% to 5.6%), and the proportion of early-stage cancer patients imaged decreased (relative decrease = −2.5%, 95% CI = −3.2% to −1.9%).
Conclusions Diagnostic imaging is used frequently in patients with stage IV disease, and its use increased more rapidly over the decade of study than that in patients with early-stage disease.
More than a quarter of Medicare dollars are spent at the end of life. As the American population ages, Medicare enrollment is projected to double between 2000 and 2030. Cancer, currently the second leading cause of death, will affect increasing numbers of people and consume an ever greater proportion of overall medical expenditures. The annualized net costs of cancer are highest in the last year of life, and care delivered during this time period is intensifying.
Diagnostic imaging is the most rapidly growing sector of Medicare-reimbursed services, and among Medicare patients with cancer, imaging costs have risen at a rate outpacing total costs of care. Advanced imaging has expanded dramatically in both availability and usage. The Medicare Payment Advisory Commission (MedPAC) has designated the following types of procedures as "high-cost imaging services": computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and nuclear medicine (NM). In 2008, these four procedure types accounted for 49% of Medicare physician payments for imaging.
Little is currently known about the use of high-cost imaging in cancer patients at the end of life. We sought to characterize imaging use in patients who presented with stage IV disease of the four most common causes of cancer death: breast, colorectal, lung, or prostate cancer. Specifically, our objectives were to describe recent practices in imaging these patients and to examine changes over time. A greater understanding of existing patterns of care in this vulnerable population is critical, given the recent attention both high-cost imaging and end-of-life care have received as potential targets for decreasing healthcare expenditures and the need to ensure maintenance or improvement in the quality of care received.
Abstract and Introduction
Abstract
Background Medicare expenditures for high-cost diagnostic imaging have risen faster than those for total cancer care and have been targeted for potential cost reduction. We sought to determine recent and long-term patterns in high-cost diagnostic imaging use among elderly (aged ≥65 years) patients with stage IV cancer.
Methods We identified claims within the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with computed tomography, magnetic resonance imaging, positron emission tomography, and nuclear medicine scans between January 1994 and December 2009 for patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer between January 1995 and December 2006 (N = 100 594 patients). The proportion of these patients imaged and rate of imaging per-patient per-month of survival were calculated for each phase of care in patients diagnosed between January 2002 and December 2006 (N = 55 253 patients). Logistic regression was used to estimate trends in imaging use in stage IV patients diagnosed between January 1995 and December 2006, which were compared with trends in imaging use in early-stage (stages I and II) patients with the same tumor types during the same period (N = 192 429 patients).
Results Among the stage IV patients diagnosed between January 2002 and December 2006, 95.9% underwent a high-cost diagnostic imaging procedure, with a mean number of 9.79 (SD = 9.77) scans per patient and 1.38 (SD = 1.24) scans per-patient per-month of survival. After the diagnostic phase, 75.3% were scanned again; 34.3% of patients were scanned in the last month of life. Between January 1995 and December 2006, the proportion of stage IV cancer patients imaged increased (relative increase = 4.6%, 95% confidence interval [CI] = 3.7% to 5.6%), and the proportion of early-stage cancer patients imaged decreased (relative decrease = −2.5%, 95% CI = −3.2% to −1.9%).
Conclusions Diagnostic imaging is used frequently in patients with stage IV disease, and its use increased more rapidly over the decade of study than that in patients with early-stage disease.
Introduction
More than a quarter of Medicare dollars are spent at the end of life. As the American population ages, Medicare enrollment is projected to double between 2000 and 2030. Cancer, currently the second leading cause of death, will affect increasing numbers of people and consume an ever greater proportion of overall medical expenditures. The annualized net costs of cancer are highest in the last year of life, and care delivered during this time period is intensifying.
Diagnostic imaging is the most rapidly growing sector of Medicare-reimbursed services, and among Medicare patients with cancer, imaging costs have risen at a rate outpacing total costs of care. Advanced imaging has expanded dramatically in both availability and usage. The Medicare Payment Advisory Commission (MedPAC) has designated the following types of procedures as "high-cost imaging services": computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and nuclear medicine (NM). In 2008, these four procedure types accounted for 49% of Medicare physician payments for imaging.
Little is currently known about the use of high-cost imaging in cancer patients at the end of life. We sought to characterize imaging use in patients who presented with stage IV disease of the four most common causes of cancer death: breast, colorectal, lung, or prostate cancer. Specifically, our objectives were to describe recent practices in imaging these patients and to examine changes over time. A greater understanding of existing patterns of care in this vulnerable population is critical, given the recent attention both high-cost imaging and end-of-life care have received as potential targets for decreasing healthcare expenditures and the need to ensure maintenance or improvement in the quality of care received.
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