Original ResearchHigh-cost cancer imaging: Opportunities for utilization management
Introduction
The costs of cancer care are escalating, both domestically and internationally, calling into question the long-term sustainability of health systems and health care practices in high-income countries [1], [2]. The escalating costs of diagnostic technologies have continued to exceed increases in other cancer care expenditures, drawing greater attention to utilization patterns of high-cost tomographic imaging [3], [4], [5]. The extent to which benefits are derived from greater rates of imaging utilization has not been studied extensively in oncology, but studies have generally been unable to confirm benefits from increased tomographic imaging and associated treatments during the end of life [6], [7]. Given that one-third of end-of-life cancer care expenditures concentrate in the last month due to escalating treatment aggressiveness [8], exploration of imaging intensity within this period may reveal opportunities to improve healthcare value through the elimination of imaging that does not lead to improved outcomes.
Section snippets
Patients and methods
We conducted a retrospective analysis of cancer patients’ tomographic imaging utilization from diagnosis to death at an academic comprehensive cancer center in California to explore variations in oncologist ordering. Collective and individual oncologist imaging rates per patient were the outcomes of interest. Collection of data for this study was approved by the institutional review board and did not require patient consent.
Descriptive statistics
The patient population was comprised of 4,605 patients with 29,740 tomographic imaging studies ordered by oncologists. CT accounted for 67.5% of tomographic imaging (n = 20,083); MR accounted for 19.5% (n = 5,782); and PET accounted for 13% (n = 3,875). Patient demographics and cancer characteristics may be found in Table 1. Table 2 provides frequencies of surgery, radiation, and chemotherapy treatments. All patients had at least one of the three treatment types. Mean tomographic imaging intensity
Discussion
In this 15-year retrospective analysis of imaging utilization among 104 oncologists, we found indications that oncologists’ ordering patterns were highly heterogeneous. There was substantial variation in imaging utilization both between and within oncologic specialties. High-ordering oncologists were found to be substantial drivers of imaging utilization, with 58% more per patient imaging than their peers. Greater total collective per-patient imaging in larger combinations of ordering
Conclusions
Variability in tomographic imaging utilization is not based solely upon patient factors and treatment intensity, but is dependent on provider ordering preferences. An inverse relationship between increasing imaging intensity as temporal proximity to death decreases implies decision support around end-of-life treatment efficacy is lacking.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
We would like to thank Ann Griffin and Joseph McGuire, of the UCSF Helen Diller Family Comprehensive Cancer Center Cancer Registry; Christopher Jovais, of the UCSF Radiology Information Systems; and Dana Ludwig, of the UCSF Academic Research Systems.
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