Veterans who seek care for low-risk prostate cancer receive more imaging that doesn't comply with established guidelines when they go outside of the Veterans Affairs (VA) system to Medicare sources, according to a study published online August 17 in JAMA Network Open.
The findings suggest there's more work to be done to ensure that men with low-risk prostate cancer don't undergo imaging they may not need, wrote a team led by Dr. Danil Makarov of New York University School of Medicine. The issue is especially important as the U.S. government is looking at ways to let veterans receive care outside the VA system.
"Outside the VA health system, there may be higher rates of guideline-discordant prostate cancer imaging, suggesting a trade-off of resources for quality of care in a fee-for-service setting. ... The results of this study may help policymakers understand the implications of particular healthcare policies ... and highlight areas for improvement in the cost-effectiveness and quality of healthcare for veterans," the group wrote.
In 2014, Congress passed the Veterans Access, Choice, and Accountability Act (the Choice Act) to reduce wait time for veterans requiring specialized healthcare by providing funding for them to seek it outside of the VA system. But it's unclear whether this legislation actually translates into appropriate prostate cancer imaging, Makarov and colleagues wrote. So the researchers analyzed rates of imaging that complied with guidelines and rates of imaging that didn't comply among patients with prostate cancer who sought care within the VA health system. They then compared the rates with those of patients who sought care outside the system, in this case within the Medicare system.
The study included data from 98,867 men who received a prostate cancer diagnosis between January 2004 and March 2008. Data were collected from the VA Central Cancer Registry and linked to Medicare claims and utilization records as well as the Surveillance, Epidemiology, and End Results Program (SEER). Most of the patients (69.8%) had low-risk prostate cancer.
Of the total patient cohort, Makarov's team established three different subgroups:
- Those who received care from Medicare sources only (57.3%)
- Those who received care from VA sources only (28.1%)
- Those who received care from both (14.5%)
The researchers assessed whether patients with low-risk prostate cancer received care that met recommendations set by the National Comprehensive Cancer Network (NCCN), tracking whether they underwent radionuclide bone scans, CT scans, or MRI exams, and then determined whether these scans were appropriate; in general, men who meet the requirements for these imaging tests have high-risk prostate cancer.
Among men with low-risk prostate cancer, those who sought care from Medicare sources only had the highest rates of imaging that did not comply with NCCN guidelines (52.5%), followed by the group that sought care from both Medicare and VA sources (50.9%). The group that sought care from the VA only had the lowest guideline-discordant imaging rate (45.9%).
| Guideline-discordant imaging by care setting | |||
| Medicare only | VA and Medicare | VA only | |
| Imaging among men with low-risk prostate cancer | 52.5% | 50.9% | 45.9% |
"We found that veterans treated in a VA-only setting received the least amount of guideline-discordant imaging among patients with low-risk prostate cancer, without any significant difference in imaging utilization for patients with high-risk prostate cancer, for whom the imaging was necessary," the researchers wrote. "In addition, although veterans who sought care through both the VA and Medicare would seem to be the most likely to experience the most imaging overuse because of the potential for fragmented care in two systems, patients seen in the Medicare-only setting had the most guideline-discordant imaging."
Ensuring that men with low-risk prostate cancer receive appropriate imaging remains a significant problem, according to the researchers.
"These results reveal important differences between integrated and fee-for-service health systems regarding guideline concordance and quality of care," they wrote. "The results also suggest that patients using the Choice Act are likely to experience more utilization of care without a guarantee of improved quality of care."
