In the current hyper-charged United States healthcare debate, the focus on lowering cost without compromising quality of care remains a priority. But according to a new study by researchers at NYU Langone Medical Center and colleagues, one common approach may have serious unintended consequences.
Funded by the Robert Wood Johnson Foundation's (RWJF) Clinical Scholars program and the United States Department of Veterans Affairs (VA), the study, which appears today in the April issue of Health Affairs, examines the potential impact of policies to reduce inappropriate imaging for prostate cancer. Such overutilization began receiving national attention, in part, through an article in the New Yorker in 2009. A week later, a New York Times article detailed how the concept had captured government's attention and highlighted the resulting interest in lowering costs through reducing the over-use of various medical tests, imaging, screening and procedures. Such efforts are beginning to yield results and lead to guideline change, such as last week's move by nine medical specialty societies to identify the top five overused practices in each specialty for which no evidence exists to support their value.
"We're in the middle of a huge healthcare debate, where government, hospitals and physician groups are working to lower healthcare costs while still providing quality care," said lead investigator Danil V. Makarov, MD, MHS, assistant professor of urology at NYU School of Medicine, part of NYU Langone Medical Center, and an assistant professor of health policy at NYU Wagner School of Public Service. "One area being reviewed is imaging use. Changing practices in regions of high use to make them more like those in areas of low use to lower costs may seem like an appealing strategy. However, our study suggests that such an approach might sacrifice quality by depriving patients of needed services."
The study, performed with colleagues while Makarov was a RWJF and VA Clinical Scholar at Yale, looked at regional patterns of imaging, both appropriate and inappropriate, to stage newly diagnosed cases of prostate cancer. The research was conducted in prostate cancer patients because prostate cancer is a common disease and there are clear, well-established guidelines for the use of imaging to stage it.
"Appropriate imaging" was defined as prostate cancer staging imaging for patients who are at high risk of metastatic spread. These include patients with clearly evident, observable or tangible cancer, for whom National Comprehensive Cancer Network guidelines indicate further screening, in the form of a bone scan, computed tomography (CT) or MRI, to see whether and how far the cancer has progressed. "Inappropriate imaging" was defined as the use of those same imaging techniques in patients without high-risk features, suspected of having only early stage prostate cancer. These men were not at a stage where accepted guidelines indicate the use of imaging.
The researchers found that regions of the country with high rates of inappropriate imaging also had high rates of appropriate imaging. Similarly, regions with low rates of inappropriate imaging also had low rates of appropriate imaging. The investigators dubbed this finding the "Thermostat Model," and concluded that imaging use appears to be determined strongly by regional practice patterns and affinity for imaging, rather than solely by medical indication.
"Ultimately there appears to be an underuse of important services and overuse of nonessential ones," said Dr. Makarov. "This forces us to wonder if low use areas, which may spend less money but also provide fewer of the recommended services for those patients who need them, are necessarily the model we should be promoting."
According to the investigators, simply limiting inappropriate healthcare use may have the unintended consequences of limiting appropriate care for patients who need it.
"New policies aimed at controlling costs can not be a 'one size fits all' approach," Dr. Makarov said. "Instead, policies must be multifaceted to carefully blend cutting inappropriate use while promoting appropriate use."
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