Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review.

ABSTRACT

BACKGROUND: The overuse of radiologic services, where imaging tests are provided in circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health care systems. Advanced imaging in the staging of low-risk prostate cancer is considered an overused procedure by many professional societies, yet the determinants that drive this phenomenon are not fully appreciated. METHODS: We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that contain original data and describe determinants associated with the overuse of imaging in low-risk prostate cancer. Paired reviewers independently screened abstracts, assessed quality, and extracted data. We synthesized the identified determinants as patient-level, clinician-level, or system-level factors of overuse. RESULTS: A total of 14 articles were included; the 13 empirical studies defined overuse as being the use of imaging that was discordant with clinical guidelines. Patient- and system-related factors were most commonly described as being associated with overuse; clinician-level determinants were examined infrequently. Older patient age (n = 5), more patient comorbidities (n = 7), and characteristics related to geography (n = 6), higher regional income (n = 6), and less education (n = 5) were the most consistently identified statistically significant determinants of overuse. Meaningful differences were detected between health care settings; large integrated health care systems provided less variable care and had lower rates of overuse. Clinical indicators related to prostate cancer were inconsistently associated with overuse. CONCLUSION: Many patient- and system-related determinants were identified as contributing to the overuse of advanced imaging to stage low-risk prostate cancer. Overuse may be the consequence of systematized clinician behavior and be relatively invariant of patient characteristics. The identified system-level determinants suggest that payment models that are not tied to volume or that reward, enhanced care co-ordination may curb overuse. We propose further examination of physician-level determinants and implore researchers to rank the relative importance of the identified factors and to test their influence through experimental and quasi-experimental methods.