Geriatric Skiers: Active But Still at Risk, a National Trauma Data Bank Study.

BACKGROUND: Downhill skiing accounts for a large portion of geriatric sport-related trauma. We assessed the national burden of geriatric versus nongeriatric ski trauma. MATERIALS AND METHODS: Adults presenting to level 1/2 trauma centers after ski-associated injuries from 2011 to 2015 were identified from the National Trauma Data Bank by ICD-9 code. We compared demographics, injury patterns, and outcomes between geriatric (age ≥65 y) and nongeriatric adult skiers (age 18-64 y). A multiple regression analysis assessed for risk factors associated with severe injury (Injury Severity Score >15). RESULTS: We identified 3255 adult ski trauma patients, and 16.7% (543) were geriatric. Mean ages for nongeriatric versus geriatric skiers were 40.8 and 72.1 y, respectively. Geriatric skiers more often suffered head (36.7 versus 24.3%, P < 0.0001), severe head (abbreviated injury scale score >3, 49.0 versus 31.5%, P < 0.0001) and thorax injuries (22.2 versus 18.1%, P = 0.03) as compared with nongeriatric skiers. Geriatric skiers were also more often admitted to the ICU (26.5 versus 14.9%, P < 0.0001), discharged to a facility (26.7 versus 11.6%, P < 0.0001), and suffered higher mortality rates (1.3 versus 0.4%, P = 0.004). Independent risk factors for severe injury included being male (OR: 1.68, CI: 1.22-2.31), helmeted (OR: 1.41, CI: 1.07-1.85), and having comorbidities (OR: 1.37, CI: 1.05-1.80). Geriatric age was not independently associated with severe injury. CONCLUSIONS: At level 1/2 trauma centers, geriatric age in ski trauma victims was associated with unique injury patterns, higher acuity, increased rates of facility care at discharge, and higher mortality as compared with nongeriatric skiers. Our findings indicate the need for specialized care after high impact geriatric ski trauma.

Medical Care Costs Were Similar Across the Low-dose Computed Tomography and Chest X-Ray Arms of the National Lung Screening Trial Despite Different Rates of Significant Incidental Findings.

BACKGROUND: The National Lung Screening Trial (NLST) reported lung cancer and all-cause mortality reductions for low-dose computed tomography (LDCT) versus chest x-ray (CXR) screening. Although LDCT lung screening has received a grade B from the United States Preventive Services Task Force and is a covered service under most health plans, concerns remain on the costs engendered by screening, and the impact of the high rate of significant incidental finding (SIF) detection on those costs. METHODS: We linked American College of Radiology Imaging Network NLST and Medicare fee-for-service claims data for participants from 23 sites for 2002-2009. We performed participant-level analyses using generalized linear regression models to estimate the adjusted annual mean of the 3-year total medical costs per person in each study arm and within screen outcome categories (ever positive with abnormalities suspicious for lung cancer, always negative for abnormalities suspicious for lung cancer, but with SIFs, and always negative without SIFs). RESULTS: The adjusted annual mean total per person costs were not significantly different between screening arms [LDCT, $11,029 (95% confidence interval, $10,107-$11,951); CXR, $10,905 (95% confidence interval, $10,059-$11,751)], despite higher proportions of individuals with SIFs in the LDCT versus the CXR arm (18% vs. 4%; P<0.0001). CONCLUSIONS: We found little difference in total annual per person costs between LDCT-screened and CXR-screened Medicare participants, despite the higher number of SIFs in the LDCT arm of the study.

Understanding the value of minimally invasive procedures for the treatment of lumbar spinal stenosis: the case of interspinous spacer devices.

BACKGROUND CONTEXT: Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value. PURPOSE: This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices ("spacers") relative to decompression surgery as a case study. STUDY DESIGN: Model-based cost-effectiveness analysis. PATIENT SAMPLE: The Medicare Provider Analysis and Review database for the years 2005-2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery. OUTCOME MEASURES: Costs, quality-adjusted life years (QALYs), and cost per QALY gained were the outcome measures. METHODS: A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies: conservative care, spacer surgery, and decompression surgery. Incremental cost-effectiveness ratios (ICER) reported as cost per QALY gained included direct medical costsfor surgery. Medicare claims data were used to estimate complication rates, reoperation, and related costs within 3 years. Utilities and long-term reoperation rates for decompression were derived frompublished studies. Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4-10 (cumulative failure: 47%). In a "worst-case" analysis, the 10-year cumulative reoperation rate was increased steeply (to 90%). Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery. RESULTS: The spacer strategy had an ICER of $89,500/QALY gained under base-case assumptions, and remained under $100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54%. Under worst-case assumptions, the spacer ICER was $482,000/QALY and fell below $100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of spacer surgery was $1,600 less than the cost of decompression surgery. CONCLUSIONS: Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis. Their value is expected to improve if procedure costs are lower in outpatient settings where these procedures are increasingly being performed. Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospective health utility assessment.

Diffusion of digital breast tomosynthesis among women in primary care: associations with insurance type.

Digital breast tomosynthesis (DBT) has shown potential to improve breast cancer screening and diagnosis compared to digital mammography (DM). The FDA approved DBT use in conjunction with conventional DM in 2011, but coverage was approved by CMS recently in 2015. Given changes in coverage policies, it is important to monitor diffusion of DBT by insurance type. This study examined DBT trends and estimated associations with insurance type. From June 2011 to September 2014, DBT use in 22 primary care centers in the Dartmouth -Brigham and Women's Hospital Population-based Research Optimizing Screening through Personalized Regimens research center (PROSPR) was examined among women aged 40-89. A longitudinal repeated measures analysis estimated the proportion of DBT performed for screening or diagnostic indications over time and by insurance type. During the study period, 93,182 mammograms were performed on 48,234 women. Of these exams, 16,506 DBT tests were performed for screening (18.1%) and 2537 were performed for diagnosis (15.7%). Between 2011 and 2014, DBT utilization increased in all insurance groups. However, by the latest observed period, screening DBT was used more frequently under private insurance (43.4%) than Medicaid (36.2%), Medicare (37.8%), other (38.6%), or no insurance (32.9%; P < 0.0001). No sustained differences in use of DBT for diagnostic testing were seen by insurance type. DBT is increasingly used for breast cancer screening and diagnosis. Use of screening DBT may be associated with insurance type. Surveillance is required to ensure that disparities in breast cancer screening are minimized as DBT becomes more widely available.

Falling Down on the Job: Evaluation and Treatment of Fall Risk Among Older Adults With Upper Extremity Fragility Fractures.

Background: Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline. Objective: The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk. Design: Observational cohort. Methods: Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used. Results: There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race. Limitations: Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results. Conclusions: A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.

Insurance Reimbursement for Complementary Healthcare Services.

INTRODUCTION: Insurance reimbursement for clinical services provided by complementary healthcare professionals in the United States likely differs by provider specialty. It is hypothesized that a lower likelihood of insurance reimbursement demonstrates that complementary healthcare services are not utilized to an optimal level and are not financially accessible to all who may need or want these services. The purpose of this project was to evaluate the likelihood of insurance reimbursement for complementary healthcare services compared with other complementary services and with conventional primary care medical services in New Hampshire. METHODS: The authors studied health claims for services provided in a nonemergent outpatient setting in New Hampshire in 2014. The study population consisted of New Hampshire residents aged 18-99 years with claims for selected clinical services commonly provided by complementary healthcare providers. The authors modeled the proportion of reimbursed claims by specialty of complementary healthcare service provider, compared with the reimbursement rate for primary care physicians' claims. The authors modeled first for the proportion of reimbursement for any selected clinical service, next for any evaluation and management (E&M) service, and finally for the most commonly used E&M procedure code, current procedural terminology (CPT) 99213 (reevaluation of established patient). RESULTS: Compared with primary care physicians, the likelihood of reimbursement for any service was 69% lower for acupuncturists, 71% lower for doctors of chiropractic medicine, and 62% lower for doctors of naturopathic medicine. For any E&M service, likelihood of reimbursement was 69% lower for acupuncturists, 78% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. With further restriction to CPT 99213 only, likelihood of reimbursement was 34% lower for acupuncturists, 77% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. CONCLUSIONS: In New Hampshire, the likelihood of health insurance reimbursement for certain clinical services differs significantly by provider specialty. More research is needed to evaluate the extent and cause of such differences and the effect of such differences on the utilization of complementary healthcare services in the United States.

Medical home transformation and breast cancer screening.

OBJECTIVES: The patient-centered medical home (PCMH) continues to gain momentum as a primary care delivery system. We evaluated whether medical home transformation of primary care practices is associated with the use of breast cancer screening, a broadly endorsed preventive service. STUDY DESIGN: Retrospective cohort study evaluating 12 Brigham and Women's Hospital (BWH)-affiliated primary care clinics in greater Boston, Massachusetts. METHODS: Practice transformation was measured quarterly using a continuous PCMH transformation score (range = 0-100) modeled after National Committee for Quality Assurance recognition requirements. We included women aged 50 to 74 years who had at least 1 primary care visit at a participating clinic between April 2012 and December 2013 (n = 20,349)-a period of medical home transformation. The main measures included: a) whether screening was up-to-date at the time of the visit (mammography completion within 24 months prior to the visit); and b) if screening was overdue at the visit (ie, it had been more than 24 months since the last mammogram), and whether timely screening was completed within 3 months after the visit. RESULTS: In adjusted analyses, PCMH transformation scores were negatively associated with up-to-date screening status (odds ratio [OR] for a 20-point change, 0.93; 95% confidence interval [CI], 0.89-0.96) and with timely screening of women who were overdue (OR, 0.94; 95% CI, 0.87-1.02). CONCLUSIONS: Preventative care, such as breast cancer screening, may not improve in early PCMH implementation.

The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities.

OBJECTIVE: The purpose of this study was to determine whether use of chiropractic manipulative treatment (CMT) was associated with lower healthcare costs among multiply-comorbid Medicare beneficiaries with an episode of chronic low back pain (cLBP). METHODS: We conducted an observational, retrospective study of 2006 to 2012 Medicare fee-for-service reimbursements for 72326 multiply-comorbid patients aged 66 and older with cLBP episodes and 1 of 4 treatment exposures: chiropractic manipulative treatment (CMT) alone, CMT followed or preceded by conventional medical care, or conventional medical care alone. We used propensity score weighting to address selection bias. RESULTS: After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided. Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories. While patients who used only CMT had the lowest Part A and Part B expenditures per episode day, we found no indication of lower psychiatric or pain medication expenditures associated with CMT. CONCLUSIONS: This study found that older multiply-comorbid patients who used only CMT during their cLBP episodes had lower overall costs of care, shorter episodes, and lower cost of care per episode day than patients in the other treatment groups. Further, costs of care for the episode and per episode day were lower for patients who used a combination of CMT and conventional medical care than for patients who did not use any CMT. These findings support initial CMT use in the treatment of, and possibly broader chiropractic management of, older multiply-comorbid cLBP patients.

Comparing Propensity Score Methods for Creating Comparable Cohorts of Chiropractic Users and Nonusers in Older, Multiply Comorbid Medicare Patients With Chronic Low Back Pain.

OBJECTIVE: Patients who use complementary and integrative health services like chiropractic manipulative treatment (CMT) often have different characteristics than do patients who do not, and these differences can confound attempts to compare outcomes across treatment groups, particularly in observational studies when selection bias may occur. The purposes of this study were to provide an overview on how propensity scoring methods can be used to address selection bias by balancing treatment groups on key variables and to use Medicare data to compare different methods for doing so. METHODS: We described 2 propensity score methods (matching and weighting). Then we used Medicare data from 2006 to 2012 on older, multiply comorbid patients who had a chronic low back pain episode to demonstrate the impact of applying methods on the balance of demographics of patients between 2 treatment groups (those who received only CMT and those who received no CMT during their episodes). RESULTS: Before application of propensity score methods, patients who used only CMT had different characteristics from those who did not. Propensity score matching diminished observed differences across the treatment groups at the expense of reduced sample size. However, propensity score weighting achieved balance in patient characteristics between the groups and allowed us to keep the entire sample. CONCLUSIONS: Although propensity score matching and weighting have similar effects in terms of balancing covariates, weighting has the advantage of maintaining sample size, preserving external validity, and generalizing more naturally to comparisons of 3 or more treatment groups. Researchers should carefully consider which propensity score method to use, as using different methods can generate different results.

The SPORT value compass: do the extra costs of undergoing spine surgery produce better health benefits?

BACKGROUND: The Spine Patient Outcomes Research Trial aimed to determine the comparative effectiveness of surgical care versus nonoperative care by measuring longitudinal values: outcomes, satisfaction, and costs. METHODS: This paper aims to summarize available evidence from the Spine Patient Outcomes Research Trial by addressing 2 important questions about outcomes and costs for 3 types of spine problem: (1) how do outcomes and costs of spine patients differ depending on whether they are treated surgically compared with nonoperative care? (2) What is the incremental cost per quality adjusted life year for surgical care over nonoperative care? RESULTS: After 4 years of follow-up, patients with 3 spine conditions that may be treated surgically or nonoperatively have systematic differences in value endpoints. The average surgical patient enjoys better health outcomes and higher treatment satisfaction but incurs higher costs. CONCLUSIONS: Spine care is preference sensitive and because outcomes, satisfaction, and costs vary over time and between patients, data on value can help patients make better-informed decisions and help payers know what their dollars are buying.

Indications for spine surgery: validation of an administrative coding algorithm to classify degenerative diagnoses.

STUDY DESIGN: Retrospective analysis of Medicare claims linked to a multicenter clinical trial. OBJECTIVE: The Spine Patient Outcomes Research Trial (SPORT) provided a unique opportunity to examine the validity of a claims-based algorithm for grouping patients by surgical indication. SPORT enrolled patients for lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis. We compared the surgical indication derived from Medicare claims with that provided by SPORT surgeons, the "gold standard." SUMMARY OF BACKGROUND DATA: Administrative data are frequently used to report procedure rates, surgical safety outcomes, and costs in the management of spinal surgery. However, the accuracy of using diagnosis codes to classify patients by surgical indication has not been examined. METHODS: Medicare claims were link to beneficiaries enrolled in SPORT. The sensitivity and specificity of 3 claims-based approaches to group patients on the basis of surgical indications were examined: (1) using the first listed diagnosis; (2) using all diagnoses independently; and (3) using a diagnosis hierarchy on the basis of the support for fusion surgery. RESULTS: Medicare claims were obtained from 376 SPORT participants, including 21 with disc herniation, 183 with spinal stenosis, and 172 with degenerative spondylolisthesis. The hierarchical coding algorithm was the most accurate approach for classifying patients by surgical indication, with sensitivities of 76.2%, 88.1%, and 84.3% for disc herniation, spinal stenosis, and degenerative spondylolisthesis cohorts, respectively. The specificity was 98.3% for disc herniation, 83.2% for spinal stenosis, and 90.7% for degenerative spondylolisthesis. Misclassifications were primarily due to codes attributing more complex pathology to the case. CONCLUSION: Standardized approaches for using claims data to group patients accurately by surgical indications have widespread interest. We found that a hierarchical coding approach correctly classified more than 90% of spine patients into their respective SPORT cohorts. Therefore, claims data seem to be a reasonably valid approach to classifying patients by surgical indication. LEVEL OF EVIDENCE: 3.

Intended versus inferred care after PET performed for initial staging in the National Oncologic PET Registry.

UNLABELLED: The National Oncologic PET Registry (NOPR) collected data on intended management before and after PET in cancer patients. We have previously reported that PET was associated with a change in intended management of about one third of patients and was consistent across cancer types. It is uncertain if intended management plans reflect the actual care these patients received. One approach to assess actual care received is using administrative claims to categorize the type and timing of clinical services. METHODS: NOPR data from 2006 to 2008 were linked to Medicare claims for consenting patients aged 65 y or older undergoing initial-staging PET scanning for bladder, ovarian, pancreatic, small cell lung, or stomach cancers. We determined the 60-d agreement between claims-inferred care and NOPR treatment plans. RESULTS: Patients (n = 4,661) were assessed, and 30%-52% had metastatic disease. Planned treatments were about two-thirds monotherapy, of which 46% was systemic therapy only, and one-third combinations. Claims paid by 60 d confirmed the NOPR plan of any systemic therapy, radiotherapy, or surgery in 79.3%, 64.7%, and 63.6%, respectively. Single-mode plans were much more often confirmed: systemic therapy in more than 85% of patients with ovarian, pancreatic, and small cell lung cancers and surgery in more than 73% of those with bladder, pancreatic, and stomach cancers. Intended combination treatments had claims for both in only 28% of patients receiving surgery-based combinations and in 55% receiving chemoradiotherapy. About 90% of patients with NOPR-planned systemic therapy had evaluation or management claims from a medical oncologist. An age of less than 75 y was associated more often with confirmation of chemotherapy, less often for radiotherapy but not with confirmation of surgery. Performance status or comorbidity did not explain confirmation rates within action categories, but confirmation rates were higher if the referrer specialized in the planned treatment. CONCLUSION: Claims confirmations of NOPR intent for initial staging were widely variable but were higher than previously reported for restaging PET, suggesting that measuring change in intended management is a reasonable method for assessing the impact diagnostic tests have on actual care.

The increasing incidence of thyroid cancer: the influence of access to care.

BACKGROUND: The rapidly rising incidence of papillary thyroid cancer may be due to overdiagnosis of a reservoir of subclinical disease. To conclude that overdiagnosis is occurring, evidence for an association between access to health care and the incidence of cancer is necessary. METHODS: We used Surveillance, Epidemiology, and End Results (SEER) data to examine U.S. papillary thyroid cancer incidence trends in Medicare-age and non-Medicare-age cohorts over three decades. We performed an ecologic analysis across 497 U.S. counties, examining the association of nine county-level socioeconomic markers of health care access and the incidence of papillary thyroid cancer. RESULTS: Papillary thyroid cancer incidence is rising most rapidly in Americans over age 65 years (annual percentage change, 8.8%), who have broad health insurance coverage through Medicare. Among those under 65, in whom health insurance coverage is not universal, the rate of increase has been slower (annual percentage change, 6.4%). Over three decades, the mortality rate from thyroid cancer has not changed. Across U.S. counties, incidence ranged widely, from 0 to 29.7 per 100,000. County papillary thyroid cancer incidence was significantly correlated with all nine sociodemographic markers of health care access: it was positively correlated with rates of college education, white-collar employment, and family income; and negatively correlated with the percentage of residents who were uninsured, in poverty, unemployed, of nonwhite ethnicity, non-English speaking, and lacking high school education. CONCLUSION: Markers for higher levels of health care access, both sociodemographic and age-based, are associated with higher papillary thyroid cancer incidence rates. More papillary thyroid cancers are diagnosed among populations with wider access to healthcare. Despite the threefold increase in incidence over three decades, the mortality rate remains unchanged. Together with the large subclinical reservoir of occult papillary thyroid cancers, these data provide supportive evidence for the widespread overdiagnosis of this entity.

Intended versus inferred management after PET for cancer restaging: analysis of Medicare claims linked to a coverage with evidence development registry.

BACKGROUND: The National Oncologic PET Registry (NOPR) ascertained changes in the intended management of cancer patients using questionnaire data obtained before and after positron emission tomography (PET) under Medicare's coverage with evidence development policy. OBJECTIVE: To assess the concordance between intended care plans and care received as ascertained through administrative claims data. RESEARCH DESIGN: Analysis of linked data of NOPR participants from 2006 to 2008 and their corresponding Medicare claims. SUBJECTS: Consenting patients aged older than 65 years having their first PET for restaging of bladder, kidney, ovarian, pancreas, prostate, small cell lung, or stomach cancer. MEASURES: : Agreement (positive predictive values and κ) between NOPR post-PET intended management plans for treatment (systemic therapy, radiotherapy, surgery, or combinations), biopsy, or watching as compared to claims-inferred care 30 days after PET. RESULTS: A total of 8460 patients with linked data were assessed. A total of 43.5% had metastatic disease and 45.3% had treatment planned (predominantly systemic therapy only), 11.1% biopsy and 43.5% watching. Claims-confirmed intended plans (positive predictive value) for single-mode systemic therapy in 62.0%, radiation in 66.0%, surgery in 45.6%, and biopsy in 55.7%. A total of 25.7% of patients with a plan of watching had treatment claims. By cancer type, κ ranged for systemic therapy only from 0.17 to 0.40 and for watching from 0.21 to 0.41. Agreement rates varied by cancer types but were minimally associated with patient age, performance status, comorbidity, or stage. CONCLUSIONS: Among elderly cancer patients undergoing PET for restaging, there was moderate concordance between their physicians' planned management and claims-inferred actions within a narrow time window. When higher accuracy levels are required in future coverage with evidence development studies, alternative designs will be needed.

Geographic and sociodemographic disparities in PET use by Medicare beneficiaries with cancer.

PURPOSE: PET use for cancer care has increased unevenly, possibly because of regional health care market characteristics or underlying population characteristics. The aim of this study was to examine variation in advanced imaging use among individuals with cancer in relation to population and hospital service area (HSA) characteristics. METHODS: A retrospective national study of fee-for-service Medicare beneficiaries with diagnoses of 1 of 5 cancers covered by Medicare for PET (2004-2008) was conducted. Crude and adjusted rates of PET, CT, and MRI were estimated for HSAs and sociodemographic subgroups. Generalized linear mixed models were used to assess the effects of race/ethnicity, area-level income, and HSA-level physician supply and spending on imaging utilization. RESULTS: On the basis of an annual average of 116,452 beneficiaries with cancer, adjusted PET rates (imaging days per person-year) showed significantly higher use for whites compared with blacks in both 2004 (whites, 0.35 [95% confidence interval, 0.34-0.36]; blacks, 0.31 [95% confidence interval, 0.30-0.33]) and 2008 (whites, 0.64 [95% confidence interval, 0.63-0.65]; blacks, 0.57 [95% confidence interval, 0.55-0.59]). This trend was similar for the highest quartile of group-level median household income but was opposite for CT use, with blacks having higher rates than whites. The highest Medicare-spending HSAs had significantly higher adjusted PET rates compared with lower spending areas (0.57 [95% confidence interval, 0.55-0.60] vs 0.69 [95% confidence interval, 0.67-0.71] imaging days/person-year). CONCLUSIONS: The use of PET among Medicare beneficiaries with cancer increased from 2004 to 2008, with higher rates observed among whites, among higher socioeconomic groups, and in higher Medicare spending areas. Sociodemographic differences in advanced imaging use are modality specific.

Growth in the use of PET for six cancer types after coverage by medicare: additive or replacement?

BACKGROUND: In July 2001, PET became a covered service for Medicare beneficiaries when used for the diagnosis, staging, and restaging of non-small-cell lung, esophageal, colorectal, and head and neck cancers as well as lymphoma and melanoma. Whether physicians use PET as a replacement for or in addition to CT, MRI, or bone scintigraphy (BS) is uncertain. METHODS: A 20% sample of Medicare fee-for-service beneficiaries aged > 64 years from 2004 through 2008 was used. Annually for each cancer type, a cohort of patients was created defined as having at least one admission with a primary cancer diagnosis or two nonhospital claims with a cancer diagnosis ≥7 days apart per calendar year. Each year, imaging claims and claim-days were counted by modality and cancer type. The sequence of PET use was examined as before, after, or instead of other imaging. RESULTS: About 125,000 beneficiaries (2.5% of the cohort) met the cancer definition each year. In 2008, the combined annual imaging days per person-year were 2.3 for CT, 0.49 for MRI, 0.70 for PET, and 0.13 for BS. The annual rates of imaging from 2004 to 2008 increased by 0.5% for CT, 3.2% for MRI, and 18.0% for PET (range, 14.6%-19.9% by cancer type) and decreased by 12.7% for BS. The growth in PET use was not associated with meaningful changes in body CT. In 2007 and 2008, body CT preceded PET within 30 days in about half of patients, whereas PET preceded CT in only 22%. CONCLUSIONS: Several years after its introduction, PET continued to grow rapidly, with evidence that it is replacing BS. Growth of PET occurred without evidence of a decline in body CT. About half of PET use occurred shortly after body CT, suggesting an additive or final arbiter role.

Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation.

STUDY DESIGN: Cost-effectiveness analysis of a randomized plus observational cohort trial. OBJECTIVE: Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH). SUMMARY OF BACKGROUND DATA: Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain. METHODS: Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year. RESULTS: Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088). CONCLUSION: Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.

The impact of workers' compensation on outcomes of surgical and nonoperative therapy for patients with a lumbar disc herniation: SPORT.

STUDY DESIGN: Prospective randomized and observational cohorts. OBJECTIVE: To compare outcomes of patients with and without workers' compensation who had surgical and nonoperative treatment for a lumbar intervertebral disc herniation (IDH). SUMMARY OF BACKGROUND DATA: Few studies have examined the association between worker's compensation and outcomes of surgical and nonoperative treatment. METHODS: Patients with at least 6 weeks of sciatica and a lumbar IDH were enrolled in either a randomized trial or observational cohort at 13 US spine centers. Patients were categorized as workers' compensation or nonworkers' compensation based on baseline disability compensation and work status. Treatment was usual nonoperative care or surgical discectomy. Outcomes included pain, functional impairment, satisfaction and work/disability status at 6 weeks, 3, 6, 12, and 24 months. RESULTS: Combining randomized and observational cohorts, 113 patients with workers' compensation and 811 patients without were followed for 2 years. There were significant improvements in pain, function, and satisfaction with both surgical and nonoperative treatment in both groups. In the nonworkers' compensation group, there was a clinically and statistically significant advantage for surgery at 3 months that remained significant at 2 years. However, in the workers' compensation group, the benefit of surgery diminished with time; at 2 years no significant advantage was seen for surgery in any outcome (treatment difference for SF-36 bodily pain [-5.9; 95% CI: -16.7-4.9] and physical function [5.0; 95% CI: -4.9-15]). Surgical treatment was not associated with better work or disability outcomes in either group. CONCLUSION: Patients with a lumbar IDH improved substantially with both surgical and nonoperative treatment. However, there was no added benefit associated with surgical treatment for patients with workers' compensation at 2 years while those in the nonworkers' compensation group had significantly greater improvement with surgical treatment.

Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years.

BACKGROUND: The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain. OBJECTIVE: To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis. DESIGN: Prospective cohort study. DATA SOURCES: Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants. TARGET POPULATION: Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis. TIME HORIZON: 2 years. PERSPECTIVE: Societal. INTERVENTION: Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis). OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77,600 (CI, $49,600 to $120,000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus nonoperative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115,600 (CI, $90,800 to $144,900) per QALY gained. RESULT OF SENSITIVITY ANALYSIS: Surgery cost markedly affected the value of surgery. LIMITATION: The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment nonadherence among randomly assigned participants. CONCLUSION: The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.

The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Spine Patient Outcomes Research Trial observational and randomized cohort participants with a confirmed diagnosis of intervertebral disc herniation (IDH) who received either usual nonoperative care and/or standard open discectomy were followed from baseline at 6 weeks, 3, 6, 12, and 24 months at 13 spine clinics in 11 US states. OBJECTIVE: To evaluate the cost-effectiveness of surgery relative to nonoperative care among patients with a confirmed diagnosis of lumbar IDH. SUMMARY OF BACKGROUND DATA: The cost-effectiveness of surgery as a treatment for conditions associated with low back and leg symptoms remains poorly understood. METHODS: Incremental cost-effectiveness ratio, reported as discounted cost per quality adjusted life year (QALY) gained in 2004 US dollars based on EuroQol EQ-5D health state values with US scoring, and information on resource utilization and time away from work. RESULTS: Among 775 patients who underwent surgery and 416 who were treated nonoperatively, the mean difference in QALYs over 2 years was 0.21 (95% CI: 0.16-0.25) in favor of surgery. Surgery was more costly than nonoperative care; the mean difference in total cost was $14,137(95% CI: $11,737-16,770). The cost per QALY gained for surgery relative to nonoperative care was $69,403 (95% CI: $49,523-94,999) using general adult surgery costs and $34,355 (95% CI: $20,419-52,512) using Medicare population surgery costs. CONCLUSION: Surgery for IDH was moderately cost-effective when evaluated over 2 years. The estimated economic value of surgery varied considerably according to the method used for assigning surgical costs.