Universal Versus Targeted Screening for Lynch Syndrome: Comparing Ascertainment and Costs Based on Clinical Experience.

BACKGROUND: Strategies to screen colorectal cancers (CRCs) for Lynch syndrome are evolving rapidly; the optimal strategy remains uncertain. AIM: We compared targeted versus universal screening of CRCs for Lynch syndrome. METHODS: In 2010-2011, we employed targeted screening (age < 60 and/or Bethesda criteria). From 2012 to 2014, we screened all CRCs. Immunohistochemistry for the four mismatch repair proteins was done in all cases, followed by other diagnostic studies as indicated. We modeled the diagnostic costs of detecting Lynch syndrome and estimated the 5-year costs of preventing CRC by colonoscopy screening, using a system dynamics model. RESULTS: Using targeted screening, 51/175 (29 %) cancers fit criteria and were tested by immunohistochemistry; 15/51 (29 %, or 8.6 % of all CRCs) showed suspicious loss of ≥1 mismatch repair protein. Germline mismatch repair gene mutations were found in 4/4 cases sequenced (11 suspected cases did not have germline testing). Using universal screening, 17/292 (5.8 %) screened cancers had abnormal immunohistochemistry suspicious for Lynch syndrome. Germline mismatch repair mutations were found in only 3/10 cases sequenced (7 suspected cases did not have germline testing). The mean cost to identify Lynch syndrome probands was ~$23,333/case for targeted screening and ~$175,916/case for universal screening at our institution. Estimated costs to identify and screen probands and relatives were: targeted, $9798/case and universal, $38,452/case. CONCLUSIONS: In real-world Lynch syndrome management, incomplete clinical follow-up was the major barrier to do genetic testing. Targeted screening costs 2- to 7.5-fold less than universal and rarely misses Lynch syndrome cases. Future changes in testing costs will likely change the optimal algorithm.

Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost.

BACKGROUND: Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients. METHODS: A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded. RESULTS: From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905. CONCLUSIONS: Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost.

Changes in Medication Management After a Diagnosis of Cancer Among Medicare Beneficiaries With Diabetes.

PURPOSE: A new cancer diagnosis commonly initiates a cascade of health care decisions that have potentially important consequences for management of other chronic conditions such as diabetes. We sought to determine whether a new cancer diagnosis is associated with changes in medication adherence among Medicare beneficiaries with diabetes, and whether the relationship is affected by life expectancy and generosity of drug coverage. METHODS: The study population was drawn from a 5% random sample of Medicare beneficiaries with diabetes enrolled in Medicare Part D in 2007 and 2008. Patients had cancer newly diagnosed between January and December 2007 (n = 4,348) and were compared with a cancer-free control group (N = 28,507) assigned a pseudo-diagnosis date. Adherence (proportion of days covered [PDC]) with oral hypoglycemic agents, renin-angiotensin-aldosterone system inhibitors, and statins was tracked for 6 months before and after the diagnosis date. Multivariable regression models assessed the independent impact of a cancer diagnosis, life expectancy (proxy measure: died 7 to 12 months after index date), and coverage generosity (proxy measure: low-income subsidy recipient) on PDC, controlling for individual characteristics. RESULTS: Relatively larger declines in medication adherence (3 to 5 percentage points; P < .001) were observed overall for patients with cancer versus controls. Short life expectancy was associated with between 8% and 11% lower PDC (P < .001) in the cancer subgroup relative to controls. Low-income subsidy status had no differential effect on changes in drug adherence. CONCLUSION: A cancer diagnosis among patients with diabetes reduced adherence with evidence-based medications, particularly if patients' life expectancy was short.

Ductal carcinoma in situ: a brief review of treatment variation and impacts on patients and society.

Nearly 20% of all breast cancer cases are ductal carcinoma in situ (DCIS), with over 60,000 cases diagnosed each year. Many of these cases would never cause clinical symptoms or threaten the life of the woman; however, it is currently impossible to distinguish which lesions will progress to invasive disease from those that will not. DCIS is generally associated with an excellent prognosis regardless of the treatment pathway, but there is variation in treatment aggressiveness that seems to exceed the medical uncertainty associated with DCIS management. Therefore, it would seem that a significant proportion of women with DCIS receive more extensive treatment than is needed. This overtreatment of DCIS is a growing concern among the breast cancer community and has implications for both the patient (via adverse treatment-related effects, as well as out-of-pocket costs) and society (via economic costs and the public health and environmental harm resulting from health care delivery). This article discusses DCIS treatment pathways and their implications for patients and society and calls for further research to examine the factors that are leading to such wide variation in treatment decisions.

Use of and spending on supportive care medications among Medicare beneficiaries with cancer.

PURPOSE: The study objective was to provide population-based estimates of supportive care medication (SCM) use among Medicare beneficiaries with cancer and determine factors related to SCM receipt. METHODS: This retrospective cohort study of community-based Medicare beneficiaries used the Medicare Current Beneficiary Survey (1997­2007). Dependent variables comprised use and spending on SCMs for three medication classes: opioids, antidepressants/sedative/hypnotics (ASH), and antiemetics. Independent variables of interest were supplemental insurance coverage, cancer site, and treatment. Multivariate models determined factors affecting receipt of, and spending on, SCMs. We also compared SCM use and spending among beneficiaries with and without cancer in order to understand what portion of SCM use and spending could be attributed to cancer as opposed to other comorbid conditions. RESULTS: A total of 1,836 Medicare beneficiaries with cancer and 9,898 beneficiaries without cancer were eligible for the study. Beneficiaries with cancer were more likely to receive opioids, ASH, and antiemetics compared to non-cancer beneficiaries. Adjusted annual payments for antiemetics were on average $637 higher in with cancer versus without cancer (p<0.01), while ASH payments were $184 lower (p<0.01). Opioid spending was similar among cancer and non-cancer users. Relative to colon cancer, beneficiaries with prostate cancer were least likely to receive any of the three SCM classes. Receipt of antineoplastic treatment increased the probability of use of all three classes of SCMs. Insurance coverage did not influence the use of or spending on opioids or antiemetics, but was associated with both outcomes for ASH. The use of all three SCM classes was significantly lower during years before Part D implementation of the new Medicare Part D prescription drug benefit and was higher after implementation of Part D. CONCLUSION: This study provides population-based information on SCM use among Medicare beneficiaries with cancer. Cancer site and treatment modality were important predictors of SCM use.

The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer.

OBJECTIVES: To examine whether patients with newly diagnosed cancer respond differently to supplemental coverage than the general Medicare population. METHODS: A cohort of newly diagnosed cancer patients (n = 1,799) from the 1997-2007 Medicare Current Beneficiary Survey and a noncancer cohort (n = 9,726) were identified and matched by panel year. Two-year total medical care spending was estimated by using generalized linear models with gamma distribution and log link-including endogeneity-corrected models. Interactions between cancer and type of insurance allowed testing for differential effects of a cancer diagnosis. RESULTS: The cancer cohort spent an adjusted $15,605 more over 2 years than did the noncancer comparison group. Relative to those without supplemental coverage, beneficiaries with employer-sponsored insurance, other private with prescription drug coverage, and public coverage had significantly higher total spending ($3,510, $2,823, and $4,065, respectively, for main models). For beneficiaries with cancer, supplemental insurance effects were similar in magnitude yet negative, suggesting little net effect of supplemental insurance for cancer patients. The endogeneity-corrected models produced implausibly large main effects of supplemental insurance, but the Cancer × Insurance interactions were similar in both models. CONCLUSIONS: Medicare beneficiaries with cancer are less responsive to the presence and type of supplemental insurance than are beneficiaries without cancer. Proposed restrictions on the availability of supplemental insurance intended to reduce Medicare spending would be unlikely to limit expenditures by beneficiaries with cancer, but would shift the financial burden to those beneficiaries. Policymakers should consider welfare effects associated with coverage restrictions.

How does drug treatment for diabetes compare between Medicare Advantage prescription drug plans (MAPDs) and stand-alone prescription drug plans (PDPs)?

OBJECTIVE: To compare the use of guideline-recommended prescription medications for diabetes among Medicare beneficiaries enrolled in stand-alone prescription drug plans (PDPs) with Medicare Advantage prescription drug plans (MAPDs) in the presence of potential selection bias. DATA SOURCES/STUDY SETTING: Centers for Medicare and Medicaid Services' Chronic Condition Data Warehouse (2006, 2007). STUDY DESIGN: Retrospective cross-sectional comparison of drug use and proportion of days covered (PDC) for oral-antidiabetics, ACE-inhibitors/ARBs, and antihyperlipidemics among PDP and MAPD enrollees with diabetes. We estimated "naïve" regression models assuming exogenous plan choice and two-stage residual inclusion (2SRI) models to study endogeneity in choice of Part D plan type. DATA COLLECTION/EXTRACTION METHODS: We identified 111,290 diabetics based on ICD-9 codes in Medicare claims from a random 5 percent sample of Medicare beneficiaries in 2005 excluding dual eligibles. PRINCIPAL FINDINGS: The naïve regression models indicated lower probability of drug use for oral-antidiabetics (-4 percent; p < .001) and ACE-inhibitors/ARBS (-2 percent; p = .004) among PDP enrollees, but their PDC was higher (3-5 percent) for all drug classes (p < .001). 2SRI models produced no significant differences in any-use equations, but significantly higher PDC values for PDP enrollees for oral-antidiabetics and ACE-inhibitors/ARBs. CONCLUSIONS: We found similar overall use of recommended drugs in diabetes treatment and no consistent evidence of favorable or adverse selection into PDPs and MAPDs.

Use and spending on antineoplastic therapy for Medicare beneficiaries with cancer.

BACKGROUND: Oral antineoplastic drugs, not generally covered by Medicare Part B, have assumed an increasingly important role in cancer treatment. OBJECTIVE: We examined use and spending on infused/injected (Part B covered) and non-Part B antineoplastic agents in a Medicare beneficiary population with cancer, and the effect of supplemental insurance. RESEARCH DESIGN: This retrospective, observational study used pooled 1997-2007 data from the Medicare Current Beneficiary Survey, linked to Medicare claims. Logistic regression models identified factors associated with antineoplastic use. Generalized linear models were used to estimate spending among antineoplastic users. POPULATION STUDIED: A total of 1836 Medicare beneficiaries with newly diagnosed cancer were selected based on the presence of claims-based diagnoses after a 12-month washout period. RESULTS: Five hundred fifty-nine (31.0%) Medicare beneficiaries received antineoplastic therapy; 395 (21.3%) used Part B, 253 (14.6%) used non-Part B antineoplastics. Spending per user was $7841 (any), $10,364 (Part B), and $1535 for non-Part B antineoplastics. Supplemental insurance was associated with antineoplastic use. Primary cancer site and age were key predictors of spending among users. Spending on non-Part B antineoplastics increased during 2006-2007 relative to 2004-2005 but time trends were not significant in multivariate analysis. CONCLUSIONS: Antineoplastic therapy use by Medicare beneficiaries is sensitive to the presence but not type of supplemental insurance. Non-Part B therapy was used by a relatively large proportion of beneficiaries with cancer receiving therapy, although spending was less than for Part B therapy. Monitoring the role of supplemental insurance, and particularly the role of Medicare Part D is a critical area for ongoing research.