Original articleGrowth in the Use of PET for Six Cancer Types After Coverage by Medicare: Additive or Replacement?
Introduction
Medical imaging serves an integral role at most decision points in cancer care, from diagnosis and initial staging to the termination of therapy for metastatic disease. Advanced imaging use evolved in a disorderly manner after the introduction of CT and, subsequently, MRI. In the absence of randomized trials, appropriateness criteria based on expert opinion using clinical vignettes have been the predominant source of practice guidelines [1, 2, 3].
Over the past decade, 4 trends arose related to cancer imaging. First, the costs of chemotherapies and targeted agents increased rapidly [4]. If cancer imaging could guide the effective use of these therapies, then increased imaging would be more easily defended. Second, the overall costs of medical imaging (not just for cancer) doubled between 2000 and 2006 [5, 6]. Third, CT and MRI scan volumes rose dramatically—by 9.5% per year for CT and 13.1% for MRI between 1998 and 2005—and shifted from predominantly hospital-based sites to freestanding outpatient sites [5, 7, 8]. Fourth, PET using 18F-fluorodeoxyglucose and integrated PET/CT (together referred to hereinafter as PET), a new technology based on a paradigm of characterizing metabolic processes rather than anatomy, was introduced for use in selected cancers. In July 2001 [9], CMS approved reimbursement for PET imaging for evaluating beneficiaries across the natural history—diagnosis, initial staging, and restaging—for 6 cancer types (non–small-cell lung, esophageal, colorectal, and head and neck cancers as well as lymphoma and melanoma).
It remains uncertain whether the growth in PET after the 2001 CMS coverage decision was associated with declines in other imaging. In this study, we assessed for 2004 through 2008 the temporal trends in PET use compared with the concurrent use of CT, MRI, and bone scintigraphy (BS) for these common cancer types. In addition, we assessed the temporal clustering and sequencing of PET use as “new” relative to “established” technologies (CT, MRI, and BS) to characterize its role as an additive or a replacement tool.
Section snippets
Design Overview
To characterize changes in cancer imaging after the 2001 CMS coverage decision for PET, we evaluated Medicare fee-for-service (FFS) claims for cancer beneficiaries identified annually over the period from 2004 to 2008. We used these data to examine the rates and sequencing of advanced cancer imaging. The institutional review board at Dartmouth Medical School approved this study.
Settings and Participants
For each of these 5 years, we assessed a 20% sample of FFS beneficiaries aged ≥ 65 years as of January 1, enrolled in
Results
The numbers of beneficiaries, cancer cases, and cancer person-years are shown in Table 2. From 2004 to 2008, the number of beneficiaries in the 20% FFS sample declined as more beneficiaries enrolled in Medicare Advantage plans. However, the demographics of the samples with respect to age (mean, 75.5 years), gender (58.5% women), and ethnicity (88.0% white, 7.5% black, and 4.5% other) all changed by ≤0.1% from 1 year to another.
Overall, the number of cases meeting our case definition per 1,000
Discussion
Over the past 2 decades, rapid growth in imaging volume and a shift to more expensive tests has been observed in Medicare beneficiaries and younger, privately insured patients [5, 6, 7, 8, 12, 13, 14]. This concern received national attention in a 2005 Medicare Payment Advisory Commission report [15]. Factors influencing the growth and likely overutilization of imaging [16] include wider availability, patient demand, self-referral among nonradiologists, competition among specialists, defensive
Conclusions
After Medicare coverage of PET, cancer providers rapidly incorporated the use of PET into their management of 6 common cancers. This change in practice was to use the new technique, PET, after first using the current imaging standard, body CT, in about half of cases. Whether PET is associated with superior patient outcomes and affects overall costs will require either studies that measure changes in major decision points along a cancer's natural history or studies that directly measure outcomes.
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Primary funding source: National Institutes of Health; National Cancer Institute Grand Opportunity Award RC2CA148259.