An Economic Analysis of Radiation Therapy Oncology Group 94-10: Cost-Efficacy of Concurrent vs. Sequential Chemoradiotherapy.

BACKGROUND: Cost can be a major issue in therapeutic decision-making, and in particular for patients with locally advanced non-small cell lung cancer (LA-NSCLC). METHODS: The specific aim of this analysis was to evaluate the costs and outcomes of patients treated on Radiation Therapy Oncology Group (RTOG) 94-10, Medicare Part A and Part B costs from all for patients treated from 1991 to 1996 on RTOG 94-10, a phase III trial showing a survival benefit for concurrent chemoradiation (STD RT) over sequential (RT day 50) chemoradiation in LA-NSCLC with intermediate outcome for concurrent twice daily radiation and chemotherapy (HFX RT). 26-month expected costs for each arm of the trial in 1996 dollars were determined, with Kaplan Meier sampling average estimates of survival probabilities for each month and mean monthly costs. The analysis was performed from a payer's perspective. Incremental cost-effectiveness ratios were calculated comparing RT on day 50 and HFX RT to the STD RT. RESULTS: Of the 610 patients entered, Medicare cost data and clinical outcomes were available for 92 patients. In this subset, compared to STD RT, RT on day 50 proved less costly but resulted in reduced survival at 1 year. In addition, HFX RT cost slightly more than STD RT but was less effective in this cohort of patients. CONCLUSIONS: In patients with Medicare insurance and with significant toxicity burden, RT on day 50 is the least expensive but also least effective treatment in this subset of patients treated on RTOG 94-10.

Clinical and Demographic Factors Associated With Receipt of Non Guideline-concordant Initial Therapy for Nonmetastatic Prostate Cancer.

OBJECTIVES: To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care. METHODS: Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care. RESULTS: Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE. CONCLUSIONS: Receipt of less aggressive therapy than indicated among high-risk group men with >5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology survey.

PURPOSE: The objective of this study is to describe the impact of sociodemographic (SOC) factors on the management of lung cancer patients treated at radiation therapy facilities participating in the Quality Research in Radiation Oncology survey. METHODS AND MATERIALS: A 2-stage stratified random sample of lung cancer patients treated in 2006 to 2007 at 45 facilities yielded 340 stage I-III non-small cell lung cancer (NSCLC) and 144 limited-stage small cell lung cancer (LS-SCLC) cases. Five SOC variables based on data from the 2000 US Census were analyzed for association with the following clinical factors: patients living in urban versus rural settings (U/R); median household income (AHI); % below poverty level (PPV); % unemployed (PUE); and % with college education (PCE). RESULTS: The 340 NSCLC patients were stage I, 16%; stage II, 11%; stage III, 62%; stage unknown, 11%. Histologic subtypes were adenocarcinoma, 31.8%; squamous cell carcinoma, 35.3%; large cell carcinoma, 3.2%; and NSCLC NOS, 27.7%. The median age was 66 years. Median Karnofsky performance status (KPS) was 80. The 144 LS-SCLC had a median age of 63; 73 were male (50.7%). Median KPS was 80. Stereotactic body radiation therapy (SBRT) and modern imaging utilization was associated with treatment at facilities located in higher SOC regions. SBRT was employed in 46.8% stage I NSCLC patients treated in centers where %PUE was below median versus 14.8% in centers where %PUE was above median (P = .02). Four-dimensional computed tomography was utilized in 14.2% of patients treated in centers located in regions with %PPV below median versus 3.7% in centers located in regions with %PPV above median (P < .01). SCLC patients were more likely to receive all of their planned RT when treated at centers located in regions with lower PPV (95.0% vs 79.1%; P = .04). CONCLUSIONS: SOC factors may impact use of modern treatment planning and delivery and multidisciplinary management of NSCLC and SCLC. These results may suggest an impact of these SOC factors on access to health care.

Can patient comorbidities be included in clinical performance measures for radiation oncology?

PURPOSE: Patient comorbidities may affect the applicability of performance measures that are inherent in multidisciplinary cancer treatment guidelines. This article describes the distribution of common comorbid conditions by disease site and by patient and facility characteristics in patients who received radiation therapy as part of treatment for cancer of the breast, cervix, lung, prostate, and stomach, and investigates the association of comorbidities with treatment decisions. MATERIALS AND METHODS: Stratified two-stage cluster sampling provided a random sample of radiation oncology facilities. Eligible patients were randomly sampled from each participating facility for each disease site, and data were abstracted from medical records. The Adult Comorbidity Evaluation Index (ACE-27) was used to measure comorbid conditions and their severity. National estimates were calculated using SUDAAN statistical software. RESULTS: Multivariable logistic regression models predicted the dependent variable "treatment changed or contraindicated due to comorbidities." The final model showed that ACE-27 was highly associated with change in treatment for patients with severe or moderate index values compared to those with none or mild (P < .001). Two other covariates, age and medical coverage, had no (age) or little (medical coverage) significant contribution to predicting treatment change in the multivariable model. Disease site was associated with treatment change after adjusting for other covariates in the model. CONCLUSIONS: ACE-27 is highly predictive of treatment modifications for patients treated for these cancers who receive radiation as part of their care. A standardized tool identifying patients who should be excluded from clinical performance measures allows more accurate use of these measures.

Type and dose of radiotherapy used for initial treatment of non-metastatic prostate cancer.

BACKGROUND: We sought to describe patterns of initial radiotherapy among non-metastatic prostate cancer (PC) patients by recurrence risk groups. METHODS: Medical records were abstracted for a sample of 9017 PC cases diagnosed in 2004 as a part of the Center for Disease Control and Prevention's Prostate and Breast Patterns of Care Study in seven states. Non-metastatic PC cases are categorized as low-risk (LR), intermediate-risk (IR) or high-risk (HR) groups based on pretreatment PSA, tumor stage, and Gleason score per 2002 NCCN guidelines. Univariate and multivariate analyses were employed to determine factors associated with the type and dose of radiotherapy by the risk groups. RESULTS: Of the 9,017 patients, 3153 who received definitive radiotherapy either alone or in combination with hormone therapy (HT) were selected for in-depth analysis. Multivariate models showed that LR patients were more likely to receive seed implant brachytherapy (BT) than those in higher risk groups. Those in the IR group were most likely to receive external beam radiotherapy (EBRT) combined with BT or high-dose radiotherapy. Use of HT in combination with radiotherapy was more common in the IR and HR groups than for LR patients. Intensity modulated radiation treatment (IMRT) was used to treat 32.6% of PC patients treated with EBRT, with the majority (60.6%) treated with high-dose radiotherapy. CONCLUSIONS: Radiotherapy types and dosage utilization varied by PC risk groups. Patients in IR were more likely than those in LR or HR to receive high-dose radiotherapy. IMRT was used in about one third of patients to deliver high-dose radiotherapy.

Patterns of radiation therapy practice for patients treated for intact cervical cancer in 2005 to 2007: a quality research in radiation oncology study.

PURPOSE: To assess practice patterns and compliance with clinical performance measures for radiation therapy (RT) for patients with intact carcinoma of the cervix. METHODS AND MATERIALS: Trained research associates reviewed the records of 261 randomly selected patients who received RT for cervix carcinoma between 2005 and 2007 from 45 facilities randomly selected after stratification by practice type. National estimates of patient and treatment characteristics were calculated from survey data using SUDAAN statistical software. RESULTS: From the survey data, we estimated that only 8% of US facilities treated on average more than 3 eligible patients per year. No small or medium nonacademic facilities in the survey treated more than 3 eligible patients per year. Approximately 65.5% of patients began treatment in a facility that treated 3 or fewer eligible patients per year. Although 87.5% of patients had brachytherapy as part of their treatment, the proportion treated with external beam RT only was about double that estimated from the 1996 to 1999 survey. The use of high-dose-rate brachytherapy sharply increased, particularly in small nonacademic facilities. Overall, patients treated in nonacademic facilities were more likely to have incomplete or protracted treatment; 43% of patients treated in small nonacademic facilities did not have treatment completed within 10 weeks. Also, patients treated in facilities that treated 3 or fewer eligible patients per year were significantly less likely to receive concurrent chemotherapy than were patients treated in other facilities. CONCLUSION: Survey results indicate a disturbingly high rate of noncompliance with established criteria for high-quality care of patients with cervical cancer. Noncompliance rates are particularly high in nonacademic facilities, especially those that treat relatively few patients with intact cervical cancer.

Treatment patterns for prostate cancer: comparison of Medicare claims data to medical record review.

BACKGROUND: As evidence-based guidelines increasingly define standards of care, the accurate reporting of patterns of treatment becomes critical to determine if appropriate care has been provided. We explore the level of agreement between claims and record abstraction for treatment regimens for prostate cancer. METHODS: Medicare claims data were linked to medical records abstraction using data from the Centers for Disease Control and Prevention's National Program of Cancer Registry-funded Breast and Prostate Patterns of Care study. The first course of therapy included surgery, radiation therapy (RT), and hormonal therapy with luteinizing hormone-releasing hormone agonists. RESULTS: The linked sample included 2765 men most (84.7%) of whom had stage II prostate cancer. Agreement was excellent for surgery (κ=0.92) and RT (κ=0.92) and lower for hormonal therapy (κ=0.71); however, most of the discrepancies were due to greater number of patients reported who received hormonal therapy in the claims database than in the medical records database. For some standard multicomponent management strategies sensitivities were high, for example, hormonal therapy with either combination RT (86.9%) or cryosurgery (96.6%). CONCLUSIONS: Medicare claims are sensitive for determining patterns of multicomponent care for prostate cancer and for detecting use of hormonal therapy when not reported in the medical records abstracts.

Evaluation of Adherence to Quality Measures for Prostate Cancer Radiotherapy in the United States: Results from the Quality Research in Radiation Oncology (QRRO) Survey.

PURPOSE: To test the feasibility of using proposed quality indicators to assess radiotherapy quality in prostate cancer management based on a 2007 stratified random survey of treating academic and non-academic US institutions. METHODS AND MATERIALS: 414 patients with clinically localized prostate cancer treated with external beam radiotherapy (EBRT) or brachytherapy were selected from 45 institutions. Indicators used as specific measurable clinical performance measures to represent surrogates for quality of radiotherapy delivery included established measures, such as the use of prescription doses ≥75 Gy for intermediate- and high-risk EBRT patients and androgen-deprivation therapy (ADT) in conjunction with EBRT for patients with high-risk disease, and emerging measures, including daily target localization (image-guidance) to correct for organ motion for EBRT patients. RESULTS: 167 patients (47%) were treated with 6 MV photons, 31 (9%) were treated with 10 MV, 65 (18%) received 15 MV, and the remaining 90 (26%) 16-23 MV. For intermediate- plus high-risk patients (n=181), 78% were treated to ≥75 Gy. Among favorable-risk patients, 72% were treated to ≥75 Gy. Among high-risk EBRT patients, 60 (87%) were treated with ADT in conjunction with EBRT and 13% (n=9) with radiotherapy alone. Among low- and intermediate-risk patients, 10% and 42%, respectively, were treated with ADT plus EBRT. For 24% of EBRT patients (85/354), weekly electronic portal imaging was obtained as verification films without daily target localization and the remaining 76% were treated with daily localization of the target using various methods. CONCLUSIONS: Adherence to defined quality indicators was observed in a majority of patients. ≈90% of high-risk patients are treated with ADT plus EBRT and ≈80% of intermediate- and high-risk patients receive prescription doses >=75 Gy, consistent with the published results of randomized trials.

Penetration of recommended procedures for lung cancer staging and management in the United States over 10 years: a quality research in radiation oncology survey.

PURPOSE: To document the penetration of clinical trial results, practice guidelines, and appropriateness criteria into national practice, we compared the use of components of staging and treatment for lung cancer among patients treated in 2006-2007 with those used in patients treated in 1998-1999. METHODS AND MATERIALS: Patient, staging work-up, and treatment characteristics were extracted from the process survey database of the Quality Research in Radiation Oncology (QRRO), consisting of records of 340 patients with locally advanced non-small cell lung cancer (LA-NSCLC) at 44 institutions and of 144 patients with limited-stage small cell lung cancer (LS-SCLC) at 39 institutions. Data were compared for patients treated in 2006-2007 versus those for patients treated in 1998-1999. RESULTS: Use of all recommended procedures for staging and treatment was more common in 2006-2007. Specifically, disease was staged with brain imaging (magnetic resonance imaging or computed tomography) and whole-body imaging (positron emission tomography or bone scanning) in 66% of patients with LA-NSCLC in 2006-2007 (vs 42% in 1998-1999, P=.0001) and in 84% of patients with LS-SCLC in 2006-2007 (vs 58.3% in 1998-1999, P=.0011). Concurrent chemoradiation was used for 77% of LA-NSCLC patients (vs 45% in 1998-1999, P<.0001) and for 90% of LS-SCLC patients (vs 62.5% in 1998-1999, P<.0001). Use of the recommended radiation dose (59-74 Gy for NSCLC and 60-70 Gy as once-daily therapy for SCLC) did not change appreciably, being 88% for NSCLC in both periods and 51% (2006-2007) versus 43% (1998-1999) for SCLC. Twice-daily radiation for SCLC was used for 21% of patients in 2006-2007 versus 8% in 1998-1999. Finally, 49% of patients with LS-SCLC received prophylactic cranial irradiation (PCI) in 2006-2007 (vs 21% in 1998-1999). CONCLUSIONS: Although adherence to all quality indicators improved over time, brain imaging and recommended radiation doses for stage III NSCLC were used in <90% of cases. Use of full thoracic doses and PCI for LS-SCLC also requires improvement.

Place of residence and primary treatment of prostate cancer: examining trends in rural and nonrural areas in Wisconsin.

OBJECTIVE: To determine whether rural residents were at a disadvantage compared with urban residents with regard to the receipt of curative therapy for prostate cancer. MATERIALS AND METHODS: Using the Breast and Prostate Cancer Data Quality and Patterns of Care Study II, patients with prostate cancer who were diagnosed in 2004 were identified. Registrars reviewed the medical records of randomly selected patients with incident prostate cancer (n = 1906). The patients' residential address was geocoded and linked to the census tract from the 2000 U.S. Census. The place of residence was defined as rural or nonrural according to the census tract and rural-urban commuting area categorization. The distance from the residence to the nearest radiation oncology facility was calculated. The odds ratio and 95% confidence intervals associated with receipt of noncurative treatment was calculated from logistic regression models and adjusted for several potential confounders. RESULTS: Of the incident patients, 39.1% lived in urban census tracts, 41.5% lived in mixed tracts, and 19.4% lived in rural tracts. Hormone-only or active surveillance was received by 15.4% of the patients. Relative to the urban patients, the odds ratio for noncurative treatment was 1.01 (95% confidence interval 0.59-1.74) for those living in mixed tracts and 0.96 (95% confidence interval 0.52-1.77) for those living in rural tracts. No association was found for noncurative treatment according to the Rural-Urban Commuting Area categorization. The linear trend was null between noncurative treatment and the distance to nearest radiation oncology facility (P = .92). CONCLUSION: The choice of curative treatment did not significantly depend on the patient's place of residence, suggesting a lack of geographic disparity for the primary treatment of prostate cancer.

Quality Research in Radiation Oncology analysis of clinical performance measures in the management of gastric cancer.

BACKGROUND: The specific aim was to determine national patterns of radiation therapy (RT) practice in patients treated for stage IB-IV (nonmetastatic) gastric cancer (GC). METHODS AND MATERIALS: A national process survey of randomly selected US RT facilities was conducted which retrospectively assessed demographics, staging, geographic region, practice setting, and treatment by using on-site record review of eligible GC cases treated from 2005 to 2007. Three clinical performance measures (CPMs), (1) use of computed tomography (CT)-based treatment planning; (2) use of dose volume histograms (DVHs) to evaluate RT dose to the kidneys and liver; and (3) completion of RT within the prescribed time frame; and emerging quality indicators, (i) use of intensity modulated RT (IMRT); (ii) use of image-guided tools (IGRT) other than CT for RT target delineation; and (iii) use of preoperative RT, were assessed. RESULTS: CPMs were computed for 250 eligible patients at 45 institutions (median age, 62 years; 66% male; 60% Caucasian). Using 2000 American Joint Committee on Cancer criteria, 13% of patients were stage I, 29% were stage II, 32% were stage IIIA, 10% were stage IIIB, and 12% were stage IV. Most patients (43%) were treated at academic centers, 32% were treated at large nonacademic centers, and 25% were treated at small to medium sized facilities. Almost all patients (99.5%) underwent CT-based planning, and 75% had DVHs to evaluate normal tissue doses to the kidneys and liver. Seventy percent of patients completed RT within the prescribed time frame. IMRT and IGRT were used in 22% and 17% of patients, respectively. IGRT techniques included positron emission tomography (n=20), magnetic resonance imaging (n=1), respiratory gating and 4-dimensional CT (n=22), and on-board imaging (n=10). Nineteen percent of patients received preoperative RT. CONCLUSIONS: This analysis of radiation practice patterns for treating nonmetastatic GC indicates widespread adoption of CT-based planning with use of DVH to evaluate normal tissue doses. Most patients completed adjuvant RT in the prescribed time frame. IMRT and IGRT were not routinely incorporated into clinical practice during the 2005-2007 period. These data will be a benchmark for future Quality Research in Radiation Oncology GC surveys.

Results from the Quality Research in Radiation Oncology (QRRO) survey: Evaluation of dosimetric outcomes for low-dose-rate prostate brachytherapy.

PURPOSE: We report on quality of dose delivery to target and normal tissues from low-dose-rate prostate brachytherapy using postimplantation dosimetric evaluations from a random sample of U.S. patients. METHODS AND MATERIALS: Nonmetastatic prostate cancer patients treated with external beam radiotherapy or brachytherapy in 2007 were randomly sampled from radiation oncology facilities nationwide. Of 414 prostate cancer cases from 45 institutions, 86 received low-dose-rate brachytherapy. We collected the 30-day postimplantation CT images of these patients and 10 test cases from two other institutions. Scans were downloaded into a treatment planning system and prostate/rectal contours were redrawn. Dosimetric outcomes were reanalyzed and compared with calculated outcomes from treating institutions. RESULTS: Median prostate volume was 33.4cm(3). Reevaluated median V(100), D(90), and V(150) were 91.1% (range, 45.5-99.8%), 101.7% (range, 59.6-145.9%), and 53.9% (range, 15.7-88.4%), respectively. Low gland coverage included 27 patients (39%) with a D(90) lower than 100% of the prescription dose (PD), 12 of whom (17% of the entire group) had a D(90) lower than 80% of PD. There was no correlation between D(90) coverage and prostate volume, number of seeds, or implanted activity. The median V(100) for the rectum was 0.3cm(3) (range, 0-4.3cm(3)). No outcome differences were observed according to the institutional strata. Concordance between reported and reevaluated D(90) values (defined as within ±10%) was observed in 44 of 69 cases. CONCLUSIONS: Central review of postimplantation CT scans to assess the quality of prostate brachytherapy is feasible. Most patients achieved excellent dosimetric outcomes, yet 17% had less than optimal target coverage by the PD. There was concordance between submitted target-coverage parameters and central dosimetric review in 64% of implants. These findings will require further validation in a larger cohort of patients.

Regional, provider, and economic factors associated with the choice of active surveillance in the treatment of men with localized prostate cancer.

Data on initial treatment of 8232 cases of localized prostate cancer diagnosed in 2004 were obtained by medical record abstraction (including hospital and outpatient locations) from seven state cancer registries participating in the Centers for Disease Control and Prevention's Breast and Prostate Cancer Data Quality and Patterns of Care Study. Distinction was made between men receiving no therapy with no monitoring plan (no therapy/no plan [NT/NP]) and those receiving active surveillance (AS). Overall, 8.6% received NT/NP and 4.7% received AS. Older age at diagnosis, lower clinical risk group, and certain registry locations were significant predictors of use of both AS and NT/NP. AS was also related to having more severe comorbidities, whereas nonwhite race was predicted receiving NT/NP. Men receiving AS lived in areas with a higher number of urologists per 100 000 men than those receiving NT/NP. In summary, physician and clinical factors were stronger predictors of AS, whereas demographic and regional factors were related to receiving NT/NP. Physicians appear reluctant to recommend AS for younger patients with no comorbidities.

Feasibility of economic analysis of Radiation Therapy Oncology Group (RTOG) 91-11 using Medicare data.

PURPOSE: The specific aim of this analysis was to evaluate the feasibility of performing a cost-effectiveness analysis using Medicare data from patients treated on a randomized Phase III clinical trial. METHODS AND MATERIALS: Cost data included Medicare Part A and Part B costs from all providers--inpatient, outpatient, skilled nursing facility, home health, hospice, and physicians--and were obtained from the Centers for Medicare & Medicaid Services for patients eligible for Medicare, treated on Radiation Therapy Oncology Group (RTOG) 9111 between 1992 and 1996. The 47-month expected discounted (annual discount rate of 3%) cost for each arm of the trial was calculated in 1996 dollars, with Kaplan-Meier sampling average estimates of survival probabilities for each month and mean monthly costs. Overall and disease-free survival was also discounted 3%/year. The analysis was performed from a payer's perspective. Incremental cost-effectiveness ratios were calculated comparing the chemotherapy arms to the radiation alone arm. RESULTS: Of the 547 patients entered, Medicare cost data and clinical outcomes were available for 66 patients. Reasons for exclusion included no RTOG follow-up, Medicare HMO enrollment, no Medicare claims since trial entry, and trial entry after 1996. Differences existed between groups in tumor characteristics, toxicity, and survival, all which could affect resource utilization. CONCLUSIONS: Although we were able to test the methodology of economic analysis alongside a clinical trial using Medicare data, the results may be difficult to translate to the entire trial population because of non-random missing data. Methods to improve Medicare data capture and matching to clinical trial samples are required.

Shifting the focus to practice quality improvement in radiation oncology.

To demonstrate how the American College of Radiology, Quality Research in Radiation Oncology (QRRO) process survey database can serve as an evidence base for assessing quality of care in radiation oncology. QRRO has drawn a stratified random sample of radiation oncology facilities in the USA and invited those facilities to participate in a Process Survey. Information from a prior QRRO Facilities Survey has been used along with data collected under the current National Process Survey to calculate national averages and make statistically valid inferences for national process measures for selected cancers in which radiation therapy plays a major role. These measures affect outcomes important to patients and providers and measure quality of care. QRRO's survey data provides national benchmark data for numerous quality indicators. The Process Survey is "fully qualified" as a Practice Quality Improvement project by the American Board of Radiology under its Maintenance of Certification requirements for radiation oncology and radiation physics.

Frequency of use of imaging tests in the diagnosis of pulmonary embolism: effects of physician specialty, patient characteristics, and region.

OBJECTIVE: The purpose of this study was to ascertain whether clinical practice in diagnosing pulmonary embolism is consistent with recommendations in the literature and to explore variations in practice across site of care (e.g., emergency department), physician and patient characteristics, and geographic location. MATERIALS AND METHODS: Medicare 5% research identifiable files were analyzed. The cases of patients with emergency department visits or inpatient stays for a diagnosis of pulmonary embolism or for symptoms related to pulmonary embolism (shortness of breath, chest pain, and syncope) were identified. We determined the number of patients who underwent each type of relevant imaging test and evaluated variations in the first non-chest-radiographic test by site of care and treating physician specialty. Using logistic regression, we studied variations in the use of common imaging tests, exploring variations associated with patient characteristics, physician specialty, site of care, and geographic location. RESULTS: For patients in whom pulmonary embolism might have been suspected, the most common tests were echocardiography (26% of the patients), CT or CT angiography of the chest (11%), cardiac perfusion study (6.9%), and duplex ultrasound (7.3%). For patients with an inpatient diagnosis of pulmonary embolism, the most common tests were chest CT or CT angiography (49%), duplex ultrasound (18%), echocardiography (10.9%), and ventilation-perfusion scintigraphy (10.9%). For patients for whom pulmonary embolism might have been suspected, many large variations were found in practice patterns among physician specialties and geographic locations. There were fewer variations among patients with the inpatient diagnosis of pulmonary embolism. CONCLUSION: Physician practice in the diagnosis of pulmonary embolism is broadly consistent with recommendations. However, variations by physician specialty and geographic location may be evidence of inappropriate imaging.

Imaging evaluation for suspected pulmonary embolism: what do emergency physicians and radiologists say?

OBJECTIVE: The utility of various imaging techniques and strategies for the diagnosis of pulmonary embolism has been studied in randomized control trials and extensively described in the literature. CT and ventilation-perfusion scintigraphy are the mainstays of diagnosis, and MRI is emerging. The purpose of this study was to assess the diagnostic approach to pulmonary embolism practiced by emergency physicians and advised by radiologists. MATERIALS AND METHODS: Questionnaires were sent to emergency physicians and radiologists in Pennsylvania. The questions covered diagnostic strategies for the detection of pulmonary embolism in the usual situations and in clinical circumstances in which the primary imaging technique is considered less desirable. RESULTS: Sixty-two radiologists and 52 emergency physicians completed the survey. Ninety percent of radiologists and 96% of emergency physicians answered that CT was their first-line choice for the diagnosis of pulmonary embolism. The use of ventilation-perfusion scintigraphy increased in the care of patients with renal failure and allergy to iodinated contrast material. MRI was chosen infrequently. CONCLUSION: CT is the overwhelmingly preferred technique for the diagnosis of pulmonary embolism. The role of ventilation-perfusion scintigraphy increases when the use of iodinated contrast material is contraindicated. MRI does not seem to have an important role in practice.

The actual role of CT and ventilation-perfusion scanning in workup for suspected pulmonary embolism: evidence from hospitals.

OBJECTIVE: Over the past two decades, CT has been found valuable in the diagnosis of pulmonary embolism (PE). We sought to ascertain the relative roles of CT and ventilation-perfusion (V/Q) scanning, the previously preferred technique, in the diagnosis of PE in recent practice and whether there is variation among hospital types. MATERIALS AND METHODS: Using the Medicare anonymized 5% of beneficiaries complete claims file for 2005, we studied the use of relevant CT and V/Q scanning in the evaluation of patients with a diagnosis of PE and of patients with symptoms that might have been due to PE (chest pain, syncope, difficulty breathing). In 2008, we surveyed the radiology departments of Pennsylvania hospitals about the use of CT and V/Q scanning for PE, service availability hours, and what equipment was used. RESULTS: In all data, we found that CT was used approximately six times as frequently as V/Q scanning. In the Medicare data, only small differences in frequency of use of CT and V/Q scanning were associated with hospital characteristics. Academic hospitals did not differ in a major way from other hospitals, nor did small or rural hospitals. In the survey, 97% of radiology departments reported that CT was available for evaluation of PE 24 hours a day 7 days a week. Ninety-three percent of departments reported V/Q scanning was available at some times; 77% reported V/Q available at all times. CONCLUSION: CT was a fully disseminated and dominant technique for the diagnosis of PE by 2005, and it was readily available at small and rural hospitals. The lack of availability of off-hours V/Q scanning at a substantial fraction of hospitals may be a problem for patients with contraindications to CT.

Using QRRO survey data to assess compliance with quality indicators for breast and prostate cancer.

PURPOSE: Quality Research in Radiation Oncology (QRRO) has embarked on a new national process survey to provide benchmark data that will allow radiation oncologists to assess the quality of care in their own practices by measuring quality indicators (QIs) and comparing individual with national practice. METHODS: Investigators at QRRO developed QIs on the basis of nationally recognized, evidence-based guidelines such as those of the National Comprehensive Cancer Network, as well as additional emerging QIs for processes involving rapidly emerging technology. They specifically defined the QIs as clinical performance measures. Published results of the national survey database for patients treated in 1998 and 1999 were reviewed and additional analyses conducted to assess data adequacy to measure compliance with these clinical performance measures. RESULTS: Examples of workup QIs for breast cancer patients showed that 97% underwent diagnostic bilateral mammography, 96% underwent pathology reviews, 83% underwent the determination of estrogen receptor status, 81% underwent the determination of progesterone receptor status, and 31% underwent the determination of human epidermal growth factor receptor 2 status. Compliance with treatment QIs for field recommendations on the basis of nodal findings can be measured. Of patients with prostate cancer, 90% underwent digital rectal examinations, 99% underwent prostate-specific antigen tests, and 99% had their Gleason scores determined. Compliance with QIs on the basis of prognostic group can also be measured. CONCLUSIONS: Benchmarking utilization patterns provides a foundation for assessing the appropriateness of cancer care in the future. The QRRO database is a rich data source, and the new survey will provide contemporary benchmark data for these measures.

Feasibility of using administrative claims data for cost-effectiveness analysis of a clinical trial.

OBJECTIVE: This study was performed retrospectively to determine if Medicare claims data could be used to evaluate the cost effectiveness, from a payer perspective, of different radiation treatment schedules evaluated in a national clinical trial. METHODS: Medicare costs from all providers and all places of service were obtained from the Centers for Medicare & Medicaid Services for patients treated in the period 1992-1996 on Radiation Therapy Oncology Group 90-03, and combined with data on outcomes from the trial. RESULTS: Of the 1,113 patients entered, Medicare cost data and clinical outcomes were available for 187 patients. Significant differences in tolerance of treatment and outcome were noted between patients with Medicare data included in the study and patients without Medicare data, and non-Medicare patients excluded from it. Ninety-five percent confidence ellipses on the incremental cost-effectiveness scatterplots crossed both axes, indicating non-significant differences in cost effectiveness between radiation treatment schedules. CONCLUSIONS: Claims data permit estimation of cost effectiveness, but Medicare data provide inadequate representation of results applicable to patients from the general population.