Neuroimaging overuse is more common in Medicare compared with the VA

Abstract

Objective: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.Methods: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n 5 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n 5 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.Results: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p , 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p , 0.001), and the difference persisted after excluding nontarget conditions. Conclusions:Overuse of neuroimaging is likely less common in the VA than in a Medicare population.Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing. Neurology ® 2016;87:792-798 GLOSSARY HRS 5 Health and Retirement Study; ICD-9 5 International Classification of Diseases-9; NCS 5 nerve conduction studies; SPEP 5 serum protein electrophoresis; VA 5 Veterans Affairs.

Neuroimaging utilization and findings in headache outpatients: Significance of red and yellow flags

“…In the National Ambulatory Medical Care Survey (NAMCS), neurologist visits were associated with increased neuroimaging (3). However, within the Veterans Administration system, neuroimaging rates for patients with headache is lower when compared to Medicare patients; although it is unclear whether neurologist input into the imaging decisions or other system factors explain these differences (33).…”

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

“…14 , 15 Nevertheless, several studies focused on the use of individual low-value health services (eg, prostate cancer screening and colonoscopy) have demonstrated that the delivery of low-value care still occurs at VAMCs. 3 , 16 , 17 , 18 , 19 , 20 , 21 , 22 …”

“…14,15 Nevertheless, several studies focused on the use of individual low-value health services (eg, prostate cancer screening and colonoscopy) have demonstrated that the delivery of low-value care still occurs at VAMCs. 3,[16][17][18][19][20][21][22] As health care costs continue to increase and recent legislation provides veterans with increasing flexibility regarding whether they receive care within or outside the VHA, quantifying the frequency and patterns of low-value care delivery is essential for the VHA to reduce wasteful health care spending without compromising quality or patient satisfaction. 15,23 Our objective was to characterize the frequency of and VAMC-level variation in the delivery of low-value care, with a focus on low-value diagnostic testing for 4 common conditions in the VHA.…”

Caution Ahead

“…Although clinical practice guidelines for neuroimaging in headache have been widely distributed, challenges continue to emerge regarding cor-rect identification of patients requiring neuroimaging. For instance, a study evaluating appropriate neuroimaging in headache suggested that while patients with headache may be receiving fewer inappropriate neuroimaging tests, these patients may also be receiving fewer appropriate neuroimaging tests (Burke et al, 2016). Furthermore, roughly 9% of patients assessed in the ED with nonspecific, transient, or mild symptoms are misdiagnosed and not appropriately evaluated for CVA.…”