Neuroimaging Overuse More Common among Medicare Patients Compared to VA Patients
Neuroimaging is common and costly, and may be both overused and underused. Recently, Choosing Wisely guidelines focused on overuse by questioning the use of diagnostic neuroimaging in two highly prevalent neurological conditions: headache and peripheral neuropathy. This retrospective study sought to determine whether rates of inappropriate neuroimaging for headache and neuropathy differ between Veterans receiving VA care and a Medicare population enrolled in the Health and Retirement Study (HRS). Investigators compared frequency and appropriateness of diagnostic testing between these two systems of care from 2004 to 2011. Participants were age 66 and older for headache, allowing time for Medicare enrollment, and 67 and older for neuropathy, allowing for a two-year neuropathy-free period. Using VA and Medicare data, investigators identified 1,244 HRS-Medicare patients with headache and 998 for neuropathy, and 93,755 VA patients with headache and 183,642 with neuropathy. Neuroimaging use was measured with CPT (Current Procedural Terminology) codes, and potential overuse was defined using published criteria for use with administrative data. Imaging that was performed in the inpatient or emergency department setting was excluded. Neuropathy measures were separately estimated in the overall population – and in the population with and without diabetes.
- While neuroimaging overuse was high in both populations, it was much less common for patients treated in VA compared to those who received care through Medicare coverage: 49% of all headache patients received neuroimaging in HRS-Medicare compared with 22% of VA patients, and 24% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9% in VA.
- After excluding non-target conditions for neuroimaging in neuropathy (e.g., dementia, stroke, multiple sclerosis), imaging rates decreased in both VA and HRS-Medicare, but the use of neuroimaging remained significantly lower among VA patients than HRS-Medicare patients (6% vs. 15%).
- Future initiatives to reduce the overuse of diagnostic testing should learn from what is working in VA to limit inappropriate imaging – but not lose sight of the imperative to enhance the overall quality of care by also motivating the appropriate use of needed services.
- In the absence of detailed clinical data, conclusions about the appropriateness of care can only be tentatively advanced.
- Diagnostic reliabilitiy of ICD-9 algorithms may differ between VA and HRS-Medicare settings.
- Some VA patients may have received care outside VA, and to the extent that VA providers knew the results they may have refrained from repeatings tests.
This study was partly supported by VA's Office of Informatics and Analytics. Dr. Kerr is part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.
Burke J, Kerr E, McCammon R, et al. Neuroimaging Overuse is More Common in Medicare Compared to the VA. Neurology. July 8, 2016;e-pub ahead of print.