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Publication Briefs

Men Using VA More Likely to Receive Appropriate Prostate Cancer Imaging Tests Compared to Those Using Medicare

Reducing guideline-discordant prostate cancer imaging is a national priority. Within VA, physicians receive no financial incentive to provide more services. Outside VA, the fee-for-service model used in Medicare may encourage provision of more healthcare services due to direct physician reimbursement. Many of these additional services may have limited efficacy or be quantifiably unnecessary. This study sought to assess the association between the quality of healthcare within VA vs. Medicare, by comparing rates of guideline-concordant and guideline-discordant staging imaging among patients with newly diagnosed prostate cancer utilizing VA services only, Medicare only, or a combination of the two. Data included men with a diagnosis of prostate cancer between January 2004 and March 2008 (n=98,867). Guideline concordance was determined on the basis of the National Comprehensive Cancer Network imaging recommendations for staging prostate cancer.


  • Among men with low-risk prostate cancer, the VA-only and VA-Medicare groups were most likely to receive guideline-concordant care (61% and 56%, respectively) compared with the Medicare-only group (53%).
  • Among men with low-risk prostate cancer, more in the Medicare-only group received at least one inappropriate, guideline-discordant imaging test for staging (53%) compared with the VA-Medicare group (51%) and the VA-only group (46%).
  • For men diagnosed with high-risk prostate cancer, guideline-concordance was similar across the 3 groups, with 71% of the VA-Medicare group, 69% of the VA-only group, and 67% of the Medicare-only group receiving guideline-concordant imaging.

Findings suggest that Veterans using the Choice Act to seek care outside VA may experience more utilization of care with no guarantee of improved quality of care. Future research should consider the role of healthcare systems, the cost implications of guideline-discordant care, and the potential savings from an effort to align practice with evidence.


  • Assessment of imaging used only analyses of claims data, so there is a possibility that imaging could have been misclassified as guideline-discordant due to lack of clinical information.
  • Analyses did not control for providers with dual appointments, some of whom have reported altering imaging practices based on health care setting in an earlier study.

This study was supported by HSR&D (CDP 12-254). Dr. Makarov is an HSR&D Career Development Awardee and Chief of Urology Section at the Manhattan Campus of VA's New York Harbor Health Care System.

Makarov D, Ciprut S, Walter D, et al.. Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients. JAMA Network Open. August 17, 2018;1(4).

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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