Quality initiative could reduce unnecessary PCa bone scans

One gentle “nudge” may be all it takes to start reducing the number of unnecessary bone scans ordered for asymptomatic men with low-risk prostate cancer, results of a recent quality improvement intervention suggest.

The rate of bone scans for low-risk patients at one Veterans Affairs (VA) hospital dropped from 86.5% (32/37) in the year prior to the intervention, compared with 65.5% (19/29; p=.043) in the year afterward, according to results of a quasi-experimental before-and-after study published as a research letter inAdvances in Radiation Oncology (in press).

The intervention consisted of a single presentation at a tumor board meeting, followed by a short group discussion. Attendees at the meeting included the chiefs of radiation oncology and urology, the chair of the Cancer Committee, and resident physicians/physician assistants from both services.

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“The whole thing probably lasted 15 minutes or so,” said Eric Ojerholm, MD, of the University of Pennsylvania and the Crescenz VA Medical Center, Philadelphia. “Everyone pretty quickly agreed that we could improve on our rates of bone scans.”

Of note, the presentation was specifically designed to include social comparisons and appeals to professional norms, two behavioral science concepts that, when combined, may have powerful effects in influencing physician behavior(JAMA 2016; 316:1151–2). For social comparison, attendees were shown current rates of bone scans from peer institutions in the United States, including VA hospitals; for appeals to norms, guidelines from various professional groups were reviewed.

Next: “The next step would be to test the intervention again in a different practice, and try to confirm the findings.”

Dr. Ojerholm cautioned that these results, from one small study at a single institution, are not definitive.

“The results simply invite us to examine this type of intervention (peer comparison and normative appeal) more closely,” he said in an interview with Urology Times. “The next step would be to test the intervention again in a different practice, and try to confirm the findings.”

And while the 20-percentage-point drop in bone scans was significant by Fisher’s Exact Test (one-tailed), it is modest, suggesting other factors at play that require more study, investigators said.

Reinforcing the message might also help. The intervention was designed to be “minimally intrusive,” investigators said, and while compelling, might only produce modest changes if only done once. Accordingly, investigators plan to again gently nudge physicians and physician assistants at the Philadelphia VA in an effort to further reduce use of bone scans.

Ramping up to a more intrusive strategy, such as providing default options-the option that happens if no other choice is made-could have a stronger impact. Dr. Ojerholm has previously published on the potential of using default options to improve quality and value across the continuum of cancer care(J Clin Oncol 2016; 1844-7).

Also see: How do height, adiposity affect prostate Ca risk?

These findings are timely and potentially relevant, given that the rate of bone scans for patients with low-risk prostate cancer is now a specialty-specific quality measure for oncologists and urologists under the Medicare Access and CHIP Reauthorization Act (MACRA) final rule, released in October 2016.

VA hospitals, such as the one in this study, aren't affected by MACRA, and the present study was started prior to the MACRA regulations being finalized, so it wasn't intentionally driven by any specific quality indicators. However, “Many practices could start being penalized for overuse of bone scans in the future,” Dr. Ojerholm noted. “Based on this study, they could consider our intervention as one way to reduce their bone scan use.”

Although cost analysis wasn’t part of Dr. Ojerholm’s investigation, the cost savings of eliminating unnecessary bone scans is potentially substantial. A study of the Surveillance, Epidemiology, and End Results-Medicare database found that one-third to one-half of patients diagnosed with low- or intermediate-risk prostate cancer between 2004 and 2007 received bone scans, resulting in an $11 million bill paid by Medicare annually(Int J Radiat Oncol Biol Phys 2014; 89:243-8).