Value Judgments in Diagnostic Imaging for Prostate Cancer: A Paradox in Healthcare Reform

摘要

As federal agencies work to reduce the cost of healthcare delivery in this country, the high cost of cancer therapy-which is delivered primarily to Medicare recipients-is being especially targeted. Beyond safety and efficacy, the value of medical procedures will increasingly need to be justified to payors, who for more than 60% of Americans is now the federal government. One of six chief obstacles to affordable, high-quality healthcare that have been identified by the Institute of Medicine (IOM) is the "overuse and misuse of medical resources and care that do not align with clinical practice guidelines." The IOM has indicated that many screening interventions, especially imaging technologies, are often overused or adopted before clinical benefits have been proven. In the same report that identified obstacles to affordable high-quality care, the IOM suggested four criteria for assessing value in medical care: Increased survival. Reduced side effects. Improved quality of life. Reduced costs. Consistent with the goals of the Patient Protection and Affordable Care Act (PPACA), the IOM recommended that any treatment or procedure, in order to be deemed "of value," should demonstrate at least one of these four benefits. The 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen screening applied the IOM approach to assessing value in healthcare. The potential harms from screening evaluations and from treatment of indolent disease were thought by the USPSTF to far outweigh any potential benefit from earlier detection, and watchful waiting was determined to be an acceptable alternative to radical prostatectomy in men 65 years of age and older. Previously, the strategy in cancer screening was to identify patients with cancer and determine the most appropriate and effective treatment for each. Now the emphasis is on avoiding the potential harms associated with diagnostic procedures, such as biopsies, and treatment for asymptomatic disease, especially in patients with multiple comorbidities.