Use of imaging and biomarker tests for posttreatment care of early-stage breast cancer survivors

BACKGROUND: The American Society of Clinical Oncology (ASCO) recently released a “Top Five” list of opportunities to improve the quality of cancer care.Item four on the list advises against using advanced imaging and biomarkers for surveillance in breast cancer patients treated with curative intent. We examined concordance with ASCO follow-up care guidelines for breast cancer survivors treated at an academic medical center. METHODS: Claims data and medical records were reviewed and abstracted for early stage breast cancer survivors starting one year post diagnosis. A trained abstractor classified imaging tests as diagnostic or surveillance. Proportions and frequencies were generated for receipt of services. Multilevel logistic regression was used to estimate factors associated with receiving recommended and non-recommended services and biomarker tests. RESULTS: Records were available for 258 patients. Mean age at diagnosis was 58 (SD 13), mean time since diagnosis was 6 years (SD 2), 71% were stage 0/1. Only 47% of the sample received a mammogram within one year of diagnosis. Fifty-five percent of the sample received at least one non-recommended imaging service for surveillance purposes. Seventy-seven percent of the sample received at least one non-recommended biomarker test. Regression results indicate that main treating physician, advanced disease stage, younger age at diagnosis, and greater number of years since diagnosis were associated with receiving non-recommended services for surveillance. CONCLUSIONS: Use of non-recommended services for surveillance occurs frequently among early stage survivors. There are opportunities to increase use of guideline concordant post-treatment care for breast cancer survivors

How can bedside rationing be justified despite coexisting inefficiency? The need for 'benchmarks of efficiency'

Imperfect efficiency in healthcare delivery is sometimes given as a justification for refusing to ration or even discuss how to pursue fair rationing. This paper aims to clarify the relationship between inefficiency and rationing, and the conditions under which bedside rationing can be justified despite coexisting inefficiency. This paper first clarifies several assumptions that underlie the classification of a clinical practice as being inefficient. We then suggest that rationing is difficult to justify in circumstances where the rationing agent is or should be aware of and contributes to clinical inefficiency. We further explain the different ethical implications of this suggestion for rationing decisions made by clinicians. We argue that rationing is more legitimate when sufficient efforts are undertaken to decrease inefficiency in parallel with efforts to pursue unavoidable but fair rationing. While the qualifier ‘sufficient’ is crucial here, we explain why ‘sufficient efforts’ should be translated into ‘benchmarks of efficiency’ that address specific healthcare activities where clinical inefficiency can be decreased. Referring to recent consensus papers, we consider some examples of specific clinical situations where improving clinical inefficiency has been recommended and consider how benchmarks for efficiency might apply. These benchmarks should state explicitly how much inefficiency shall be reduced in a reasonable time range and why these efforts are ‘sufficient’. Possible strategies for adherence to benchmarks are offered to address the possibility of non-compliance