Accountable Care Organizations linked to modest increase in appropriate cancer screening

1. Enrollment in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACO) was associated with a decrease in breast cancer screening, increase in colorectal cancer screening, and decreased prostate cancer screening, reflecting more appropriate utilization of screening tests.

2. Changes in breast and colon cancer screening were strongly influenced by participant age.

Evidence Rating Level: 3 (Average)       

Study Rundown: Efforts to improve the appropriateness of healthcare resources and limit the potential harm linked to use of diagnostic or screening tests with uncertain benefit have led to the introduction of Accountable Care Organizations (ACOs). Early studies have demonstrated that participation with ACOs can lower the rates of low-value care. This study sought to evaluate the changes in cancer screening following ACO introduction. The study found that, when compared to contemporary changes in non-ACO patients, ACO participation was linked to decreased rates of breast cancer screening, increased colorectal cancer screening, and a reduction in prostate cancer screening. This reflected better utilization of screening tests. The changes in screening rates were linked to participant age for breast and colon cancer, but not for prostate cancer screening.

The study demonstrates a reduction in low-value screening for breast cancer in older women; and an increase in high-value screening for colorectal cancer in younger patients. The strengths of the study included the large sample size, reflecting both before and after ACO implementation. The main limitations of the study included the reliance on voluntary participation in MSSP, and reliance on claims-based data which may misclassify diagnostic or screening purposes for tests.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review

In-Depth [retrospective cohort]: This study used data from Medicare enrollment and claims from 2006-2013, and included only those adults who were 65-years or older, and enrolled in Medicare Parts A or B. ACO attribution was based off the 2013 Shared Savings Beneficiary file, with a 20% randomly selected sample. Cancer screening was determined using inpatient, outpatient, and carrier claims. Data on comorbidities was used to model projected 5-year survival. Cancer screening was deemed not appropriate if used in participants older then 75 years, or in those in the lowest quartile for predicted 5-year overall survival.

There were no significant difference in baseline demographics for the 40,010,199 person-years of non-ACO participants and the 13,460,798 person years of ACO participants. The adjusted rate of decline in screening for breast cancer was 0.79% (P < .001), and was influenced by age (P<0.001). Colon cancer screening was increased with an adjusted rate of 0.24% (P = .03), also influenced by participant age (P<0.001). Prostate cancer adjusted screening rates decreased by 1.20%.

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