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Intended Versus Inferred Management After PET For Cancer Restaging: Analysis of Medicare Claims Linked to a Coverage With Evidence Development Registry

Hillner, Bruce E. MD*; Tosteson, Tor D. ScD; Tosteson, Anna N. A. ScD; Wang, Qianfei MS; Song, Yunjie PhD; Onega, Tracy PhD; Hanna, Lucy G. MA; Siegel, Barry A. MD§

doi: 10.1097/MLR.0b013e318287d860
Original Articles

Background: The National Oncologic PET Registry (NOPR) ascertained changes in the intended management of cancer patients using questionnaire data obtained before and after positron emission tomography (PET) under Medicare’s coverage with evidence development policy.

Objective: To assess the concordance between intended care plans and care received as ascertained through administrative claims data.

Research Design: Analysis of linked data of NOPR participants from 2006 to 2008 and their corresponding Medicare claims.

Subjects: Consenting patients aged older than 65 years having their first PET for restaging of bladder, kidney, ovarian, pancreas, prostate, small cell lung, or stomach cancer.

Measures: Agreement (positive predictive values and κ) between NOPR post-PET intended management plans for treatment (systemic therapy, radiotherapy, surgery, or combinations), biopsy, or watching as compared to claims-inferred care 30 days after PET.

Results: A total of 8460 patients with linked data were assessed. A total of 43.5% had metastatic disease and 45.3% had treatment planned (predominantly systemic therapy only), 11.1% biopsy and 43.5% watching. Claims-confirmed intended plans (positive predictive value) for single-mode systemic therapy in 62.0%, radiation in 66.0%, surgery in 45.6%, and biopsy in 55.7%. A total of 25.7% of patients with a plan of watching had treatment claims. By cancer type, κ ranged for systemic therapy only from 0.17 to 0.40 and for watching from 0.21 to 0.41. Agreement rates varied by cancer types but were minimally associated with patient age, performance status, comorbidity, or stage.

Conclusions: Among elderly cancer patients undergoing PET for restaging, there was moderate concordance between their physicians’ planned management and claims-inferred actions within a narrow time window. When higher accuracy levels are required in future coverage with evidence development studies, alternative designs will be needed.

Supplemental Digital Content is available in the text.

*Department of Internal Medicine and the Massey Cancer Center, Virginia Commonwealth University, Richmond, VA

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH

Center for Statistical Sciences, Brown University, Providence, RI

§Division of Nuclear Medicine, Mallinckrodt Institute of Radiology and Siteman Cancer Center, Washington University School of Medicine, St Louis, MO

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by National Cancer Institute Grand Opportunity Award RC2CA148259 and the Academy for Molecular Imaging (BEH). Funding for development of the NOPR was provided by the Academy for Molecular Imaging, but the registry is otherwise self-supported by the fees paid by participating PET facilities.

The authors declare no conflict of interest.

Reprints: Bruce E. Hillner, MD, Department of Internal Medicine and the Massey Cancer Center, Virginia Commonwealth University, 1101 E. Marshall Street, Richmond, VA 23298. E-mail:

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.