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Background Although cancer mortality has been decreasing since 1991, many cancers are still not detected until later stages with poorer outcomes. Screening for early-stage cancer can save lives because treatments are generally more effective at earlier than later stages of disease. Evidence of the aggregate benefits of guideline-recommended single-site cancer screenings has been limited. This article assesses the benefits in terms of life-years gained and associated value from major cancer screening technologies in the United States. Methods A mathematical model was built to estimate the aggregate benefits of screenings for breast, colorectal, cervical, and lung cancer over time since the start of US Preventive Services Task Force (USPSTF) recommendations. For each type, the full potential benefits under perfect adherence and the benefits considering reported adherence rates were estimated. The effectiveness of each screening technology was abstracted from published literature on the life-years gained per screened individual. The number of individuals eligible for screening per year was estimated using US Census data matched to the USPSTF recommendations, which changed over time. Adherence rates to screening protocols were based on the National Health Interview Survey results with extrapolation. Results Since initial USPSTF recommendations, up to 417 million people were eligible for cancer screening. Assuming perfect adherence to screening recommendations, the life-years gained from screenings are estimated to be 15.5–21.3 million (2.2–4.9, 1.4–3.6, 11.4–12.3, and 0.5 million for breast, colorectal, cervical, and lung cancer, respectively). At reported adherence rates, combined screening has saved 12.2–16.2 million life-years since the introduction of USPSTF recommendations, ~ 75% of potential with perfect adherence. These benefits translate into a value of $8.2-$11.3 trillion at full potential and $6.5-$8.6 trillion considering current adherence. Therefore, single-site screening could have saved an additional 3.2–5.1 million life-years, equating to $1.7-$2.7 trillion, with perfect adherence. Conclusions Although gaps persist between the full potential benefit and benefits considering adherence, existing cancer screening technologies have offered significant value to the US population. Technologies and policy interventions that can improve adherence and/or expand the number of cancer types tested will provide significantly more value and save significantly more patient lives.

Health care spending varies widely across hospital referral regions (HRRs), which comprise many smaller hospital service areas (HSAs). High-spending HRRs often include low-spending HSAs, raising questions about the appropriateness of payment reforms that target HRRs. A substantial body of evidence has emerged highlighting wide geographic variation in health care spending that is not driven by patient characteristics and is not associated with the quality of care or patient outcomes. 1 – 7 In light of this evidence, many policy proposals suggest targeting high-spending areas for lower Medicare payments or other coverage constraints, with a focus on areas such as the hospital referral regions (HRRs) described in the Dartmouth Atlas of Health Care. 1 These policies are predicated on the idea that there is a system-level component driving some areas to have high utilization and others low. The effectiveness . . .

Increasing the use of high-value medical services and reducing the use of services with little or no clinical value are key goals for efficient health systems. Yet encouraging the use of high-value services may unintentionally affect the use of low-value services. We examined the likelihood of high- and low-value service use in the first two years after an insurance benefit change in 2011 for one state's employees that promoted use of high-value preventive services. In the intervention group, compared to a control sample with stable benefit plans, in year 1 the likelihood of high-value service use increased 11.0 percentage points, and the likelihood of low-value service use increased 7.9 percentage points. For that year we associated 74 percent of the increase in high-value services and 57 percent of the increase in low-value services with greater use of preventive visits. Our results imply that interventions aimed at increasing receipt of high-value preventive services can cause spillovers to low-value services and should include deterrents to low-value care as implemented in later years of this program.

The authors of this editorial highlight some of the myths surrounding complex care management, identify areas where research could be most informative, and recommend best next steps in developing effective and efficient complex care management programs.

Cascades of care are common and can lead to significant harms for patients, clinicians, and the health care system at large. In this commentary, we argue that there are 2 ways to reduce cascades: decrease the use of unnecessary services that often initiate cascades (ie, close the floodgates) and mitigate cascades once they begin (ie, slow the flow through the floodgates). So far, most efforts to address cascades have focused on identifying, measuring, and educating clinicians on low-value services, with only modest success. We explore potential solutions for both closing the floodgates and slowing a cascade once the floodgates have been opened, including information to assist patients and clinicians in making better decisions, relationships that enable shared decision-making, and policy changes. Ultimately, reducing cascades while maintaining our commitment to high-quality care requires equipping patients and clinicians with the information, tools, and support needed to embrace uncertainty.

Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown. To assess national trends in low-value care use and spending. In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020. Being enrolled in fee-for-service Medicare for a period of time, in years. The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation. Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level. This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.

Introduction: Asian Americans have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups. Given the importance of early detection and subsequent treatment in improving survival, this study examines adherence to first-time multitarget stool DNA (mt-sDNA) testing among Asian American patients. Methods: This retrospective study linked two data sources: Komodo Research Data + MapEnhance Komodo Lab database and the Exact Sciences Laboratories database. Asian American’s 45 years and older who were first-time users of mt-sDNA testing between 2017 and 2023, with continuous insurance enrollment for two years, were included. Adherence to mt-sDNA testing was analyzed using descriptive statistics and logistic regression to identify factors associated with adherence. Results: The final sample included 336 288 Asian American patients, primarily covered by commercial insurance (70.3%), aged 50-75 years (80.7%), female (56.5%), living in metropolitan areas (95.4%), and under the care of a primary care physician (74.9%). Overall adherence to mt-sDNA testing was 70.9%, with significant variation by payer type ranging from 60.7% for Medicaid to 72.2% for Medicare (P < 0.0001). Overall adherence rates were approximately 70% across all age groups, sexes, and geographic regions but were notably high among gastroenterology (GI) provider patients (81.6%) and those receiving full digital outreach (via both SMS and email) (72.8%). Logistic regression identified several significant predictors of adherence: older age, males, coverage by commercial insurance, residing outside metropolitan areas, seeing GI providers, receiving digital outreach via SMS or both SMS and email, and preferring English. Conclusion: This study found that Asian American patients that were first-time users of mt-sDNA testing had high adherence rates. However, significant disparities existed within this population based on payer type and sociodemographic factors. Targeted outreach strategies are essential to reduce barriers and improve CRC screening uptake, ultimately reducing the burden of CRC in the Asian American population. Plain Language Summary This study looked at how well Asian Americans followed through with at-home mt-sDNA tests for colon cancer screening. Researchers used data from a large database of patient, focusing on those who were using the test for the first time. Overall, about 71% of patients completed the test; however, those with Medicaid had the lowest adherence rates (61%). In addition, disparities in adherence persisted across different payer types, sociodemographic groups, and geographic regions. Targeted intervention strategies are warranted to address disparities in colon cancer screening and ensure adherence to mt-sDNA testing, as they are crucial for the early detection and treatment of colon cancer.

Real-world adherence to colorectal cancer (CRC) screening strategies is imperfect. The CRC-AIM microsimulation model was used to estimate the impact of imperfect adherence on the relative benefits and burdens of guideline-endorsed, stool-based screening strategies. Predicted outcomes of multi-target stool DNA (mt-sDNA), fecal immunochemical tests (FIT), and high-sensitivity guaiac-based fecal occult blood tests (HSgFOBT) were simulated for 40-year-olds free of diagnosed CRC. For robustness, imperfect adherence was incorporated in multiple ways and with extensive sensitivity analysis. Analysis 1 assumed adherence from 0%-100%, in 10% increments. Analysis 2 longitudinally applied real-world first-round differential adherence rates (base-case imperfect rates = 40% annual FIT vs 34% annual HSgFOBT vs 70% triennial mt-sDNA). Analysis 3 randomly assigned individuals to receive 1, 5, or 9 lifetime (9 = 100% adherence) mt-sDNA tests and 1, 5, or 9 to 26 (26 = 100% adherence) FIT tests. Outcomes are reported per 1000 individuals compared with no screening. Each screening strategy decreased CRC incidence and mortality versus no screening. In individuals screened between ages 50-75 and adherence ranging from 10%a-100%, the life-years gained (LYG) for triennial mt-sDNA ranged from 133.1-300.0, for annual FIT from 96.3-318.1, and for annual HSgFOBT from 99.8-320.6. At base-case imperfect adherence rates, mt-sDNA resulted in 19.1% more LYG versus FIT, 25.4% more LYG versus HSgFOBT, and generally had preferable efficiency ratios while offering the most LYG. Completion of at least 21 FIT tests is needed to reach approximately the same LYG achieved with 9 mt-sDNA tests. Adherence assumptions affect the conclusions of CRC screening microsimulations that are used to inform CRC screening guidelines. LYG from FIT and HSgFOBT are more sensitive to changes in adherence assumptions than mt-sDNA because they require more tests be completed for equivalent benefit. At imperfect adherence rates, mt-sDNA provides more LYG than FIT or HSgFOBT at an acceptable tradeoff in screening burden.

Kim et al discuss whether COVID-19 could help set a path to improved health care efficiency. How the health care system will respond to the ongoing pandemic and its aftermath remains unclear. During Mar 2020, the frequency of all routine cancer screenings nose-dived, regardless of clinical benefit. What is certain is that a large and rapid infusion of funds is necessary to support substantial unmet clinical demand and to restore the financial footing of clinicians and hospitals. A multipronged strategy that aligns provider-facing incentives and consumer-facing incentives is warranted to ensure that a greater proportion of health care spending is dedicated to high-value care that improves health and a lower proportion to low-value care that produces no or little clinical benefit.