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Title: Potentially inappropriate cancer screening patterns among community-dwelling older adults 

Author: Jamie Kwak, BS; Annie W Yang, MD; Mei Leng, MS; Chi-Hong Tseng, PhD; Dan Ly, MD, PhD; Catherine Sarkisian, MD, MSPH; Cheryl Damberg, PhD; Nina T Harawa, PhD, MPH; A. Mark Fendrick, MD; John N. Mafi, MD, MPH 

Keywords: low-value care, dementia, cancer screenings, older adults, quality of care 

Background: Older adults with cognitive impairment are vulnerable to the harms of inappropriate cancer screenings because they offer limited health benefits, raise costs, and lead to risky downstream procedures. Although large efforts have been made to reduce low-value cancer screenings, it is unknown if screening rates among older adults with cognitive impairment or dementia have changed over time, in the context of greater guideline dissemination and awareness of this issue.  

Methods: Using nationally representative data from the Health Retirement Study (HRS) linked to Medicare fee-for-service claims (January 1, 2010-December 31, 2021), we conducted a retrospective cohort study to examine trends in utilization and spending of potentially inappropriate cancer screenings among community-dwelling older adults with and without cognitive impairment (MCI) and dementia between 2010-2021. We used multivariable mixed regression models to estimate changes in rates of cancer screenings (any, indicated, potentially inappropriate) over time.  

Results: We identified 27,027 HRS participants, representing approximately 129 million Medicare beneficiaries during the study period. Nearly 2 in 3 older adults eligible for a potentially inappropriate cancer screening received a screening test, most commonly for breast and prostate cancer. Lower rates of potentially inappropriate screening were associated with older age, cognitive impairment, and socioeconomic disadvantage (LIS-Dual).  The rate of potentially inappropriate composite cancer screenings did not show a significant change from 2010 to 2021 (-0.03, p=0.10), but the rates of indicated cancer screenings showed a significant decline (-0.06, p<0.01). Potentially inappropriate screenings cost $7.2 billion during the study period. Although costs for indicated screenings also modestly declined over time, expenditures for potentially inappropriate screenings increased, showing a shift towards more unnecessary spending. 

Conclusion: In this nationally representative analysis, potentially inappropriate cancer screenings among older adults with cognitive impairment have not substantively declined despite increased awareness and guidelines over the past decade. Stronger policy measures, such as financial incentives, are needed to curb inappropriate screenings and improve the value of care delivered to older Americans.