Variation in the Cost of Managing Actinic Keratosis

Abstract

Importance: Actinic keratosis (AK), a skin growth induced by ultraviolet light exposure, requires chronic management because a small proportion can progress into squamous cell skin cancer. Spending for AK management was more than $1 billion in 2004. Investigating geographic variation in AK spending presents an opportunity to decrease waste or recoup excess spending.

Objective: To evaluate geographic variation in health care cost for management of AKs and the association with patient-related and health-related factors.

Design, setting, and participants: This retrospective cohort study was performed using data from the MarketScan medical claims database of 488 324 continuously enrolled members with 2 or more claims for AK. Data from January 1, 2008, to December 31, 2012, was used.

Main outcomes and measures: Annual costs of care were calculated for outpatient visits, AK destruction, and medications for AKs, and the total of these components. Costs were adjusted for inflation to 2014 US dollars. To display cost variation, we calculated the ratio of mean cost in the highest quintile (Q5) relative to the mean in the lowest quintile (Q1), or the Q5:Q1 ratio; Q5:Q1 ratios were adjusted based on age, sex, history of nonmelanoma skin cancer, US geographic region, and population density (metropolitan statistical area).

Results: Overall, data from 488 324 continuously enrolled members (mean [SD] age, 53.1 [7.5] years; 243 662 women) with 2 or more claims for AK were included. Overall, patients had 1 085 985 claims related to AK, and dermatologists accounted for 71.0% of claims. The 2-year total cost was $111.5 million, with $52.4 million in 2011 and $59.1 million in 2012. The unadjusted Q5:Q1 ratios for total annual cost per patient ranged from 9.49 to 15.10. Adjusted ratios ranged from 1.72 to 1.80.

Conclusions and relevance: There is variation in AK management cost within and between regions. This is not fully explained by differences in patient characteristics such as age, sex, or comorbidities. The annual cost for 10 common conditions from Medicare had lower Q5:Q1 ratios that ranged from 1.33 (joint degeneration of back/neck) to 1.69 (chronic sinusitis) when compared with 1.72 to 1.80 for AKs. This suggests an opportunity to investigate and improve the value of health care delivery in the management of AKs.

Figure 1.. Allocation of Years of Study Data

A 5-year study period was used (January 2008 to December 2012). The first 3 years of data were sequestered and used to determine whether patients had a diagnosis of nonmelanoma skin cancer (NMSC). The latter 2 years of data were used to determine annual health care usage and cost related to actinic keratosis.

Figure 2.. Adjusted Mean Annual Actinic Keratosis Costs Across Quintiles

The adjusted mean annual costs for patients in a metropolitan statistical area are shown for patients from all regions in the metropolitan statistical area, and a metropolitan statistical area is defined as a geographical area with a relatively high population density and economic ties throughout the area. To display cost variation, we calculated the ratio of mean cost in the highest quintile (Q5) relative to the mean in the lowest quintile (Q1), or the Q5:Q1 ratio. Total cost includes the categories of office visits plus cryotherapy and/or prescription topical medications.