title: Variation in the Cost of Managing Actinic Keratosis.
abstract: 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.
  
  
  
  To evaluate geographic variation in health care cost for management of AKs and the association with patient-related and health-related factors.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
authors.forename: Joslyn S
authors.initials: JS
authors.lastname: Kirby
authors.affiliation: Penn State College of Medicine, Hershey, Pennsylvania.
authors.forename: Tanner
authors.initials: T
authors.lastname: Gregory
authors.affiliation: Department of Public Health Sciences, Penn State-Hershey, Hershey, Pennsylvania.
authors.forename: Guodong
authors.initials: G
authors.lastname: Liu
authors.affiliation: Department of Public Health Sciences, Penn State-Hershey, Hershey, Pennsylvania.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Leslie
authors.affiliation: Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Miller
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D055623:Keratosis, Actinic / Q000191:economics / Q000628:therapy*; D008297:Male; D006278:Medicare; D008875:Middle Aged; D012189:Retrospective Studies; D012878:Skin Neoplasms / Q000453:epidemiology*; D014466:Ultraviolet Rays / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology