26
|
Welch HG, Skinner JS, Schroeck FR, Zhou W, Black WC. Regional Variation of Computed Tomographic Imaging in the United States and the Risk of Nephrectomy. JAMA Intern Med 2018; 178:221-227. [PMID: 29279887 PMCID: PMC5838611 DOI: 10.1001/jamainternmed.2017.7508] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE While computed tomography (CT) represents a tremendous advance in diagnostic imaging, it also creates the problem of incidental detection-the identification of tumors unrelated to the clinical symptoms that initiate the test. OBJECTIVE To determine the geographic variation in the United States in CT imaging and the corresponding association with one of the most consequential sequelae of incidental detection: nephrectomy. DESIGN, SETTING, AND PARTICIPANTS This study is a cross-sectional analysis of age-, sex-, and race-adjusted Medicare data (January 2010-December 2014) from 306 hospital referral regions (HRRs) in the United States and includes information from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years. EXPOSURES Regional CT risk (ie, the proportion of the population receiving either a chest or abdominal CT over 5 years). MAIN OUTCOMES AND MEASURES Five-year risk of nephrectomy (partial or total). RESULTS Data from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years were gathered and illustrate that 43% of Medicare beneficiaries age 65 to 85 years received either a chest or abdominal CT from January 2010 to December 2014. This risk varied across the HRRs, ranging from 31% in Santa Cruz, California, to 52% in Sun City, Arizona. Increased regional CT risk was associated with a higher nephrectomy risk (r = 0.38; 95% CI, 0.28-0.47), particularly among HRRs with more than 50 000 beneficiaries (r = 0.47; 95% CI, 0.31-0.61). After controlling for HRR adult smoking rates, imaging an additional 1000 beneficiaries was associated with 4 additional nephrectomies (95% CI, 3-5). Case-fatality rates for those who underwent nephrectomy were 2.1% at 30 days and 4.3% at 90 days. CONCLUSIONS AND RELEVANCE Fee-for-service Medicare beneficiaries are commonly exposed to CT imaging. Those residing in high-scanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses. Additional surgery should be considered one of the risks of excessive CT imaging.
Collapse
|
27
|
Schroeck FR, Patterson OV, Alba PR, Pattison EA, Seigne JD, DuVall SL, Robertson DJ, Sirovich B, Goodney PP. Development of a Natural Language Processing Engine to Generate Bladder Cancer Pathology Data for Health Services Research. Urology 2017; 110:84-91. [PMID: 28916254 PMCID: PMC5696035 DOI: 10.1016/j.urology.2017.07.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/13/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To take the first step toward assembling population-based cohorts of patients with bladder cancer with longitudinal pathology data, we developed and validated a natural language processing (NLP) engine that abstracts pathology data from full-text pathology reports. METHODS Using 600 bladder pathology reports randomly selected from the Department of Veterans Affairs, we developed and validated an NLP engine to abstract data on histology, invasion (presence vs absence and depth), grade, the presence of muscularis propria, and the presence of carcinoma in situ. Our gold standard was based on an independent review of reports by 2 urologists, followed by adjudication. We assessed the NLP performance by calculating the accuracy, the positive predictive value, and the sensitivity. We subsequently applied the NLP engine to pathology reports from 10,725 patients with bladder cancer. RESULTS When comparing the NLP output to the gold standard, NLP achieved the highest accuracy (0.98) for the presence vs the absence of carcinoma in situ. Accuracy for histology, invasion (presence vs absence), grade, and the presence of muscularis propria ranged from 0.83 to 0.96. The most challenging variable was depth of invasion (accuracy 0.68), with an acceptable positive predictive value for lamina propria (0.82) and for muscularis propria (0.87) invasion. The validated engine was capable of abstracting pathologic characteristics for 99% of the patients with bladder cancer. CONCLUSION NLP had high accuracy for 5 of 6 variables and abstracted data for the vast majority of the patients. This now allows for the assembly of population-based cohorts with longitudinal pathology data.
Collapse
|
28
|
Schroeck FR, Sirovich B, Seigne JD, Robertson DJ, Goodney PP. Assembling and validating data from multiple sources to study care for Veterans with bladder cancer. BMC Urol 2017; 17:78. [PMID: 28877694 PMCID: PMC5585934 DOI: 10.1186/s12894-017-0271-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 08/31/2017] [Indexed: 11/17/2022] Open
Abstract
Background Despite the high prevalence of bladder cancer, research on optimal bladder cancer care is limited. One way to advance observational research on care is to use linked data from multiple sources. Such big data research can provide real-world details of care and outcomes across a large number of patients. We assembled and validated such data including (1) administrative data from the Department of Veterans Affairs (VA), (2) Medicare claims, (3) data abstracted by tumor registrars, (4) data abstracted via chart review from the national electronic health record, and (5) full text pathology reports. Methods Based on these combined data, we used administrative data to identify patients with newly diagnosed bladder cancer who received care in the VA. To validate these data, we first compared the diagnosis date from the administrative data to that from the tumor registry. Second, we measured accuracy of identifying bladder cancer care in VA administrative data, using a random chart review (n = 100) as gold standard. Lastly, we compared the proportion of patients who received bladder cancer care among those who did versus did not have full text bladder pathology reports available, expecting that those with reports are significantly more likely to receive care in VA. Results Out of 26,675 patients, 11,323 (42%) had tumor registry data available. 90% of these patients had a difference of 90 days or less between the diagnosis dates from administrative and registry data. Among 100 patients selected for chart review, 59 received bladder cancer care in VA, 58 of which were correctly identified using administrative data (sensitivity 98%, specificity 90%). Receipt of bladder cancer care was substantially more common among those who did versus did not have bladder pathology available (96% vs. 43%, p < 0.001). Conclusion Merging administrative with electronic health record and pathology data offers new possibilities to validate the use of administrative data in bladder cancer research. Electronic supplementary material The online version of this article (10.1186/s12894-017-0271-x) contains supplementary material, which is available to authorized users.
Collapse
|
29
|
Koo K, Zubkoff L, Sirovich BE, Goodney PP, Robertson DJ, Seigne JD, Schroeck FR. The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making. Urology 2017; 108:122-128. [PMID: 28739405 DOI: 10.1016/j.urology.2017.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC). METHODS Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence. RESULTS Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care. CONCLUSION Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.
Collapse
|
30
|
Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Schroeck FR, Bekelman JE, Kahn JM, Nelson JB, Barnato AE. The early adoption of intensity-modulated radiotherapy and stereotactic body radiation treatment among older Medicare beneficiaries with prostate cancer. Cancer 2017; 123:2945-2954. [PMID: 28301689 DOI: 10.1002/cncr.30574] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/15/2016] [Accepted: 12/23/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several new prostate cancer treatments have emerged since 2000, including 2 radiotherapies with similar efficacy at the time of their introduction: intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT). The objectives of this study were to compare their early adoption patterns and identify factors associated with their use. METHODS By using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, patients who received radiation therapy during the 5 years after IMRT introduction (2001-2005) and the 5 years after SBRT introduction (2007-2011) were identified. The outcome of interest was the receipt of new radiation therapy (ie, IMRT or SBRT) compared with the existing standard radiation therapies at that time. The authors fit a series of multivariable, hierarchical logistic regression models accounting for patients nested within health service areas to examine the factors associated with the receipt of new radiation therapy. RESULTS During 2001 to 2005, 5680 men (21%) received IMRT compared with standard radiation (n = 21,555). Men who received IMRT were older, had higher grade tumors, and lived in more populated areas (P < .05). During 2007 through 2011, 595 men (2%) received SBRT compared with standard radiation (n = 28,255). Men who received ng SBRT were more likely to be white, had lower grade tumors, lived in more populated areas, and were more likely to live in the Northeast (P < .05). Adjusting for cohort demographic and clinical factors, the early adoption rate for IMRT was substantially higher than that for SBRT (44% vs 4%; P < .01). CONCLUSIONS There is a stark contrast in the adoption rates of IMRT and SBRT at the time of their introduction. Further investigation of the nonclinical factors associated with this difference is warranted. Cancer 2017;123:2945-54. © 2017 American Cancer Society.
Collapse
|
31
|
Reinstatler L, Schroeck FR, Hyams ES. Ensuring Evidence-Based Practice: A Study of Factors Associated with Nonuse of American Urological Association Guidelines. UROLOGY PRACTICE 2017; 4:25-29. [PMID: 37592609 DOI: 10.1016/j.urpr.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Evidence-based guidelines are published by the AUA (American Urological Association) to improve the quality and consistency of urological care. The 2014 AUA Census reported a unique field regarding provider utilization of AUA Guidelines. We sought to identify factors associated with nonuse of AUA Guidelines to understand how education and dissemination of these guidelines might be improved. METHODS Using 2014 AUA Census data providers were stratified based on self-reported use or nonuse of AUA Guidelines. Bivariate analyses and multivariable logistic regression analysis were performed to identify factors associated with nonuse. Post-stratification weights were applied to calculate national estimates with SAS®, version 9.4. RESULTS The 2,202 survey respondents represented 11,680 practicing urologists. AUA guideline use was reported by 95.0% of the weighted population. There was no significant difference in utilization based on gender, race, country of origin, practice type or fellowship completion. After controlling for other variables urologists who reported practicing in a rural area were more likely to be nonusers (OR 1.06, 95% CI 1.03-1.09). Additionally, urologists who had been practicing longer were less likely to utilize guidelines compared with those earlier in the career (practicing 10 to 20 years OR 1.15, 95% CI 1.10-1.21 and more than 20 years OR 1.13, 95% CI 1.09-1.18, p <0.05). CONCLUSIONS Despite continued publication and dissemination of AUA Guidelines about 5% of urologists do not utilize guidelines. Later career status and rural geography were associated with nonuse. These data may inform efforts to improve dissemination and education regarding evidence-based practice.
Collapse
|
32
|
Schroeck FR, Pattison EA, Denhalter DW, Patterson OV, DuVall SL, Seigne JD, Robertson DJ, Sirovich B, Goodney PP. Early Stage Bladder Cancer: Do Pathology Reports Tell Us What We Need to Know? Urology 2016; 98:58-63. [PMID: 27590253 DOI: 10.1016/j.urology.2016.07.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess a large national sample of bladder cancer pathology reports to determine if they contained the components necessary for clinical decision-making. METHODS We examined a random sample of 507 bladder cancer pathology reports from the national Department of Veterans Affairs Corporate Data Warehouse to assess whether each included information on the 4 report components explicitly recommended by the College of American Pathologists' protocol for the examination of such specimens: histology, grade, presence vs absence of muscularis propria in the specimen, and microscopic extent. We then assessed variation in the proportion of reports lacking at least 1 component across Department of Veterans Affairs facilities. RESULTS One hundred eight of 507 reports (21%) lacked at least 1 of the 4 components, with microscopic extent and presence vs absence of muscularis propria in the specimen most commonly missing (each in 11% of reports). There was wide variation across facilities in the proportion of reports lacking at least 1 component, ranging from 0% to 80%. CONCLUSION One-fifth of bladder cancer pathology reports lack information needed for clinical decision-making. The wide variation in incomplete report rates across facilities implies that some facilities already have implemented best practices assuring complete reporting whereas others have room for improvement. Future work to better understand barriers and facilitators of complete reporting may lead to interventions that improve bladder cancer care.
Collapse
|
33
|
Herrel LA, Kaufman SR, Yan P, Miller DC, Schroeck FR, Skolarus TA, Shahinian VB, Hollenbeck BK. Health Care Integration and Quality among Men with Prostate Cancer. J Urol 2016; 197:55-60. [PMID: 27423758 DOI: 10.1016/j.juro.2016.07.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The delivery of high quality prostate cancer care is increasingly important for health systems, physicians and patients. Integrated delivery systems may have the greatest ability to deliver high quality, efficient care. We sought to understand the association between health care integration and quality of prostate cancer care. MATERIALS AND METHODS We used SEER-Medicare data to perform a retrospective cohort study of men older than age 65 with prostate cancer diagnosed between 2007 and 2011. We defined integration within a health care market based on the number of discharges from a top 100 integrated delivery system, and compared rates of adherence to well accepted prostate cancer quality measures in markets with no integration vs full integration (greater than 90% of discharges from an integrated system). RESULTS The average man treated in a fully integrated market was more likely to receive pretreatment counseling by a urologist and radiation oncologist (62.6% vs 60.3%, p=0.03), avoid inappropriate imaging (72.2% avoided vs 60.6%, p <0.001), avoid treatment when life expectancy was less than 10 years (23.7% vs 17.3%, p <0.001) and avoid multiple hospitalizations in the last 30 days of life (50.2% vs 43.6%, p=0.001) than when treated in markets with no integration. Additionally, patients treated in fully integrated markets were more likely to have complete adherence to all eligible quality measures (OR 1.38, 95% CI 1.27-1.50). CONCLUSIONS Integrated systems are associated with improved adherence to several prostate cancer quality measures. Expansion of the integrated health care model may facilitate greater delivery of high quality prostate cancer care.
Collapse
|
34
|
Schroeck FR, Sirovich BE. Editorial Comment. Urology 2016; 86:1198-9. [PMID: 26719119 DOI: 10.1016/j.urology.2015.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
35
|
Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Zhang Y, Hollenbeck BK. Technology diffusion and prostate cancer quality of care. Urology 2014; 84:1066-72. [PMID: 25443905 DOI: 10.1016/j.urology.2014.06.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/10/2014] [Accepted: 06/21/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the association of technological capacity with prostate cancer quality of care. Technological capacity was conceptualized as a market's ability to provide prostate cancer treatment with new technology, including robotic prostatectomy and intensity-modulated radiotherapy (IMRT). METHODS In this retrospective cohort study, we used data from the Surveillance, Epidemiology, and End Results-Medicare linked database from 2004 to 2009 to identify men with newly diagnosed prostate cancer (n = 46,274). We measured technological capacity as the number of providers performing robotic prostatectomy or IMRT per population in a health care market. We used multilevel logistic regression analysis to assess the association of technological capacity with receiving quality care according to a set of nationally endorsed quality measures, while adjusting for patient and market characteristics. RESULTS Overall, our findings were mixed with only subtle differences in quality of care comparing high-tech with low-tech markets. High robotic prostatectomy capacity was associated with better adherence to some quality measures, such as avoiding unnecessary bone scans (79.8% vs 73.0%; P = .003) and having follow-up with urologists (67.7% vs 62.6%; P = .023). However, for most measures, neither high robotic prostatectomy nor high-IMRT capacity was associated with significant increases in adherence rates. In fact, for 1 measure (treatment by a high-volume provider), high-IMRT capacity was associated with lower performance (23.4% vs 28.5%; P <.001). CONCLUSION Our findings suggest that new technology is not clearly associated with higher quality of care. To improve quality, more specific efforts will be needed.
Collapse
|
36
|
Zhang Y, Hollenbeck BK, Schroeck FR, Jacobs BL. Managed care and the dissemination of robotic prostatectomy. Surg Innov 2014; 21:566-71. [PMID: 25049319 DOI: 10.1177/1553350614524841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of robotics is unknown. We sought to better understand the relationship between a market's managed-care penetration and the dissemination of robotic prostatectomy. METHODS We used SEER-Medicare data from 2003 through 2007 to identify men ≥66 years of age treated with radical prostatectomy for prostate cancer. We categorized Health Service Areas (HSAs) according to the degree of managed-care penetration (ie, low vs high). We assessed adoption of robotic prostatectomy and utilization among adopting HSAs using Cox proportional-hazards and Poisson regression models, respectively. RESULTS Compared with markets with little managed care, highly penetrated markets had more racial diversity (24% vs 15% nonwhite, P < .01), higher population densities (1987 vs 422 people/square mile, P < .01), and higher median incomes ($49 374 vs $36 236, P < .01). Robotic prostatectomy adoption and utilization increased over time in both HSA categories. Compared with low managed-care markets, those with high managed care adopted robotic prostatectomy more rapidly (eg, probability 0.37 [low] vs 0.52 [high] in 2007; P < .01). However, the postadoption utilization of robotic prostatectomy was constrained in these highly penetrated markets (eg, probability 0.66 [low] vs 0.52 [high] in 2007; P < .01). CONCLUSIONS High managed-care penetration was associated with more rapid robotic prostatectomy adoption. However, once adopted, utilization increased more slowly in these markets. Understanding this paradox is important as more technologies are unveiled in an increasingly cost-conscious health care environment.
Collapse
|
37
|
Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Hollingsworth JM, Shahinian VB, Hollenbeck BK. Regional variation in quality of prostate cancer care. J Urol 2013; 191:957-62. [PMID: 24144685 DOI: 10.1016/j.juro.2013.10.066] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement. MATERIALS AND METHODS For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures. RESULTS Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001). CONCLUSIONS We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement.
Collapse
|
38
|
Schroeck FR, Wei JT. Reply by the authors. Urology 2013; 82:981. [PMID: 24075001 DOI: 10.1016/j.urology.2013.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 11/26/2022]
|
39
|
Jacobs BL, Zhang Y, Schroeck FR, Skolarus TA, Wei JT, Montie JE, Gilbert SM, Strope SA, Dunn RL, Miller DC, Hollenbeck BK. Use of advanced treatment technologies among men at low risk of dying from prostate cancer. JAMA 2013; 309:2587-95. [PMID: 23800935 PMCID: PMC3857348 DOI: 10.1001/jama.2013.6882] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain. OBJECTIVE To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer. DESIGN, SETTING, AND PATIENTS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010. MAIN OUTCOMES AND MEASURES The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both. RESULTS In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001). CONCLUSION AND RELEVANCE Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.
Collapse
|
40
|
Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Miller DC, Weizer AZ, Montgomery JS, Wei JT, Shahinian VB, Hollenbeck BK. Technology diffusion and diagnostic testing for prostate cancer. J Urol 2013; 190:1715-20. [PMID: 23669564 DOI: 10.1016/j.juro.2013.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 01/09/2023]
Abstract
PURPOSE While the dissemination of robotic prostatectomy and intensity modulated radiotherapy may fuel the increased use of prostatectomy and radiotherapy, these new technologies may also have spillover effects related to diagnostic testing for prostate cancer. Therefore, we examined the association of regional technology penetration with the receipt of prostate specific antigen testing and prostate biopsy. MATERIALS AND METHODS In this retrospective cohort study we included 117,857 men 66 years old or older from the 5% sample of Medicare beneficiaries living in Surveillance, Epidemiology and End Results (SEER) areas from 2003 to 2007. Regional technology penetration was measured as the number of providers performing robotic prostatectomy or intensity modulated radiotherapy per population in a health care market, ie hospital referral region. We assessed the association of technology penetration with the prostate specific antigen testing rate and prostate biopsy using generalized estimating equations. RESULTS High technology penetration was associated with an increased rate of prostate specific antigen testing (442 vs 425/1,000 person-years, p<0.01) and a similar rate of prostate biopsy (10.1 vs 9.9/1,000 person-years, p=0.69). The impact of technology penetration on prostate specific antigen testing and prostate biopsy was much less than the effect of age, race and comorbidity, eg the prostate specific antigen testing rate per 1,000 person-years was 485 vs 373 for men with only 1 vs 3+ comorbid conditions (p<0.01). CONCLUSIONS Increased technology penetration is associated with a slightly higher rate of prostate specific antigen testing and no change in the prostate biopsy rate. Collectively, our findings temper concerns that adopting new technology accelerates diagnostic testing for prostate cancer.
Collapse
|
41
|
Jacobs BL, Zhang Y, Skolarus TA, Wei JT, Montie JE, Schroeck FR, Hollenbeck BK. Managed care and the diffusion of intensity-modulated radiotherapy for prostate cancer. Urology 2013. [PMID: 23206767 DOI: 10.1016/j.urology.2012.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To better understand associations between managed care penetration in health care markets and the adoption of intensity-modulated radiotherapy (IMRT). METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who were treated with radiotherapy (n = 55,162). We categorized managed care penetration in Health Service Areas (HSAs) as low (<3%), intermediate (3%-10%), and high (>10%), and assessed our main outcomes (ie, probability of IMRT adoption, which is the ability of a health care market to deliver IMRT, and IMRT utilization in HSA markets) using a Cox proportional hazards model and Poisson regression model, respectively. RESULTS Compared with markets with low managed care penetration, populations in highly penetrated HSAs were more racially diverse (25% vs 15% non-white, P <.01), densely populated (2110 vs 145 people/square mile, P <.01), and wealthier (median income, $48,500 vs $31,900, P <.01). The probability of IMRT adoption was greatest in markets with the highest managed care penetration (eg, 0.82 [high] vs 0.72 [low] in 2007, P = .05). Among adopting markets, the use of IMRT increased in all HSA categories. However, relative to markets with low managed care penetration, IMRT use was constrained in markets with the highest penetration (0.69 [high] vs 0.76 [low] in 2007, P <.01). CONCLUSION Markets with higher managed care penetration demonstrated a greater propensity for acquiring IMRT technology. However, after adopting IMRT, more highly penetrated markets had roughly 7% slower growth in IMRT use during the study period. These findings provide insight into the implications of delivery system reforms for cancer-related technologies.
Collapse
|
42
|
Schroeck FR, Zuhlke KA, Siddiqui J, Siddiqui R, Cooney KA, Wei JT. Testing for the recurrent HOXB13 G84E germline mutation in men with clinical indications for prostate biopsy. J Urol 2013; 189:849-53. [PMID: 23036981 PMCID: PMC4193792 DOI: 10.1016/j.juro.2012.09.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 09/25/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE The G84E variant of HOXB13 was recently found to be associated with a significantly increased risk of prostate cancer in a case control study. We estimated the prevalence of this mutation in a clinical population of men at risk for prostate cancer who were scheduled to undergo prostate biopsy. MATERIALS AND METHODS We prospectively collected clinical information and DNA samples from men who underwent diagnostic prostate biopsy between June 2005 and October 2011. We genotyped samples for HOXB13 G84E using the MassARRAY® system. We determined the prevalence of the G84E variant in the overall cohort, among patients with a positive family history and among men age 55 years or younger. RESULTS A total of 1,175 subjects underwent biopsy, of whom 948 had a DNA sample for analysis. The G84E variant was detected in 4 patients (prevalence 0.42%, 95% CI 0.12-1.08), of whom 3 had prostate cancer on biopsy. None of 301 patients with a positive family history (prevalence 0.00%, 95% CI 0.00-1.22) and 1 of 226 patients age 55 years or younger tested positive (prevalence 0.44%, 95% CI 0.01-2.44). CONCLUSIONS The HOXB13 G84E variant is rare in this cohort, even among those with a positive family history. Our findings question the utility of testing for this variant among unselected men presenting for a diagnostic prostate biopsy.
Collapse
|
43
|
Schroeck FR, Jacobs BL, Hollenbeck BK. Understanding variation in the quality of the surgical treatment of prostate cancer. Am Soc Clin Oncol Educ Book 2013:278-83. [PMID: 23714522 PMCID: PMC7010404 DOI: 10.14694/edbook_am.2013.33.278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
More than 80% of men with prostate cancer undergo active treatment, which can be associated with significant morbidity. Outcomes of surgical treatment vary widely depending on who treated the patient and where the patient was treated, implying that there is room for improvement. Factors influencing outcomes include patient characteristics as well as some measure of procedure volume. Although relationships between volume and outcomes for prostatectomy can most likely be explained by differences between surgeons (e.g., experience, technical skill), the hospital environment (e.g., team communication, safety culture) has the potential to either amplify or dampen the effects. Although most patient factors are immutable, these other aspects of surgical care and the delivery environment provide opportunities for quality improvement. Collaborative quality improvement initiatives may prove to be an important vehicle for achieving better prostate cancer care. These grass roots organizations, driven largely by urologists dedicated to providing prostate cancer care, have had initial successes in improving some aspects of quality in prostate cancer care, including reducing unwarranted use of imaging and perioperative morbidity. However, much of the variation in functional outcomes after prostate cancer surgery arises from differences in technical skill. Evaluating and improving intraoperative surgeon performance will inevitably be challenging, as they require acquisition and interpretation of data collected in the operating room. To this end, several methods have been described to objectively assess what happens in the operating room.
Collapse
|
44
|
Schroeck FR, Hollingsworth JM, Kaufman SR, Hollenbeck BK, Wei JT. Population based trends in the surgical treatment of benign prostatic hyperplasia. J Urol 2012; 188:1837-41. [PMID: 22999698 PMCID: PMC4006217 DOI: 10.1016/j.juro.2012.07.049] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Laser prostatectomy has increased in popularity in the last decade. However, traditional transurethral resection of the prostate remains common. To understand decisions about the use of laser prostatectomy vs transurethral prostate resection, we evaluated trends in transurethral surgery for benign prostatic hyperplasia in an all payer data set, focusing on patient and provider factors associated with the receipt of laser prostatectomy. MATERIALS AND METHODS Using Florida State Inpatient Database and Ambulatory Surgery Database, we identified patients who underwent laser prostatectomy or transurethral prostate resection from 2001 to 2009. We calculated surgery rates with time, stratified by procedure type. We used multilevel regression to examine patient (age, race and comorbidity level) and provider (surgeon volume) factors associated with the receipt of laser prostatectomy vs transurethral prostate resection. RESULTS While the overall rates of transurethral surgery remained stable during the study period (p = 0.227), laser prostatectomy use increased 400% from 25 to 114 procedures per 100,000 men (p <0.001), replacing about half of all transurethral prostate resections. Patients were less likely to undergo laser prostatectomy if they were older (OR 0.65, 95% CI 0.61-0.70) and less healthy (OR 0.48, 95% CI 0.45-0.51). While these factors were predictive of surgery type, most of the variation in laser prostatectomy use (69%) was determined by the urologist seen by the patient. CONCLUSIONS Laser prostatectomy use has increased in the last decade at the expense of transurethral prostate resection, driven largely by provider effects. However, elderly and more infirm patients are least likely to undergo it, raising concern about underuse in this population.
Collapse
|
45
|
Schroeck FR. Editorial comment. J Urol 2012; 188:2218. [PMID: 23083658 DOI: 10.1016/j.juro.2012.08.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
46
|
Schroeck FR, Hollingsworth JM, Kaufman SR, Hollenbeck BK, Wei JT. Introduction of laser technology and procedure use for benign prostatic hyperplasia: data from Florida. Urology 2012; 80:678-83. [PMID: 22840735 PMCID: PMC3429633 DOI: 10.1016/j.urology.2012.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/17/2012] [Accepted: 05/17/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine the association of laser technology adoption in a market with surgery rates for benign prostatic hyperplasia. METHODS Using the Florida files from the State Ambulatory and Inpatient Surgery Databases (2001-2009), we identified all patients who underwent transurethral surgery for benign prostatic hyperplasia. We calculated rates of benign prostatic hyperplasia surgery for all markets within the state (defined by Hospital Service Area) over time. Markets were split into 3 categories: (1) Always offering, (2) never offering, or (3) initially not offering but adopting laser prostatectomy after 2001. We used multivariable regression models to estimate surgery rates adjusted for other market characteristics. Interaction terms were included in the models to examine differences in time trends between market categories. RESULTS After adjusting for market characteristics, time trends differed by market category (P < .001). Surgery rates decreased from 318 to 248 procedures per 100,000 men in markets always offering laser prostatectomy (P < .001). Markets never offering laser surgery had much lower rates that remained stable (180-187 procedures per 100,000 men, P = .805). In markets adopting laser technology, rates increased from 268 to 296 procedures per 100,000 men after adoption (P = .044), such that 4 years after adoption these markets had the highest rates among the 3 categories. CONCLUSION Adoption of laser technology is associated with rising rates of surgical intervention for benign prostatic hyperplasia. This trend appears to be induced by the introduction of laser surgery.
Collapse
|
47
|
Schroeck FR, Hollingsworth JM, Kaufman SR, Dunn RL, Hollenbeck BK, Wei JT. 1974 POPULATION BASED TRENDS IN THE SURGICAL TREATMENT OF BENIGN PROSTATIC HYPERPLASIA. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
48
|
Schroeck FR, Hollingsworth JM, Kaufman SR, Dunn RL, Hollenbeck BK, Wei JT. 428 ADOPTION OF LASER TECHNOLOGY IS ASSOCIATED WITH INCREASED BPH SURGERY RATES. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
49
|
Schroeck FR, Krupski TL, Stewart SB, Bañez LL, Gerber L, Albala DM, Moul JW. Pretreatment Expectations of Patients Undergoing Robotic Assisted Laparoscopic or Open Retropubic Radical Prostatectomy. J Urol 2012; 187:894-8. [DOI: 10.1016/j.juro.2011.10.135] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Indexed: 11/17/2022]
|
50
|
Kimura M, Bañez LL, Schroeck FR, Gerber L, Qi J, Satoh T, Baba S, Robertson CN, Walther PJ, Donatucci CF, Moul JW, Polascik TJ. Factors Predicting Early and Late Phase Decline of Sexual Health‐Related Quality of Life Following Radical Prostatectomy. J Sex Med 2011; 8:2935-43. [DOI: 10.1111/j.1743-6109.2011.02387.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|