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Shin JY, Chino F, Cuaron JJ, Washington C, Jablonowski M, McBride S, Gomez DR. Insurance Denials and Patient Treatment in a Large Academic Radiation Oncology Center. JAMA Netw Open 2024; 7:e2416359. [PMID: 38865128 PMCID: PMC11170304 DOI: 10.1001/jamanetworkopen.2024.16359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/11/2024] [Indexed: 06/13/2024] Open
Abstract
Importance Insurance barriers to cancer care can cause significant patient and clinician burden. Objective To investigate the association of insurance denial with changes in technique, dose, and time to delivery of radiation oncology treatment. Design, Setting, and Participants In this single-institution cohort analysis, data were collected from patients with payer-denied authorization for radiation therapy (RT) from November 1, 2021, to December 8, 2022. Data were analyzed from December 15, 2022, to December 31, 2023. Exposure Insurance denial for RT. Main Outcomes and Measures Association of these denials with changes in RT technique, dose, and time to treatment delivery was assessed using χ2 tests. Results A total of 206 cases (118 women [57.3%]; median age, 58 [range, 26-91] years) were identified. Most insurers (199 [96.6%]) were commercial payers, while 7 (3.4%) were Medicare or Medicare Advantage. One hundred sixty-one patients (78.2%) were younger than 65 years. Of 206 cases, 127 (61.7%) were ultimately authorized without any change to the requested RT technique or prescription dose; 56 (27.2%) were authorized after modification to RT technique and/or prescription dose required by the payer. Of 21 cases with required prescription dose change, the median decrease in dose was 24.0 (range, 2.3-51.0) Gy. Of 202 cases (98.1%) with RT delivered, 72 (34.9%) were delayed for a mean (SD) of 7.8 (9.1) days and median of 5 (range, 1-49) days. Four cases (1.9%) ultimately did not receive any authorization, with 3 (1.5%) not undergoing RT, and 1 (0.5%) seeking treatment at another institution. Conclusions and Relevance In this cohort study of patients with payer-denied cases, most insurance denials in radiation oncology were ultimately approved on appeal; however, RT technique and/or effectiveness may be compromised by payer-mandated changes. Further investigation and action to recognize the time and financial burdens on clinicians and clinical effects on patients caused by insurance denials of RT is needed.
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Affiliation(s)
- Jacob Y. Shin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John J. Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles Washington
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Margaret Jablonowski
- Physician Billing Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Durante M, Debus J, Loeffler JS. Physics and biomedical challenges of cancer therapy with accelerated heavy ions. NATURE REVIEWS. PHYSICS 2021; 3:777-790. [PMID: 34870097 PMCID: PMC7612063 DOI: 10.1038/s42254-021-00368-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Radiotherapy should have low toxicity in the entrance channel (normal tissue) and be very effective in cell killing in the target region (tumour). In this regard, ions heavier than protons have both physical and radiobiological advantages over conventional X-rays. Carbon ions represent an excellent combination of physical and biological advantages. There are a dozen carbon-ion clinical centres in Europe and Asia, and more under construction or at the planning stage, including the first in the USA. Clinical results from Japan and Germany are promising, but a heated debate on the cost-effectiveness is ongoing in the clinical community, owing to the larger footprint and greater expense of heavy ion facilities compared with proton therapy centres. We review here the physical basis and the clinical data with carbon ions and the use of different ions, such as helium and oxygen. Research towards smaller and cheaper machines with more effective beam delivery is necessary to make particle therapy affordable. The potential of heavy ions has not been fully exploited in clinics and, rather than there being a single 'silver bullet', different particles and their combination can provide a breakthrough in radiotherapy treatments in specific cases.
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Affiliation(s)
- Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany
- Institute of Condensed Matter Physics, Technische Universität Darmstadt, Darmstadt, Germany
| | - Jürgen Debus
- Department of Radiation Oncology and Heidelberg Ion Beam Therapy Center, Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jay S. Loeffler
- Departments of Radiation Oncology and Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Huang D, Frank SJ, Verma V, Thaker NG, Brooks ED, Palmer MB, Harrison RF, Deshmukh AA, Ning MS. Cost-Effectiveness Models of Proton Therapy for Head and Neck: Evaluating Quality and Methods to Date. Int J Part Ther 2021; 8:339-353. [PMID: 34285960 PMCID: PMC8270103 DOI: 10.14338/ijpt-20-00058.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/28/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Proton beam therapy (PBT) is associated with less toxicity relative to conventional photon radiotherapy for head-and-neck cancer (HNC). Upfront delivery costs are greater, but PBT can provide superior long-term value by minimizing treatment-related complications. Cost-effectiveness models (CEMs) estimate the relative value of novel technologies (such as PBT) as compared with the established standard of care. However, the uncertainties of CEMs can limit interpretation and applicability. This review serves to (1) assess the methodology and quality of pertinent CEMs in the existing literature, (2) evaluate their suitability for guiding clinical and economic strategies, and (3) discuss areas for improvement among future analyses. MATERIALS AND METHODS PubMed was queried for CEMs specific to PBT for HNC. General characteristics, modeling information, and methodological approaches were extracted for each identified study. Reporting quality was assessed via the Consolidated Health Economic Evaluation Reporting Standards 24-item checklist, whereas methodologic quality was evaluated via the Philips checklist. The Cooper evidence hierarchy scale was employed to analyze parameter inputs referenced within each model. RESULTS At the time of study, only 4 formal CEMs specific to PBT for HNC had been published (2005, 2013, 2018, 2020). The parameter inputs among these various Markov cohort models generally referenced older literature, excluding many clinically relevant complications and applying numerous hypothetical assumptions for toxicity states, incorporating inputs from theoretical complication-probability models because of limited availability of direct clinical evidence. Case numbers among study cohorts were low, and the structural design of some models inadequately reflected the natural history of HNC. Furthermore, cost inputs were incomplete and referenced historic figures. CONCLUSION Contemporary CEMs are needed to incorporate modern estimates for toxicity risks and costs associated with PBT delivery, to provide a more accurate estimate of value, and to improve their clinical applicability with respect to PBT for HNC.
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Affiliation(s)
- Danmeng Huang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Steven J. Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eric D. Brooks
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Ross F. Harrison
- Department of Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish A. Deshmukh
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Zhu M, Kaiser A, Mishra MV, Kwok Y, Remick J, DeCesaris C, Langen KM. Multiple Computed Tomography Robust Optimization to Account for Random Anatomic Density Variations During Intensity Modulated Proton Therapy. Adv Radiat Oncol 2020; 5:1022-1031. [PMID: 33083665 PMCID: PMC7557143 DOI: 10.1016/j.adro.2019.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 11/27/2022] Open
Abstract
Purpose To propose a method of optimizing intensity modulated proton therapy (IMPT) plans robust against dosimetric degradation caused by random anatomic variations during treatment. Methods and Materials Fifteen patients with prostate cancer treated with IMPT to the pelvic targets were nonrandomly selected. On the repeated quality assurance computed tomography (QACTs) for some patients, bowel density changes were observed and caused dose degradation because the treated plans were not robustly optimized (non-RO). To mitigate this effect, we developed a robust planning method based on 3 CT images, including the native planning CT and its 2 copies, with the bowel structures being assigned to air and tissue, respectively. The RO settings included 5 mm setup uncertainty and 3.5% range uncertainty on 3 CTs. This method is called pseudomultiple-CT RO (pMCT-RO). Plans were also generated using RO on the native CT only, with the same setup and range uncertainties. This method is referred to as single-CT RO (SCT-RO). Doses on the QACTs and the nominal planning CT were compared for the 3 planning methods. Results All 3 plan methods provided sufficient clinical target volumes D95% and V95% on the QACTs. For pMCT-RO plans, the normal tissue Dmax on QACTs of all patients was at maximum 109.1%, compared with 144.4% and 116.9% for non-RO and SCT-RO plans, respectively. On the nominal plans, the rectum and bladder doses were similar among all 3 plans; however, the volume of normal tissue (excluding the rectum and bladder) receiving the prescription dose or higher is substantially reduced in either pMCT-RO plans or SCT-RO plans, compared with the non-RO plans. Conclusions We developed a robust optimization method to further mitigate undesired dose heterogeneity caused by random anatomic changes in pelvic IMPT treatment. This method does not require additional patient CT scans. The pMCT-RO planning method has been implemented clinically since 2017 in our center.
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Pan X, Levin-Epstein R, Huang J, Ruan D, King CR, Kishan AU, Steinberg ML, Qi XS. Dosimetric predictors of patient-reported toxicity after prostate stereotactic body radiotherapy: Analysis of full range of the dose-volume histogram using ensemble machine learning. Radiother Oncol 2020; 148:181-188. [PMID: 32388444 DOI: 10.1016/j.radonc.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/22/2020] [Accepted: 04/10/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE This study aims to evaluate the associations between dosimetric parameters and patient-reported outcomes, and to identify latent dosimetric parameters that most correlate with acute and subacute patient-reported urinary and rectal toxicity after prostate stereotactic body radiotherapy (SBRT) using machine learning methods. MATERIALS AND METHODS Eighty-six patients who underwent prostate SBRT (40 Gy in 5 fractions) were included. Patient-reported health-related quality of life (HRQOL) outcomes were derived from bowel and bladder symptom scores on the Expanded Prostate Cancer Index Composite (EPIC-26) at 3 and 12 months post-SBRT. We utilized ensemble machine learning (ML) to interrogate the entire dose-volume histogram (DVH) to evaluate relationships between dose-volume parameters and HRQOL changes. The latent predictive dosimetric parameters that were most associated with HRQOL changes in urinary and rectal function were thus identified. An external cohort of 26 prostate SBRT patients was acquired to further test the predictive models. RESULTS Bladder dose-volume metrics strongly predicted patient-reported urinary irritative and incontinence symptoms (area under the curves [AUCs] of 0.79 and 0.87, respectively) at 12 months. Maximum bladder dose, bladder V102.5%, bladder volume, and conformity indices (V50/VPTV and V100/VPTV) were most predictive of HRQOL changes in both urinary domains. No strong rectal toxicity dosimetric association was identified (AUC = 0.64). CONCLUSION We demonstrated the application of advanced ML methods to identify a set of dosimetric variables that most highly correlated with patient-reported urinary HRQOL. DVH quantities identified with these methods may be used to achieve outcome-driven planning objectives to further reduce patient-reported toxicity with prostate SBRT.
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Affiliation(s)
- Xiaoying Pan
- School of Computer Science and Technology, Xi'an University of Posts & Telecommunications, China; Shaanxi Key Laboratory of Network Data Analysis and Intelligent Processing, Xi'an University of Posts and Telecommunications, China; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Jiahao Huang
- School of Computer Science and Technology, Xi'an University of Posts & Telecommunications, China
| | - Dan Ruan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Christopher R King
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - X Sharon Qi
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States.
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Kim E, Jang WI, Kim MS, Paik EK, Kim HJ, Yoo HJ, Yang K, Cho CK. Clinical utilization of radiation therapy in Korea, 2016. JOURNAL OF RADIATION RESEARCH 2020; 61:249-256. [PMID: 31913473 PMCID: PMC7246057 DOI: 10.1093/jrr/rrz095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/18/2019] [Indexed: 06/10/2023]
Abstract
Radiotherapy (RT) is one of the primary cancer treatment modalities. To estimate the actual utilization of RT and infrastructure in Korea, the current study was performed. Data from 2012 to 2016 were extracted from the Health Insurance Review and Assessment Service. In addition, a nationwide survey was conducted to collect the statistics of RT facilities, equipment and human resources in Korea. The total number of patients treated with RT was 72 563 in 2016. The five cancers that were most commonly treated with RT in 2016 were breast, lung, colorectal, liver and prostate cancer. According to analyses of specific treatment modalities, the number of patients treated with intensity-modulated radiotherapy (IMRT), stereotactic radiation therapy (SRT) and proton therapy increased from 6670, 6306 and 50 in 2012 to 21584, 9048 and 703 in 2016, respectively. Ninety radiation oncology centers were working in 2015 and there were a total of 213 megavoltage teletherapy machines. In 2015, 310 patients were treated per megavoltage RT machine, 246 patients per radiation oncologist, 501 patients per medical physicist and 111 patients per radiotherapy technologist. In conclusion, the number of patients who underwent RT in Korea has increased steadily from 2012 to 2016. The IMRT utilization rate remarkably increased in 2016, and the number of patients treated with advanced treatment modalities such as IMRT, SRT and proton therapy is expected to increase.
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Affiliation(s)
- Eunji Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Eun Kyung Paik
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Hee Jin Kim
- External Strategy Team, Strategic Planning Office, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Hyung Jun Yoo
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Kwangmo Yang
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Chul Koo Cho
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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Smith GL, Smith BD. Sea Change: A Decade of Intensity-Modulated Radiation Therapy for Treatment of Breast Cancer. J Natl Cancer Inst 2020; 112:221-223. [PMID: 31647554 DOI: 10.1093/jnci/djz199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Benjamin D Smith
- Department of Radiation Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment. Urol Oncol 2020; 38:37.e21-37.e27. [PMID: 31699490 PMCID: PMC6954961 DOI: 10.1016/j.urolonc.2019.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/30/2019] [Accepted: 09/28/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer). METHODS Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network. RESULTS We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12). CONCLUSIONS SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology-Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Dartmouth Institute Geisel School of Medicine, Lebanon, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Schad MD, Patel AK, Glaser SM, Balasubramani GK, Showalter TN, Beriwal S, Vargo JA. Declining brachytherapy utilization for cervical cancer patients - Have we reversed the trend? Gynecol Oncol 2020; 156:583-590. [PMID: 31924333 DOI: 10.1016/j.ygyno.2019.12.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Studies examining temporal trends in cervical brachytherapy use are conflicting and examined different health insurance populations. This study examined brachytherapy utilization over time by health insurance type and whether reported declines in brachytherapy have reversed. METHODS The National Cancer Database (NCDB) was queried for patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy between 2004 and 2014, identifying 17,442 patients. Brachytherapy utilization over time and by insurance type and other sociodemographic factors were compared using binary logistic regression. A sensitivity analysis was done in a sub-cohort of patients using the boost modality variable in the NCDB. RESULTS Brachytherapy utilization declined during 2008-10 (52.6%) compared to 2004-2007 (54.4%; odds ratio [OR] 0.93, 95% confidence interval [CI] 0.86-1.01) and declines were disproportionately larger for patients with government insurance (49.4% vs 52.3%, respectively) than privately-insured patients (57.6% vs 58.9%, respectively). However, rates of brachytherapy use subsequently recovered during 2011-14 in all insurance groups (58.0%, OR 1.24, 95% CI 1.16-1.34) and was especially improved for Medicaid (OR 1.44, 95% CI 1.26-1.65) and uninsured patients (OR 1.28, 95% CI 1.03-1.57). Sensitivity analysis using the boost modality variable confirmed these trends. CONCLUSIONS In patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy from 2004 to 2014, brachytherapy utilization declined during the late 2000s and disproportionately affected patients with government insurance, but subsequently recovered in the early 2010s. Since government insurance covers vulnerable patient populations at-risk for future declines in brachytherapy use, proposed alternative payment models should incentivize cervical brachytherapy to solidify gains in brachytherapy utilization.
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Affiliation(s)
- Michael D Schad
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Ankur K Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Scott M Glaser
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America
| | - Goundappa K Balasubramani
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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Schad M, Kowalchuk R, Beriwal S, Showalter TN. How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization. Brachytherapy 2019; 18:780-786. [PMID: 31439465 DOI: 10.1016/j.brachy.2019.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/21/2019] [Accepted: 07/05/2019] [Indexed: 01/22/2023]
Abstract
Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.
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Affiliation(s)
- Michael Schad
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Roman Kowalchuk
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Sushil Beriwal
- Department of Radiation Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA.
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Mohideen N, Kavanagh BD. Model Insurance Coverage Policies: The Power of Suggestion, the Force of Evidence. Int J Radiat Oncol Biol Phys 2019; 104:745-747. [PMID: 31204660 DOI: 10.1016/j.ijrobp.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 03/29/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Najeeb Mohideen
- Department of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois.
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
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Royce TJ, Dwyer K, Yu-Moe CW, DeRoo C, Jacobson JO, Tishler RB. Medical Malpractice Analysis in Radiation Oncology: A Decade of Results From a National Comparative Benchmarking System. Int J Radiat Oncol Biol Phys 2019; 103:801-808. [DOI: 10.1016/j.ijrobp.2018.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/01/2018] [Accepted: 11/03/2018] [Indexed: 01/06/2023]
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13
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Hong JC, Spiegel DY, Havrilesky LJ, Chino JP. High-volume providers and brachytherapy practice: A Medicare provider utilization and payment analysis. Brachytherapy 2018; 17:906-911. [DOI: 10.1016/j.brachy.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/08/2018] [Accepted: 07/03/2018] [Indexed: 11/25/2022]
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Gabani P, Robinson CG, Ansstas G, Johanns TM, Huang J. Use of extracranial radiation therapy in metastatic melanoma patients receiving immunotherapy. Radiother Oncol 2018. [DOI: 10.1016/j.radonc.2018.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Pan HY, Jiang J, Hoffman KE, Tang C, Choi SL, Nguyen QN, Frank SJ, Anscher MS, Shih YCT, Smith BD. Comparative Toxicities and Cost of Intensity-Modulated Radiotherapy, Proton Radiation, and Stereotactic Body Radiotherapy Among Younger Men With Prostate Cancer. J Clin Oncol 2018; 36:1823-1830. [PMID: 29561693 DOI: 10.1200/jco.2017.75.5371] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To compare the toxicities and cost of proton radiation and stereotactic body radiotherapy (SBRT) with intensity-modulated radiotherapy (IMRT) for prostate cancer among men younger than 65 years of age with private insurance. Methods Using the MarketScan Commercial Claims and Encounters database, we identified men who received radiation for prostate cancer between 2008 and 2015. Patients undergoing proton therapy and SBRT were propensity score-matched to IMRT patients on the basis of clinical and sociodemographic factors. Proportional hazards models compared the cumulative incidence of urinary, bowel, and erectile dysfunction toxicities by treatment. Cost from a payer's perspective was calculated from claims and adjusted to 2015 dollars. Results A total of 693 proton therapy patients were matched to 3,465 IMRT patients. Proton therapy patients had a lower risk of composite urinary toxicity (33% v 42% at 2 years; P < .001) and erectile dysfunction (21% v 28% at 2 years; P < .001), but a higher risk of bowel toxicity (20% v 15% at 2 years; P = .02). Mean radiation cost was $115,501 for proton therapy patients and $59,012 for IMRT patients ( P < .001). A total of 310 SBRT patients were matched to 3,100 IMRT patients. There were no significant differences in composite urinary, bowel, or erectile dysfunction toxicities between SBRT and IMRT patients ( P > .05), although a higher risk of urinary fistula was noted with SBRT (1% v 0.1% at 2 years; P = .009). Mean radiation cost for SBRT was $49,504 and $57,244 for IMRT ( P < .001). Conclusion Among younger men with prostate cancer, proton radiation was associated with significant reductions in urinary toxicity but increased bowel toxicity at nearly twice the cost of IMRT. SBRT and IMRT were associated with similar toxicity profiles; SBRT was modestly less expensive than IMRT.
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Affiliation(s)
- Hubert Y Pan
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jing Jiang
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen E Hoffman
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chad Tang
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Seungtaek L Choi
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J Frank
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mitchell S Anscher
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ya-Chen Tina Shih
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D Smith
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
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Grant SR, Smith BD, Likhacheva AO, Shirvani SM, Rosen DB, Guadagnolo BA, Shumway DA, Holliday EB, Chamberlain D, Walker GV. Provider variability in intensity modulated radiation therapy utilization among Medicare beneficiaries in the United States. Pract Radiat Oncol 2018; 8:e329-e336. [PMID: 29861349 DOI: 10.1016/j.prro.2018.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/19/2018] [Accepted: 02/13/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND In this study, we sought to examine the variation in intensity modulated radiation therapy (IMRT) use among radiation oncology providers. METHODS AND MATERIALS The Medicare Physician and Other Supplier Public Use File was queried for radiation oncologists practicing during 2014. Healthcare Common Procedural Coding System code 77301 was designated as IMRT planning with metrics including number of total IMRT plans, rate of IMRT utilization, and number of IMRT plans per distinct beneficiary. RESULTS Of 2759 radiation oncologists, the median number of total IMRT plans was 26 (mean, 33.4; standard deviation, 26.2; range, 11-321) with a median IMRT utilization rate of 36% (mean, 43%; standard deviation, 25%; range, 4% to 100%) and a median number of IMRT plans per beneficiary of 1.02 (mean, 1.07; range, 1.00-3.73). On multivariable analysis, increased IMRT utilization was associated with male sex, academic practice, technical fee billing, freestanding practice, practice in a county with 21 or more radiation oncologists, and practice in the southern United States (P < .05). The top 1% of users (28 providers) billed a mean 181 IMRT plans with an IMRT utilization rate of 66% and 1.52 IMRT plans per beneficiary. Of these 28 providers, 24 had billed technical fees, 25 practiced in freestanding clinics, and 20 practiced in the South. CONCLUSIONS Technical fee billing, freestanding practice, male sex, and location in the South were associated with increased IMRT use. A small group of outliers shared several common demographic and practice-based characteristics.
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Affiliation(s)
- Stephen R Grant
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Anna O Likhacheva
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Shervin M Shirvani
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - David B Rosen
- College of Medicine, The University of Arizona Health Sciences, Phoenix, Arizona
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Dean A Shumway
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Daniel Chamberlain
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Gary V Walker
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona.
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