Therapeutic substitutions in the midst of new technology diffusion: The case of treatment for localized prostate cancer

Technology adoption and market allocation: The case of robotic surgery

The adoption of health care technology is central to improving productivity in this sector. To provide new evidence on how technology affects health care markets, we focus on one area where adoption has been particularly rapid: surgery for prostate cancer. Within just eight years, robotic surgery grew to become the dominant intensive prostate cancer treatment method. Using a difference-in-differences design, we show that adopting a robot drives prostate cancer patients to the hospital. To test whether this result reflects market expansion or business stealing, we also consider market-level effects of adoption and find effects that are significant but smaller, suggesting that adoption expands the market while also reallocating some patients across hospitals. Marginal patients are relatively young and healthy, inconsistent with the concern that adoption broadens the criteria for intervention to patients who would gain little from it. We conclude by discussing implications for the social value of technology diffusion in health care markets.

Robotic Prostatectomy and Prostate Cancer-Related Medicaid Spending: Evidence from New York State

BACKGROUND

Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been assessed.

OBJECTIVE

To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer-related treatment costs.

DESIGN AND PARTICIPANTS

This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40-64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient's residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region.

MAIN MEASURES

Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis.

KEY RESULTS

The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer-related costs per Medicaid patient.

CONCLUSIONS

A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes.

Prostatectomy versus radiotherapy for early-stage prostate cancer (PREPaRE) study: protocol for a mixed-methods study of treatment decision-making in men with localised prostate cancer

BACKGROUND

Men diagnosed with localised prostate cancer (LPC) wanting curative treatment face a highly preference-sensitive choice between prostatectomy and radiotherapy, which offer similar cure rates but different side effects. This study aims to determine the information, decision-making needs and preferences of men with LPC choosing between robotic prostatectomy and standard external beam or stereotactic radiotherapy.

METHODS AND ANALYSIS

This study will be conducted at a large public teaching hospital in Australia offering the choice between robotic prostatectomy and radiotherapy from early 2017. Men (20-30) diagnosed with LPC who want curative treatment and meet criteria for either treatment will be invited to participate. In this mixed-methods study, patients will complete semistructured interviews before and after attending a combined clinic in which they consult a urologist and a radiation oncologist regarding treatment and four questionnaires (one before treatment decision-making and three after) assessing demographic and clinical characteristics, involvement in decision-making, decisional conflict, satisfaction and regret. Combined clinic consultations will also be audio-recorded and clinicians will report their perceptions regarding patients' suitability for, openness to and preferences for each treatment. Qualitative data will be transcribed verbatim and thematically analysed and descriptive statistical analyses will explore quantitative decision-making outcomes, with comparison according to treatment choice.

DISCUSSION

Results from this study will inform how to best support men diagnosed with LPC deciding which curative treatment option best suits their needs and may identify the need for and content required in a decision aid to support these men.

ETHICS AND DISSEMINATION

All participants will provide written informed consent. Data will be rigorously managed in accordance with national legislation. Results will be disseminated via presentations to both scientific and layperson audiences and publications in peer-reviewed scientific journals.

Underutilization of Radical Cystectomy Among Patients Diagnosed with Clinical Stage T2 Muscle-invasive Bladder Cancer

BACKGROUND

Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer (MIBC).

OBJECTIVE

We sought to identify population-based factors predicting the use of radical cystectomy.

DESIGN, SETTING, AND PATIENTS

Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 3922 patients aged ≥66 yr diagnosed with clinical stage T2 MIBC from January 1, 2002 to December 31, 2011.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes.

RESULTS AND LIMITATIONS

A total of 740 (18.9%) patients with MIBC underwent radical cystectomy. Older age at diagnosis (>80 vs 65-69 yr, odds ratio [OR] 0.15, 95% confidence interval [CI] 0.11-0.19; p<0.001) and higher comorbidity (Charlson comorbidity index 3+ vs 0, OR 0.41, 95% CI 0.29-0.57; p<0.001) were associated with lower use of radical cystectomy. Moreover, non-Hispanic black patients were less likely than white patients to undergo radical cystectomy (OR 0.62, 95% CI 0.40-0.96; p=0.032) and pelvic lymph node dissection (OR 0.65, 95% CI 0.42-1.02; p=0.058). Overall survival was better for patients who underwent radical cystectomy alone (hazard ratio [HR] 0.70, 95% CI 0.56-0.88; p=0.002) and with lymph node dissection (HR 0.45, 95% CI 0.40-0.51; p<0.001). Limitations include the limited ability of retrospective analysis to demonstrate causality.

CONCLUSIONS

There is significant underutilization of radical cystectomy among patients diagnosed with MIBC, especially among older patients with significant comorbidities and non-Hispanic black patients.

PATIENT SUMMARY

Despite guideline recommendations, there is significant underutilization of radical cystectomy among patients diagnosed with bladder cancer, especially for non-Hispanic black patients and older patients with significant comorbidities.