Association of reimbursement policy and urologists׳ characteristics with the use of medical androgen deprivation therapy for clinically localized prostate cancer11Funding: This work was supported by the American Cancer Society, Intramural Research Department, Atlanta, GA

Knowledge and Attitudes Regarding Surgical Castration in Men Receiving Androgen Deprivation Therapy for Metastatic Prostate Cancer and Their Relationship to Health-Related Quality of Life

OBJECTIVE

To determine the attitudes and education regarding surgical castration in men receiving androgen deprivation therapy (ADT) for metastatic prostate cancer (mCaP).

METHODS

We identified 142 patients receiving ADT for mCaP at our institution without prior orchiectomy who were then sent 2 surveys via mail: (1) A questionnaire to assess knowledge and understanding of ADT treatment alternatives and (2) the functional assessment of cancer therapy - prostate (FACT-P) questionnaire which determines health-related quality of life (HRQOL). Two cohorts were created based on the answer to "would you be interested in surgical orchiectomy?" and demographic, CaP and HRQOL were compared between the surgical castration yes (SC+) and surgical castration no (SC-) cohorts. A second analysis identified predictors of worse HRQOL.

RESULTS

Of 68 (47.9%) patients that responded to the survey, only 39 (59.1%) recalled a discussion regarding treatment alternatives to ADT and only 22 (33.3%) recalled a discussion regarding orchiectomy. There were 24 (40.0%) patients that stated interest in undergoing orchiectomy (SC+) as an alternative to ADT with the only independent risk factor being "…bother from the number of clinical appointments required for ADT…" Patients most bothered by side effects and cosmetic changes associated with ADT reported lower HRQOL scores on the FACT-P.

CONCLUSIONS

Few men on ADT knew about surgical alternatives, implying that educational deficits may be a significant factor in the decline in the utilization of orchiectomy. Changes in healthcare economics, utilization and delivery brought on by a global pandemic should warrant a fresh look at the use of surgical castration.

Sensitivity of Medicare Data to Identify Oncologists

BACKGROUND

Health services researchers have studied how care from oncologists impacts treatment and outcomes for cancer patients. These studies frequently identify physician specialty using files from the Center for Medicare and Medicaid Services (CMS) or the American Medical Association (AMA). The completeness of the CMS data resources, individually or combined, to identify oncologists is unknown. This study assessed the sensitivity of CMS data to capture oncologists included in the AMA Physician Masterfile.

METHODS

Oncologists were identified from three CMS data resources: physician claims, the National Plan and Provider Enumeration System Registry, and the Medicare Data on Provider Practice and Specialty file. CMS files and AMA data were linked using a unique physician identifier. Sensitivity to identify any oncologists, radiation oncologists (ROs), surgical oncologists (SOs), and medical oncologists (MOs) was calculated for individual and combined CMS files. For oncologists in the AMA data not identified as oncologists in the CMS data, their CMS specialty was assessed.

RESULTS

Individual CMS files each captured approximately 83% of the 17 934 oncologists in the AMA Masterfile; combined CMS files captured 90.4%. By specialty, combined CMS data captured 98.2% of ROs, 89.3% of MOs, and 70.1% of SOs. For ROs and SOs in the AMA data not identified as oncologists in the CMS data, their CMS specialty was usually similar to the AMA subspecialty; ROs were radiologists and SOs were surgeons.

CONCLUSION

Using combined files from CMS identified most ROs and MOs found in the AMA, but not most SOs. Determining whether to use the AMA data or CMS files for a particular research project will depend on the specific research question and the type of oncologist included in the study.

Physician and facility drivers of spending variation in locoregional prostate cancer

BACKGROUND

Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown.

METHODS

In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined.

RESULTS

Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists.

CONCLUSIONS

Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels.

Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review

Importance

Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use.

Objective

To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns.

Evidence Review

Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018.

Findings

Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy.

Conclusions and Relevance

To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.

Medication overuse in oncology: current trends and future implications for patients and society

The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.

Race and Time to Receipt of Androgen Deprivation Therapy Among Men With Metastatic Prostate Cancer

BACKGROUND

The Medicare Modernization Act (MMA) drastically reduced reimbursement for androgen deprivation therapy (ADT) in 2005. One unintended consequence of the MMA may be an increase in the racial disparities in receipt of ADT. Given these policy changes, it becomes increasingly important to assess racial disparities in timely receipt of ADT.

METHODS

The purpose of this study is to evaluate the associations between race and median time to receipt of ADT among men with metastatic prostate cancer before and after the passage of the MMA. A population-based retrospective cohort was created from the Surveillance, Epidemiology, and End Results-Medicare.

RESULTS

A total of 1,846 African-American and 9,462 Caucasian men diagnosed with metastatic prostate cancer from 2000 through 2011 were included. An accelerated failure time regression model was used to examine factors associated with racial differences in median time to receipt of ADT. Results indicate that African-American men had a longer median time to receipt of ADT both before the MMA (Time Ratio (TR): 1.15; 95% Confidence Interval (CI) [1.05, 1.27]) and after the MMA (TR: 1.29; 95% CI [1.10, 1.53]) as compared to Caucasian men. In addition to race, men residing in South had longer median time to receipt of ADT (TR: 1.26, 1.52; 95% CI [1.01, 1.52; 1.24, 1.87] before and after MMA, respectively) compared to the Northeast region.

CONCLUSION

Considering the palliative benefits of ADT, it is important to develop effective strategies to address racial differences in receipt of treatment for metastatic prostate cancer.

Four Needles in a Haystack: A Systematic Review Assessing Quality of Health Care in Specialty Practice by Practice Type

Specialists, who represent 60% of physicians in the United States, are consolidating into large group practices, but the degree to which group practice type facilitates the delivery of high quality of care in specialty settings is unknown. We conducted a systematic literature review to identify the impact of group practice type on the quality of care among specialty providers. The search resulted in 913 articles, of which only 4 met inclusion criteria. Studies were of moderate methodological quality. From the limited evidence available, we hypothesize that solo specialists deliver care that is inferior to their peers in group practice, whether measured by patient satisfaction ratings or adherence to guideline-based care. However, solo specialists and multidisciplinary group specialists may be more likely to provide some specialized services compared with their single-specialty group peers. Insufficient research compares quality of care among different practice types in specialty care. Substantial opportunity exists to test the degree to which organizational factors, whether size of practice or the mix of providers within the practice, influence quality of care in specialty settings.