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Caram MEV, Kumbier K, Burns J, Sparks JB, Tsao PA, Stensland KD, Washington SL, Hollenbeck BK, Shahinian V, Skolarus TA. Differential adoption of castration-resistant prostate cancer treatment across facilities in a national healthcare system. Cancer Med 2023; 12:6945-6955. [PMID: 36790037 PMCID: PMC10067072 DOI: 10.1002/cam4.5490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/15/2022] [Accepted: 11/17/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Over the past decade, abiraterone and enzalutamide have largely replaced ketoconazole as oral treatments for castration-resistant prostate cancer (CRPC). We investigated the differential adoption of abiraterone and enzalutamide across facilities in a national healthcare system to understand the impact a facility has on the receipt of these novel therapies. METHODS Using data from the VA Corporate Data Warehouse, we identified a cohort of men with CRPC who received the most common first-line therapies: abiraterone, enzalutamide, docetaxel, or ketoconazole between 2010 and 2017. We described variability in the adoption of abiraterone and enzalutamide across facilities by time period (2010-2013 or 2014-2017). We categorized facilities depending on the timing of adoption of abiraterone and enzalutamide relative to other facilities and described facility characteristics associated with early and late adoption. RESULTS We identified 4998 men treated with ketoconazole, docetaxel, abiraterone, or enzalutamide as first-line CRPC therapy between 2010 and 2017 at 125 national facilities. When limiting the cohort to oral therapies, most patients treated earlier in the study period (2010-2013) received ketoconazole. A dramatic shift was seen by the second half of the study period (2014-2017) with most men treated with first-line abiraterone (61%). Despite this shift and a new standard of care, some facilities persisted in the widespread use of ketoconazole in the later period, so-called late adopting facilities. After multivariable adjustment, patients who received treatment at a late adopting facility were more likely receiving care at a lower complexity, rural facility, with less urology and hematology/oncology workforce (all p < 0.01). CONCLUSION Many facilities persisted in their use of ketoconazole as first-line CRPC therapy, even when other facilities had adopted the new standard of care abiraterone and enzalutamide. Further work is needed to identify the effect of this late adoption on outcomes important to patients.
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Affiliation(s)
- Megan E. V. Caram
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Kyle Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jennifer Burns
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Phoebe A. Tsao
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | | | - Samuel L. Washington
- Department of UrologyUniversity of California San FranciscoCaliforniaSan FranciscoUSA
| | - Brent K. Hollenbeck
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Vahakn Shahinian
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of Chicago Pritzker School of MedicineIllinoisChicagoUSA
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Diffusion of robotic-assisted laparoscopic technology across specialties: a national study from 2008 to 2013. Surg Endosc 2017; 32:1405-1413. [DOI: 10.1007/s00464-017-5822-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/03/2017] [Indexed: 12/26/2022]
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Karaca‐Mandic P, Town RJ, Wilcock A. The Effect of Physician and Hospital Market Structure on Medical Technology Diffusion. Health Serv Res 2017; 52:579-598. [PMID: 27196678 PMCID: PMC5346501 DOI: 10.1111/1475-6773.12506] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the influence of physician and hospital market structures on medical technology diffusion, studying the diffusion of drug-eluting stents (DESs), which became available in April 2003. DATA SOURCES/STUDY SETTING Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey. STUDY DESIGN Retrospective claims data analyses. DATA COLLECTION/EXTRACTION METHODS All fee-for-service Medicare beneficiaries who received a percutaneous coronary intervention (PCI) with a cardiac stent in 2003 or 2004. Each PCI record was joined to characteristics on the patient, the procedure, the cardiologist, and the hospital where the PCI was delivered. We accounted for the endogeneity of physician and hospital market structure using exogenous variation in the distances between patient, physician, and hospital locations. We estimated multivariate linear probability models that related the use of a DES in the PCI on market structure while controlling for patient, physician, and hospital characteristics. PRINCIPAL FINDINGS DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered. CONCLUSIONS Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly.
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Affiliation(s)
- Pinar Karaca‐Mandic
- School of Public HealthDivision of Health Policy and ManagementUniversity of Minnesota and NBERMinneapolisMN
| | - Robert J. Town
- The Wharton SchoolColonial Penn CenterUniversity of Pennsylvania and NBERPhiladelphiaPA
| | - Andrew Wilcock
- School of Public HealthDivision of Health Policy
and ManagementUniversity of MinnesotaMinneapolisMN
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Anderson CB, Atoria CL, Touijer K, Ehdaie B, Elkin EB. Surgeon Adoption of Minimally Invasive Radical Prostatectomy. UROLOGY PRACTICE 2016; 3:505-510. [PMID: 37592612 DOI: 10.1016/j.urpr.2015.11.002] [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: 11/21/2022]
Abstract
INTRODUCTION Minimally invasive radical prostatectomy has become the most common surgical treatment for prostate cancer. In this study we describe patterns of minimally invasive radical prostatectomy adoption among surgeons who performed open radical prostatectomy before their first minimally invasive radical prostatectomy and those who did not. METHODS We performed a retrospective cohort study using the population based SEER (Surveillance, Epidemiology, and End Results)-Medicare data set. We identified all surgeons who performed minimally invasive radical prostatectomy in 2003 to 2010 in men with prostate cancer 66 years old or older. Surgeons were classified as "converters" if they performed open radical prostatectomy before their first minimally invasive radical prostatectomy or "de novos" if they had not. We estimated annual minimally invasive radical prostatectomy volume and the proportion of prostatectomies performed minimally invasively. We used logistic regression to identify predictors of minimally invasive radical prostatectomy discontinuation. RESULTS A total of 11,511 minimally invasive radical prostatectomies were performed by 738 minimally invasive radical prostatectomy surgeons (converters 337 and de novos 401). Converters performed 55% of all minimally invasive radical prostatectomies and had higher median annual minimally invasive radical prostatectomy volume than de novos (4 vs 2). About 34% of converters and 54% of de novos discontinued minimally invasive radical prostatectomy after their first year. Second year discontinuation of minimally invasive radical prostatectomy was more likely among de novo surgeons (OR 1.9, 95% CI 1.3-2.7) and less likely among surgeons with higher minimally invasive radical prostatectomy volume in their first year (OR 0.5, 95% CI 0.5-0.6). CONCLUSIONS During the years of the greatest growth in minimally invasive radical prostatectomy, surgeon adoption of this technique varied by surgeon type and volume. Many surgeons discontinued, and possibly abandoned, minimally invasive radical prostatectomy. Based on these observations, experienced and higher volume surgeons will be most successful adopting new surgical technology.
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Affiliation(s)
| | - Coral L Atoria
- Department of Epidemiology and Biostatistics, Sidney Kimmel Center for Prostate and Urological Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim Touijer
- Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Behfar Ehdaie
- Department of Epidemiology and Biostatistics, Sidney Kimmel Center for Prostate and Urological Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
- Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elena B Elkin
- Department of Epidemiology and Biostatistics, Sidney Kimmel Center for Prostate and Urological Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
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Gathara D, English M, van Hensbroek MB, Todd J, Allen E. Exploring sources of variability in adherence to guidelines across hospitals in low-income settings: a multi-level analysis of a cross-sectional survey of 22 hospitals. Implement Sci 2015; 10:60. [PMID: 25928803 PMCID: PMC4416316 DOI: 10.1186/s13012-015-0245-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 04/11/2015] [Indexed: 11/30/2022] Open
Abstract
Background Variability in processes of care and outcomes has been reported widely in high-income settings (at geographic, hospital, physician group and individual physician levels); however, such variability and the factors driving it are rarely examined in low-income settings. Methods Using data from a cross-sectional survey undertaken in 22 hospitals (60 case records from each hospital) across Kenya that aimed at evaluating the quality of routine hospital services, we sought to explore variability in four binary inpatient paediatric process indicators. These included three prescribing tasks and use of one diagnostic. To examine for sources of variability, we examined intra-class correlation coefficients (ICC) and their changes using multi-level mixed models with random intercepts for hospital and clinician levels and adjusting for patient and clinician level covariates. Results Levels of performance varied substantially across indicators and hospitals. The absolute values for ICCs also varied markedly ranging from a maximum of 0.48 to a minimum of 0.09 across the models for HIV testing and prescription of zinc, respectively. More variation was attributable at the hospital level than clinician level after allowing for nesting of clinicians within hospitals for prescription of quinine loading dose for malaria (ICC = 0.30), prescription of zinc for diarrhoea patients (ICC = 0.11) and HIV testing for all children (ICC = 0.43). However, for prescription of correct dose of crystalline penicillin, more of the variability was explained by the clinician level (ICC = 0.21). Adjusting for clinician and patient level covariates only altered, marginally, the ICCs observed in models for the zinc prescription indicator. Conclusions Performance varied greatly across place and indicator. The variability that could be explained suggests interventions to improve performance might be best targeted at hospital level factors for three indicators and clinician factors for one. Our data suggest that better understanding of performance and sources of variation might help tailor improvement interventions although further data across a larger set of indicators and sites would help substantiate these findings.
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Affiliation(s)
- David Gathara
- KEMRI Wellcome Trust Research Programme, 43640 - 00100, Nairobi, Kenya.
| | - Mike English
- KEMRI Wellcome Trust Research Programme, 43640 - 00100, Nairobi, Kenya. .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
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Jacobs BL, Kaufman SR, Morgenstern H, Hollenbeck BK, Wolf JS, Hollingsworth JM. Trends in the treatment of adults with ureteropelvic junction obstruction. J Endourol 2013; 27:355-60. [PMID: 22967009 PMCID: PMC3593686 DOI: 10.1089/end.2012.0017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Minimally invasive pyeloplasty is an effective treatment for patients with ureteropelvic junction obstruction that offers quicker convalescence than open pyeloplasty. Technical challenges, however, may have limited its dissemination. We examined population trends and determinants of surgical options for ureteropelvic junction obstruction. PATIENTS AND METHODS Using the State Inpatient and Ambulatory Surgery Databases for Florida, we identified adults who underwent ureteropelvic junction obstruction repair between 2001 and 2009. After determining the surgical approach (minimally invasive pyeloplasty, open pyeloplasty, or endopyelotomy), we estimated annual utilization rates and the effects of patient, surgeon, and hospital predictors on surgery type, using multilevel multinomial logistic regression. RESULTS Rates of minimally invasive pyeloplasty increased 360% (P for monotonic trend < 0.01), while rates of open pyeloplasty decreased 56% (P<0.01). Rates of endopyelotomy were substantially higher and remained relatively stable (P=0.27). Compared with open pyeloplasty, minimally invasive pyeloplasty was used more commonly among patients with private insurance (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.2-2.3), those treated at teaching hospitals (OR 1.6; CI 1.0-2.6), and those treated by high-volume surgeons (OR 2.9; CI 2.0-4.2). Its use was less frequent among patients with multiple comorbidities (OR 0.53; CI 0.37-0.76). Similar associations were observed when comparing receipt of minimally invasive pyeloplasty with endopyelotomy; however, patients who underwent endopyelotomy were older. CONCLUSIONS The use of minimally invasive pyeloplasty has dramatically increased, largely replacing open pyeloplasty, while the use of endopyelotomy, albeit significantly more common than the other approaches, has remained stable. The surgical approach is influenced by several patient, surgeon, and hospital factors.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, Divisions of Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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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.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan 48109, USA
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Trinh QD, Schmitges J, Sun M, Sammon J, Shariat SF, Sukumar S, Zorn K, Bianchi M, Jeldres C, Perrotte P, Graefen M, Rogers CG, Peabody JO, Menon M, Karakiewicz PI. Does partial nephrectomy at an academic institution result in better outcomes? World J Urol 2011; 30:505-10. [PMID: 21904920 DOI: 10.1007/s00345-011-0759-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 08/26/2011] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Partial nephrectomy (PN) outcomes may be better at academic institutions than at non-academic centers. Peer-review, sub-specialized practice profile, higher individual surgeon and institutional caseload may explain this observation. To the best of our knowledge, the role of institutional academic affiliation has not been examined with regard to PN postoperative outcomes. METHODS Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on PNs performed within the 10 most contemporary years (1998-2007). We explored the effect of academic status on three short-term PN outcomes (intraoperative and postoperative complications, as well as in-hospital mortality). Multivariable logistic regression analyses further adjusted for age, race, gender, Charlson Comorbidity Index (CCI), surgical approach, hospital region, annual hospital caseload and insurance status. RESULTS Overall, 8,513 PNs were identified. Of those, 5,906 (69.4%) were recorded at academic institutions. Academic institution patients had lower CCI, were less frequently Caucasian and more frequently had private insurance (all P < 0.001). Academic institution PNs were associated with fewer postoperative complications (14.6% vs. 16.6%, P = 0.018). In multivariable analyses, institutional academic status did not affect the three short-term PN outcomes. CONCLUSIONS Patient selection explains better PN postoperative outcomes at academic institutions. Control for these biases removes the outcome differences, at least when the three short-term PN outcomes are considered. However, the interpretation of these findings needs to take into account the lack of adjustment for case complexity.
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Affiliation(s)
- Quoc-Dien Trinh
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Meaningful variation in performance: what does variation in quality tell us about improving quality? Med Care 2010; 48:133-9. [PMID: 20057330 DOI: 10.1097/mlr.0b013e3181c15a6e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves. OBJECTIVES To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. POPULATION Adult members (n = 62,596-410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006. METHODS Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment. RESULTS ICCs were low for all 4 indicators at both levels (0.0021-0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities. CONCLUSIONS Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.
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