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Ellis SD, Hwang S, Morrow E, Kimminau KS, Goonan K, Petty L, Ellerbeck E, Thrasher JB. Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists. BMC Cancer 2021; 21:649. [PMID: 34058998 PMCID: PMC8165996 DOI: 10.1186/s12885-021-08386-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. METHODS We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. RESULTS Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. CONCLUSIONS Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.
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Affiliation(s)
- Shellie D. Ellis
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Soohyun Hwang
- Department of Health Policy and Management, School of Public Health, University of North Carolina Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, Chapel Hill, NC 27599-7411 USA
| | - Emily Morrow
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Kim S. Kimminau
- Department of Family Medicine, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Kelly Goonan
- Independent Researcher/Consultant/Scientific Writer, Greensboro, NC USA
| | - Laurie Petty
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Edward Ellerbeck
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
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Mitchell AP, Rotter JS, Patel E, Richardson D, Wheeler SB, Basch E, Goldstein DA. Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review. JAMA Oncol 2020; 5:893-899. [PMID: 30605222 DOI: 10.1001/jamaoncol.2018.6196] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason S Rotter
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill
| | - Esita Patel
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina
| | - Daniel Richardson
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Ethan Basch
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Daniel A Goldstein
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel
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Mitchell AP, Kinlaw AC, Peacock‐Hinton S, Dusetzina SB, Sanoff HK, Lund JL. Use of High-Cost Cancer Treatments in Academic and Nonacademic Practice. Oncologist 2020; 25:46-54. [PMID: 31611329 PMCID: PMC6964140 DOI: 10.1634/theoncologist.2019-0338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/21/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Academic physicians, such as those affiliated with National Cancer Institute (NCI)-designated Comprehensive Cancer Centers, may have different practice patterns regarding the use of high-cost cancer drugs than nonacademic physicians. MATERIALS AND METHODS For this cohort study, we linked cancer registry, administrative, and demographic data for patients with newly diagnosed cancer in North Carolina from 2004 to 2011. We selected cancer types with multiple U.S. Food and Drug Administration-approved, National Comprehensive Cancer Network-recommended treatment options and large differences in reimbursement between higher-priced and lower-priced options (stage IV colorectal, stage IV lung, and stage II-IV head-and-neck cancers). We assessed whether provider's practice setting-NCI-designated Comprehensive Cancer Center ("NCI") versus other location ("non-NCI")-was associated with use of higher-cost treatment options. We used inverse probability of exposure weighting to control for patient characteristics. RESULTS Of 800 eligible patients, 79.6% were treated in non-NCI settings. Patients treated in non-NCI settings were more likely to receive high-cost treatment than patients treated in NCI settings (36.0% vs. 23.2%), with an unadjusted prevalence difference of 12.7% (95% confidence interval [CI], 5.1%-20.0%). After controlling for potential confounding factors, non-NCI patients remained more likely to receive high-cost treatment, although the strength of association was attenuated (adjusted prevalence difference, 9.6%; 95% CI -0.1%-18.7%). Exploratory analyses suggested potential heterogeneity across cancer type and insurance status. CONCLUSION Use of higher-cost cancer treatments may be more common in non-NCI than NCI settings. This may reflect differential implementation of clinical evidence, local practice variation, or possibly a response to the reimbursement incentives presented by chemotherapy billing. IMPLICATIONS FOR PRACTICE Oncology care delivery and practice patterns may vary between care settings. By comparing otherwise similar patients treated in National Cancer Institute (NCI)-designated Comprehensive Cancer Centers with those treated elsewhere, this study suggests that patients may be more likely to receive treatment with certain expensive cancer drugs if treated in the non-NCI setting. These practice differences may result in differences in patient costs and outcomes as a result of where they receive treatment.
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Affiliation(s)
- Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Department of Hematology/Oncology, University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services Research, Memorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
| | - Alan C. Kinlaw
- Cecil G. Sheps Center for Health Services Research, Memorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, Memorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
| | - Sharon Peacock‐Hinton
- Department of Epidemiology, Gillings School of Global Public Health, Memorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
| | - Stacie B. Dusetzina
- Department of Health Policy, University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Vanderbilt‐Ingram Cancer Center, Vanderbilt University School of Medicine, University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Hanna K. Sanoff
- Department of Hematology/Oncology, University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global Public Health, Memorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Schleicher SM, Bach PB, Matsoukas K, Korenstein D. Medication overuse in oncology: current trends and future implications for patients and society. Lancet Oncol 2019; 19:e200-e208. [PMID: 29611528 DOI: 10.1016/s1470-2045(18)30099-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Stephen M Schleicher
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Konstantina Matsoukas
- Information Systems/Medical Library, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cobran EK, Young HN, Chen RC, Chen X, Reeves J, Godley PA, Shah S. Race and Time to Receipt of Androgen Deprivation Therapy Among Men With Metastatic Prostate Cancer. J Natl Med Assoc 2018; 111:246-255. [PMID: 30389146 DOI: 10.1016/j.jnma.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/05/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ewan K Cobran
- University of Georgia, College of Pharmacy, Department of Clinical and Administrative Pharmacy, Division of Pharmaceutical Health Services, Outcomes, and Policy, Robert C. Wilson Pharmacy 250 West Green Street, 270B, Athens, GA 30602, USA.
| | - Henry N Young
- University of Georgia, College of Pharmacy, Department of Clinical and Administrative Pharmacy, Division of Pharmaceutical Health Services, Outcomes, and Policy, Robert C. Wilson Pharmacy 250 West Green Street, 270J, Athens, GA 30602, USA
| | - Ronald C Chen
- University of North Carolina at Chapel Hill, School of Medicine, Department of Radiation Oncology and Urology, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Xianyan Chen
- University of Georgia, Franklin College of Arts and Sciences, Department of Statistics, Statistical Consulting Center, 310 Herty Drive, Athens, GA 30602, USA
| | - Jaxk Reeves
- University of Georgia, Franklin College of Arts and Sciences, Department of Statistics, Statistical Consulting Center, 310 Herty Drive, Athens, GA 30602, USA
| | - Paul A Godley
- University of North Carolina at Chapel Hill, School of Medicine, Department of Hematology and Oncology, 4064 Bondurant Hall, Chapel Hill, NC 27514, USA
| | - Surbhi Shah
- Evidera, Real-World Evidence, 500 Totten Pond Road, Waltham, MA 02451, USA
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Comparative effectiveness in urology: a state of the art review utilizing a systematic approach. Curr Opin Urol 2018; 27:380-394. [PMID: 28426464 DOI: 10.1097/mou.0000000000000405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Comparative effectiveness research plays a vital role in healthcare delivery by guiding evidence-based practices. We performed a state-of-the-art review of comparative effectiveness research in the urology literature for 2016, utilizing a systematic approach. Seven high-impact papers are reviewed in detail. RECENT FINDINGS Across the breadth of urology, there were several important studies in comparative effectiveness research, of which we will highlight two randomized controlled trials and five observational trials: radiotherapy, prostatectomy, and active monitoring have equivalent mortality outcomes in patients with localized prostate cancer; the ideal modality of patient education is yet to be determined, and written education has minimal effect on patient perception of prostate specific antigen screening; robotic prostatectomy is associated with higher perioperative complication rates on a population basis; racial disparities exist in incontinence rates after treatment for localized prostate cancer, but not in irritative, bowel, or sexual function; androgen deprivation therapy is associated with higher fracture, peripheral artery disease, and cardiac-related complications than bilateral orchiectomy; robotic and open cystectomy offer comparable cancer-specific mortality and perioperative outcomes; and bonuses for low-cost hospitals can inadvertently reward low-quality hospitals. SUMMARY There have been major advancements in comparative effectiveness research in urology in 2016.
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