Urologist practice divestment from radiation vault ownership and treatment patterns for prostate cancer

BACKGROUND

Urologists practicing in single-specialty groups with ownership in radiation vaults are more likely to treat men with prostate cancer. The effect of divestment of vault ownership on treatment patterns is unclear.

METHODS

A 20% sample of national Medicare claims was used to perform a retrospective cohort study of men with prostate cancer diagnosed between 2010 and 2019. Urology practices were categorized by radiation vault ownership as nonowners, continuous owners, and divested owners. The primary outcome was use of local treatment, and the secondary outcome was use of intensity-modulated radiation therapy (IMRT). A difference-in-differences framework was used to measure the effect of divestment on outcomes compared to continuous owners. Subgroup analyses assessed outcomes by noncancer mortality risk (high [>50%] vs. low [≤50%]).

RESULTS

Among 72 urology practices that owned radiation vaults, six divested during the study. Divestment led to a decrease in treatment compared with those managed at continuously owning practices (difference-in-differences estimate, -13%; p = .03). The use of IMRT decreased, but this was not statistically significant (difference-in-differences estimate, -10%; p = .13). In men with a high noncancer mortality risk, treatment (difference-in-differences estimate, -28%; p < .001) and use of IMRT (difference-in-differences estimate, -27%; p < .001) decreased after divestment.

CONCLUSIONS

Urology group divestment from radiation vault ownership led to a decrease in prostate cancer treatment. This decrease was most pronounced in men who had a high noncancer mortality risk. This has important implications for health care reform by suggesting that payment programs that encourage constraints on utilization, when appropriate, may be effective in reducing overtreatment.

The 340B Program and oral specialty drugs for advanced prostate cancer

INTRODUCTION

Expensive oral specialty drugs for advanced prostate cancer can be associated with treatment disparities. The 340B program allows hospitals to purchase medications at discounts, generating savings that can improve care of the socioeconomically disadvantaged. This study assessed the effect of hospital 340B participation on advanced prostate cancer.

METHODS

The authors performed a retrospective cohort study of Medicare beneficiaries with advanced prostate cancer from 2012 to 2019. The primary outcome was use of an oral specialty drug. Secondary outcomes included monthly out-of-pocket costs and treatment adherence. We evaluated the effects of 1) hospital 340B participation, 2) a regional measure vulnerability, the social vulnerability index (SVI), and 3) the interaction between hospital 340B participation and SVI on outcomes.

RESULTS

There were 2237 and 1100 men who received care at 340B and non-340B hospitals. There was no difference in specialty drug use between 340B and non-340B hospitals, whereas specialty drug use decreased with increased SVI (odds ratio, 0.95, p = .038). However, the interaction between hospital 340B participation and SVI on specialty drug use was not significant. Neither 340B participation, SVI, or their interaction were associated with out-of-pocket costs. Although hospital 340B participation and SVI were not associated with treatment adherence, their interaction was significant (p = .020). This demonstrated that 340B was associated with better adherence among socially vulnerable men.

CONCLUSIONS

The 340B program was not associated with specialty drug use in men with advanced prostate cancer. However, among those who were started on therapy, 340B was associated with increased treatment adherence in more socially vulnerable men.

The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer

INTRODUCTION

Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer.

METHODS

We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference-in-differences design.

RESULTS

There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference-in-differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference-in-differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference-in-differences -5.5%, p = 0.12) and those managed conservatively (difference-in-differences -2.0%, p = 0.82).

CONCLUSIONS

In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon.

The Future is Female: Urology Workforce Projection from 2020 to 2057

Multiple estimates have approximated a urologist shortage per capita of around 30% by 2030. In the context of the impending urologic workforce shortage, it is critical to have a nuanced understanding of the degree of workforce shortage in comparison with the US population to mitigate the negative downstream effects in the future. In continued growth and stagnant growth projection models, we found that female urologists make up a significant proportion of the workforce growth over the next four decades. This projection highlights the need for purposeful recruitment, structural changes, and advocacy among urology leadership to support and retain female urologists.

Acquisition of Urology Practices by Private Equity Firms and Performance in the Merit-based Incentive Payment System

INTRODUCTION

Private equity is increasingly engaged in the acquisition of urology practices. The implications of strategies to enhance practice value deployed by these firms for patients are unclear.

METHODS

We conducted a retrospective study of urologist performance in the MIPS (Merit-based Incentive Payment System) program for 2017 to 2020 using national Medicare data from the Quality Payment Program file. The primary outcome was the overall MIPS score. Secondary outcomes included MIPS component scores (ie, quality, interoperability, improvement activities, cost) and the percentage of urologists receiving a bonus payment. Generalized estimating equations were used to estimate the relationship between private equity acquisition and outcomes using a difference-in-differences framework.

RESULTS

Between 2017 and 2020, 181 urologists were in a urology practice acquired by private equity with MIPS data available the year before and after acquisition. Compared to urologists in practices not acquired by private equity, those in acquired practices had worse overall MIPS performance after acquisition (difference-in-differences estimate, -14 points, P = .04). The decrease in the overall score was driven by worse performance in the quality score (difference-in-differences estimate, -28 points, P < .001). Finally, acquisition resulted in a decrease in the percentage of urologists receiving bonus payments (difference-in-differences estimate, -43%, P < .001).

CONCLUSIONS

Private equity acquisition of urology practices was associated with significantly lower MIPS performance. As private equity acquisition of urology practices becomes more prevalent, key stakeholders should ensure that the quality of patient care is maintained and that the involvement of for-profit entities in health care is being made transparent to patients.

Association between urology practice use of multiparametric MRI and genomic testing and treatment of men with newly diagnosed prostate cancer

INTRODUCTION

Biomarkers for prostate cancer, such as multiparametric MRI (mpMRI) and tissue-based genomics, are increasingly used for treatment decision-making. Using biomarkers indiscriminately and thus ignoring competing risks of mortality may lead to treatment in some men who derive little clinical benefit. We assessed the relationship between urology practice use of biomarkers and subsequent treatment in men with newly diagnosed prostate cancer.

METHODS

We used a 20% random sample of national Medicare data to perform a retrospective cohort study of men with newly diagnosed prostate cancer diagnosed from 2015 through 2019. Urology practice-level use of biomarkers was characterized based on urology practice propensity to use either biomarker after diagnosis (never, below median, above the median). Noncancer mortality risk within 10 years of diagnosis was calculated for all men. Multilevel models were used to assess the relationship between practice-level biomarker use and treatment by noncancer mortality risk.

RESULTS

Between 2015 and 2019, 1,764 (65%) urology practices used mpMRI and 897 (33%) used genomic testing for prostate cancer. Compared with urology practices never using each biomarker, those using mpMRI above the median (56% vs. 47%, P = 0.003) and tissue-based genomics below the median (56% vs. 50%, P = 0.03) were more likely to treat men with >75% risk of noncancer mortality. Additionally, compared with urology practices never using either biomarker, use of mpMRI (72% vs. 69%, P = 0.07) or tissue-based genomics (71% vs. 70%, P = 0.65) did not impact treatment in the healthiest group (i.e., those with <25% risk of noncancer mortality).

CONCLUSIONS

Compared to practices that do not use each biomarker in men with newly diagnosed prostate cancer, urology practices using mpMRI, and tissue-based genomics to a lesser extent, are more likely to treat men at very high risk of dying from competing risks of mortality within 10 years of prostate cancer diagnosis.

Banking on Fertility Preservation: Financial Concern for Adolescent and Young Adult Cancer Patients Considering Oncofertility Services

Purpose: Financial concern is a major issue for adolescent and young adult (AYA) cancer patients. Furthermore, unaddressed oncofertility challenges (e.g., infertility) are linked to psychological distress and decreased overall quality of life. Little is known about how financial concern in terms of oncofertility (i.e., concern regarding affording fertility preservation [FP] services) impacts AYAs' decision making and experiences. Methods: AYA cancer patients (n = 27) aged 12-25 years whose cancer treatment conferred risk of infertility were recruited through electronic health record query. Participants completed semi-structured interviews, which were recorded, transcribed, and deductively coded for themes related to information needs, knowledge of treatment effects on fertility, and reproductive concerns after cancer. Emergent, inductive themes related to financial concern were identified. The Institutional Review Board at the University of Michigan approved this study (HUM#00157267). Results: Financial concern was a dominant theme across the qualitative data. Emergent themes included (1) varied access to health insurance, (2) presence of parental/guardian support, (3) reliance upon financial aid, (4) negotiating infertility risk, and (5) lack of preparation for long-term costs. AYAs relied heavily upon parents for out-of-pocket and insurance coverage support. Some participants sought financial aid when guided by providers. Several participants indicated that no financial support existed for their circumstance. Conclusions: Financial consequences in terms of oncofertility are a major issue affecting AYA cancer patients. The incidence and gravity of financial concern surrounding affording oncofertility services merits attention in future research (measuring financial resources of AYAs' parental/support networks), clinical practice (strategically addressing short- and long-term costs; tailored psychosocial support), and health care policy (promoting legislation to mandate pre- and post-treatment FP coverage).

Use of a physical activity monitor to track perioperative activity of radical cystectomy patients our first glimpse at what our patients are doing before and after surgery

PURPOSE

To optimize recovery after radical cystectomy (RC), providers stress the importance of ambulation and adequate rest. However, little is known about the activity and sleep habits of patients undergoing RC. Therefore, we utilized a wearable physical activity monitor (PAM) in the perioperative period to provide the first objective data on physical activity and sleep habits for RC patients.

MATERIALS AND METHODS

We prospectively identified patients ≥60 years old with planned RC. Participants completed a 4-week prehabilitation exercise program prior to surgery. They wore a PAM for 7-day intervals: at baseline, after prehabilitation, at postoperative day (POD) 30 and POD90. We tracked physical activity via metabolic equivalents (METs). METs were categorized by intensity: light (MET 1.5-<3), moderate (MET 3-<6), and vigorous (MET ≥6). We calculated daily step totals. We tracked hours slept and number of sleep awakenings. We correlated activity and sleep with self-reported quality of life (QOL).

RESULTS

Forty-two patients completed prehabilitation and RC. Moderate intensity exercise decreased at POD30 (61 minutes/d at baseline, 30 minutes/d at POD30, P = 0.005). Physical activity did not significantly differ for light or vigorous activity at any timepoint. RC did not significantly affect sleep. Sleep and physical activity were associated with mental and physical QOL, respectively.

CONCLUSIONS

This is the first study utilizing patient-worn monitors in RC to track physical activity and sleep. This study gives patients and providers a better understanding of postcystectomy recovery expectations. With these results in mind, interventions may be implemented to optimize activity and sleep in the perioperative period.

Can you have it all? Parenting in Urology and Work-Life Balance Satisfaction

OBJECTIVE

To evaluate the association between work-life balance satisfaction for practicing urologists who have children <18 years compared to those who do not have children or have children ≥18 years.

METHODS

We evaluated the association between work-life balance satisfaction based on partner status, partner employment status, child status, primary responsible party for family, total work hours per week, and total vacation weeks per year using 2018 and 2019 American Urological Association (AUA) census data with post-stratification adjustment methods.

RESULTS

Of 663 respondents, 77 (9.0%) were female and 586 (91%) were male. Female urologists are more likely to have an employed partner (79.vs 48.9%, P <.001), more likely to have children <18 years (75.0 vs 41.7%, P <.0001), and less likely to have a partner as primary caretaker of family (26.5 vs 50.3%, P <.0001) compared to male urologists. Urologists with children <18 years reported lower work-life balance satisfaction than those without (OR 0.65, P = .035). For every 5 additional hours works per week, urologists reported lower work-life balance (OR 0.84, P <.001). However, there are no statistically significant associations between work-life balance satisfaction and gender, employment status of their partner, primary responsible party for family responsibilities, and total weeks of vacation per year.

CONCLUSION

According to recent AUA census data, having children <18 years is associated with lower work-life balance satisfaction. This highlights opportunities to support young parents, both male and female, in the workplace to prevent burnout and maximize well-being among urologists.

Association of Medicare Beneficiary and Hospital Accountable Care Organization Alignment With Surgical Cost Savings

Importance

Although Medicare accountable care organizations (ACOs) account for half of program expenditures, whether ACOs are associated with surgical spending warrants further study.

Objective

To assess whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs.

Design, Setting, and Participants

This retrospective cohort study was conducted between 2020 and 2022 using US Medicare data from a 20% random sample of beneficiaries. Individuals 18 years of age and older and without kidney failure who had a surgical admission between 2008 and 2015 were included. For each study year, distinction was made between beneficiaries assigned to an ACO and those who were not, as well as between admissions to ACO-participating and nonparticipating hospitals.

Exposures

Time-varying binary indicators for beneficiary ACO assignment and hospital ACO participation and an interaction between them.

Main Outcomes and Measures

Ninety-day, price-standardized total episode payments. Multivariable 2-way fixed-effects models were estimated.

Results

During the study period, 2 797 337 surgical admissions (6% of which involved ACO-assigned beneficiaries) occurred at 3427 hospitals (17% ACO participating). Total Medicare payments for 90-day surgical episodes were lowest when ACO-assigned beneficiaries underwent surgery at a hospital participating in the same ACO as the beneficiary ($26 635 [95% CI, $26 426-$26 844]). The highest payments were for unassigned beneficiaries treated at participating hospitals ($27 373 [95% CI, $27 232-$27 514]) or nonparticipating hospitals ($27 303 [95% CI, $27 291-$27 314]). Assigned beneficiaries treated at hospitals participating in a different ACO and assigned beneficiaries treated at nonparticipating hospitals had similar payments (for participating hospitals, $27 003 [95% CI, $26 739-$27 267] and for nonparticipating hospitals, $26 928 [95% CI, $26 796-$27 059]). A notable factor in the observed differences in surgical episode costs was lower spending on postacute care services.

Conclusions and Relevance

In this cohort study evaluating hospital and beneficiary ACO alignment and surgical spending, savings were noted for beneficiaries treated at hospitals in the same ACO. Allowing ACOs to encourage or require surgical procedures in their own hospitals could lower Medicare spending on surgery.

Delayed urologic cancer care in the COVID-19 pandemic: Patients' experiences

Objective

To understand experiences of patients with genitourinary cancer who experienced delayed cancer care due to the COVID‐19 pandemic.

Methods

We conducted a mixed methods study with an explanatory sequential design. Qualitative findings are reported here. Patients with muscle invasive bladder, advanced prostate or kidney cancer were eligible. Participants were selected for interviews if they self‐reported low (0–3/10) or high (6–10/10) levels of distress on a previous survey. Participants were interviewed about their experiences. Interviews were transcribed, coded and categorised using thematic data analysis methodology.

Results

Eighteen patients were interviewed. Seven had prostate cancer, six bladder cancer and five kidney cancer. Six themes were derived from the interviews: (1) arriving at cancer diagnosis was hard enough, (2) response to treatment delay, (3) labelling cancer surgery as elective, (4) fear of COVID‐19 infection, (5) quality of patient‐provider relationship and communication and (6) what could have been done differently.

Conclusion

These findings offer insight into the concerns of patients with genitourinary cancers who experienced treatment delays due to COVID‐19. This information can be applied to support patients with cancers more broadly, should treatment delays occur in the future.

Association Between Organizational Quality and Out-of-Network Primary Care Among Accountable Care Organizations That Care for High vs Low Proportions of Patients of Racial and Ethnic Minority Groups

Question

How is the quality of care delivered by a Medicare accountable care organization (ACO) associated with the level of out-of-network primary care among organizations that care for high vs low proportions of patients of racial and ethnic minority groups?

Findings

In this retrospective cohort study of 3 955 951 beneficiary-years within 528 Medicare ACOs, the ACOs that cared for more patients of racial and ethnic minority groups had significantly higher rates of out-of-network primary care than those that cared for fewer patients of racial and ethnic minority groups. The level of out-of-network primary care was negatively associated with performance among ACOs with many patients of racial and ethnic minority groups across most quality metrics examined.

Meaning

The study findings suggest that organizational efforts to limit out-of-network primary care at ACOs caring for many patients of racial and ethnic minority groups could serve as a tangible, accessible corrective for reducing health care disparities among the populations that they serve.

Importance

Medicare accountable care organizations (ACOs) that disproportionately care for patients of racial and ethnic minority groups deliver lower quality care than those that do not, potentially owing to differences in out-of-network primary care among them.

Objective

To examine how organizational quality is associated with out-of-network primary care among ACOs that care for high vs low proportions of patients of racial and ethnic minority groups.

Design, Setting, and Participants

A retrospective cohort study was conducted between March 2019 and October 2021 using claims data (2013 to 2016) from a national sample of Medicare beneficiaries. Among beneficiaries who were assigned to 1 of 528 Medicare ACOs, a distinction was made between those treated by organizations that cared for high (vs low) proportions of patients of racial and ethnic minority groups. For each ACO, the amount of out-of-network primary care that it delivered annually was determined. Multivariable models were fit to evaluate how the quality of care that beneficiaries received varied by the proportion of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Exposures

The degree of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Main Outcomes and Measures

The ACO quality assessed with 5 preventive care services and 4 utilization metrics.

Results

Among 3 955 951 beneficiary-years (2 320 429 [58.7%] women; 71 218 [1.8%] Asian, 267 684 [6.8%] Black, 44 059 [1.1%] Hispanic, 4922 [0.1%] North American Native, and 3 468 987 [87.7%] White individuals and 56 157 [1.4%] of Other race and ethnicity), those assigned to ACOs serving many patients of racial and ethnic minority groups at the mean level of out-of-network primary care were less likely than those assigned to ACOs serving fewer patients of racial and ethnic minority groups to receive diabetic retinal examinations (predicted probability, 49.4% [95%CI, 49.0%-49.7%] vs 51.6% [95% CI, 51.5%-51.8%]), glycated hemoglobin testing (predicted probability, 58.5% [95% CI, 58.2%-58.5%] vs 60.4% [95% CI, 60.3%-60.6%]), or low-density lipoprotein cholesterol testing (predicted probability, 85.2% [95% CI, 85.0%-85.5%] vs 86.0% [95% CI, 85.9%-86.1%]). They were also more likely to experience all-cause 30-day readmissions (predicted probability, 16.4% [95% CI, 16.1%-16.7%] vs 15.7% [95% CI, 15.6%-15.8%]). However, as the level of out-of-network primary care decreased, these gaps closed substantially, such that beneficiaries at ACOs that served many and fewer patients of racial and ethnic minority groups in the lowest percentile of out-of-network primary care received care of comparable quality.

Conclusions and Relevance

This large cohort study found that quality performance among ACOs serving many patients of racial and ethnic minority groups was negatively associated with their level of out-of-network primary care.

Narrow band imaging versus white light cystoscopy alone for transurethral resection of non-muscle invasive bladder cancer

BACKGROUND

Disease recurrence and progression remain major challenges for the treatment of non-muscle invasive bladder cancer. Narrow band imaging (NBI) is an optical enhancement technique that may improve resection of non-muscle invasive bladder cancer and thereby lead to better outcomes for people undergoing the procedure.  OBJECTIVES: To assess the effects of NBI- and white light cystoscopy (WLC)-guided transurethral resection of bladder tumor (TURBT) compared to WLC-guided TURBT in the treatment of non-muscle invasive bladder cancer.

SEARCH METHODS

We performed a comprehensive literature search of 10 databases, including the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries, and grey literature for published and unpublished studies, irrespective of language. The search was performed per an a priori protocol on 3 December 2021.

SELECTION CRITERIA

We included randomized controlled trials of participants with suspected or confirmed non-muscle invasive bladder cancer. Participants in the control group must have received WLC-guided TURBT alone (hereinafter simply referred to as 'WLC TURBT'). Participants in the intervention group had to have received NBI- and WLC-guided TURBT (hereinafter simply referred to as 'NBI + WLC TURBT').

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion/exclusion, performed data extraction, and assessed risk of bias. We conducted meta-analysis on time-to-event and dichotomous data using a random-effects model in RevMan, according to Cochrane methods. We rated the certainty of evidence for each outcome according to the GRADE approach. Primary outcomes were time to recurrence, time to progression, and the occurrence of a major adverse event, defined as a Clavien-Dindo III, IV, or V complication. Secondary outcomes included time to death from bladder cancer and the occurrence of a minor adverse event, defined as a Clavien-Dindo I or II complication.  MAIN RESULTS: We included eight studies with a total of 2152 participants randomized to the standard WLC TURBT or to NBI + WLC TURBT. A total of 1847 participants were included for analysis.  Based on limited confidence in the time-to-event data, we found that participants who underwent NBI + WLC TURBT had a lower risk of disease recurrence over time compared to participants who underwent WLC TURBT (hazard ratio 0.63, 95% CI 0.45 to 0.89; I2 = 53%; 6 studies, 1244 participants; low certainty of evidence). No studies examined disease progression as a time-to-event outcome or a dichotomous outcome. There was likely no difference in the risk of a major adverse event between participants who underwent NBI + WLC TURBT and those who underwent WLC TURBT (risk ratio 1.77, 95% CI 0.79 to 3.96; 4 studies, 1385 participants; low certainty of evidence). No studies examined death from bladder cancer as a time-to-event outcome or a dichotomous outcome. There was likely no difference in the risk of a minor adverse event between participants who underwent NBI + WLC TURBT and those who underwent WLC TURBT (risk ratio 0.88, 95% CI 0.49 to 1.56; I2 = 61%; 4 studies, 1385 participants; low certainty of evidence).  AUTHORS' CONCLUSIONS: Compared to WLC TURBT alone, NBI + WLC TURBT may lower the risk of disease recurrence over time while having little or no effect on the risks of major or minor adverse events.

Promotional Payments to Medical Oncologists and Urologists and Prescriptions for Abiraterone and Enzalutamide

OBJECTIVE

To understand the influence of drug manufacturers on the prescribing patterns of medical oncologists and urologists, we examined the relationship between promotional payments from the manufacturers of abiraterone and enzalutamide and prescriptions for either drug by medical oncologists and urologists.

METHODS

Promotional payments for abiraterone or enzalutamide made to medical oncologists and urologists between January 2014 and December 2017 reported through the Open Payments Program were categorized as $0, $1$999, and $1000 or more. Prescriptions filled between January 2013 and December 2017 were identified in the Medicare Part D File. Associations between promotional payments and prescribing were assessed using generalized linear models.

RESULTS

From 2013 through 2017, the number of medical oncologists and urologists prescribing abiraterone or enzalutamide increased by 38% - 298%, respectively. The odds of prescribing among medical oncologists receiving $1--$999 and those receiving $1,000 or more were 1.69 (95%CI:1.59--1.79) and 2.61 (95% CI: 2.14--3.18) times that of medical oncologists receiving no payments. Among urologists receiving $1--$999 and those receiving $1,000 or more, the odds of prescribing were 4.04 (95%CI: 3.59--4.54) and 13.57 (95%CI: 9.69--19.0) times that of urologists receiving no payments.

CONCLUSION

Increasing promotional payments were associated with prescribing among medical oncologists and urologists, with a stronger relationship evident for urologists. Prescribing patterns for abiraterone and enzalutamide, particularly among urologists, may be influenced by payments from drug manufacturers.

Intensity of end-of-life care for dual-eligible beneficiaries with cancer and the impact of delivery system affiliation

BACKGROUND

Dual-eligible beneficiaries, who qualify for Medicare and Medicaid, are a vulnerable population with much to gain from efforts to improve quality. Integrated delivery networks and cancer centers, with their emphasis on care coordination and communication, may improve quality of care for dual-eligible patients with cancer at the end of life.

METHODS

This study used Surveillance, Epidemiology, and End Results registry data linked with Medicare claims to evaluate quality for beneficiaries who died of cancer and were diagnosed from 2009 to 2014. High-intensity care was evaluated with 7 end-of-life quality measures according to dual-eligible status with multivariable logistic regression models. Regression-based techniques were used to assess the effect of delivery system affiliation (ie, cancer center or integrated delivery network vs no affiliation).

RESULTS

Among 100,549 beneficiaries who died during the study interval, 22% were dually eligible. Inferior outcomes were identified for dual-eligible beneficiaries in comparison with nondual beneficiaries across nearly every quality measure assessed, including >1 hospitalization in the last 30 days (12.6% vs 11.3%; P < .001) and a greater proportion of deaths occurring in a hospital setting (30.2% vs 26.2%; P < .001). Receipt of care in an affiliated delivery system was associated with reduced deaths in a hospital setting and increased hospice utilization for dual-eligible beneficiaries.

CONCLUSIONS

Dual-eligible status is associated with higher intensity care at the end of life. Delivery system affiliation has a modest impact on quality at the end of life, and this suggests that targeted efforts may be needed to optimize quality for this group of vulnerable patients.

Projected US Urology Workforce per Capita, 2020-2060

Importance

Projections to 2035 have demonstrated concern regarding a worsening urology workforce shortage.

Objective

To project the size and demographic characteristics of the urology workforce per capita into 2060 and to anticipate the timing and degree of the impending urology workforce shortage.

Design, Setting, and Participants

This population-based cross-sectional study used the 2019 American Urological Association Annual Census data and the Accreditation Council for Graduate Medical Education's Data Resource Book from 2007 to 2018. The cohort included practicing urologists in 2019. US Census data were used to approximate the projected US population. Data analysis was performed from June 2020 to March 2021.

Exposures

Continued growth stock and flow model of 13.8% and stagnant growth model of 0% increase of the incoming urology workforce with cohort projection per projected US population.

Main Outcomes and Measures

The primary outcome was urology workforce projection per the population aged 65 years and older. Urology workforce projections per capita and demographic characteristics of the urology workforce up to 2060 were calculated under guided assumptions with 2 stock and flow models.

Results

In 2019, there were 13 044 urologists (11 758 men [90.1.%]; 1286 women [9.9%]; median age range, 55-59 years), with 3.99 urologists per 100 000 persons and 311 new urologists entering the workforce. In a continued growth model, 2030 will have the lowest number of urologists per capita of 3.3 urologists per 100 000 persons, and recovery to baseline will occur by 2050. There are 23.8 urologists per 100 000 persons aged 65 years and older in 2020, which decreases to 15.8 urologists per 100 000 persons aged 65 years and older in 2035 and never recovers to its baseline level by 2060. In a stagnant growth model, there will be a continued decrease of urologists per capita to 3.1 urologists per 100 000 persons by 2060. There is a continued decrease in per capita urologists at each time point, with 13.1 urologists per 100 000 persons aged 65 years and older by 2060.

Conclusions and Relevance

With the impending urology workforce shortage, there will be an exaggerated shortage of total urologists per persons aged 65 years and older in both models. This projection highlights the need for structural changes and advocacy to maximize the available urology workforce.

Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative

OBJECTIVES

To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient.

METHODS

We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients.

RESULTS

Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87).

CONCLUSIONS

Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN.

Adherence and out-of-pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer

BACKGROUND

Abiraterone and enzalutamide are high-cost oral therapies that increasingly are used to treat patients with advanced prostate cancer; these agents carry the potential for significant financial consequences to patients. In the current study, the authors investigated coping and material measures of the financial hardship of these therapies among patients with Medicare Part D coverage.

METHODS

The authors performed a retrospective cohort study on a 20% sample of Medicare Part D enrollees who underwent treatment with abiraterone or enzalutamide between July 2013 and June 2015. The authors described the variability in adherence rates and out-of-pocket payments among hospital referral regions in the first 6 months of therapy and determined whether adherence and out-of-pocket payments were associated with patient factors and the socioeconomic characteristics of where a patient was treated.

RESULTS

There were 4153 patients who filled abiraterone or enzalutamide prescriptions through Medicare Part D in 228 hospital referral regions. The mean adherence rate was 75%. The median monthly out-of-pocket payment for abiraterone and enzalutamide was $706 (range, $0-$3505). After multilevel, multivariable adjustment for patient and regional factors, adherence was found to be lower in patients who were older (69% for patients aged ≥85 years vs 76% for patients aged <70 years; P < .01) and in those with low-income subsidies (69% in those with a subsidy vs 76% in those without a subsidy; P < .01). Both Hispanic ethnicity and living in a hospital referral region with a higher percentage of Hispanic beneficiaries were found to be independently associated with higher out-of-pocket payments for abiraterone and enzalutamide.

CONCLUSIONS

There were substantial variations in the adherence rate and out-of-pocket payments among Medicare Part D beneficiaries who were prescribed abiraterone and enzalutamide. Sociodemographic patient and regional factors were found to be associated with both adherence and out-of-pocket payments.

The Future is Female: Urology Workforce Projection From 2020 to 2060

OBJECTIVE

To project the size and demographics of the female urology workforce into 2060.

METHODS

We assessed current urology workforce estimates using 2019 American Urological Association Annual Census data. We used the Accreditation Council for Graduate Medical Education's Data Resource Book from 2007 to 2018 to determine the incoming urology workforce. With these inputs, we calculated urologic workforce projections using two stock and flow models.

RESULTS

In our continued growth model, the total number of urologists will be lowest in 2025 with 11,600 urologists and recover to baseline by 2040 with 13,377 urologists. The total number of female urologists will grow 3.77-fold from 2020 to 2060 with an absolute increase of 3,792 urologists. Comparatively, the total number of male urologists will grow 1.33-fold with an absolute increase of 3,996 urologists. In our stagnant growth model, the total number of urologists will be lowest in 2030 with 11,354 urologists and will not recover to baseline by the end of our projection. The total number of female urologists will grow 2.18-fold from 2020 to 2060 with an absolute increase of 1,615 urologists. Comparatively, the total number of male urologists will decrease by 21.5% with an absolute decrease of 2,579 urologists.

CONCLUSION

In the context of the impending urologic workforce shortage, female urologists make up a significant proportion of the workforce growth over the next four decades in both the continued growth and growth stagnant models. This projection highlights the need for purposeful recruitment, structural changes, and advocacy among urology leadership to support female urologists.

Medicare Accountable Care Organizations Reduce Spending on Surgery

BACKGROUND

Surgical care among older adults is costly. While Medicare accountable care organizations (ACOs) are designed around primary care, there are reasons to believe that participation may also affect spending on surgery. This study examines the impact that Medicare ACO alignment has on spending for inpatient and outpatient surgical care.

STUDY DESIGN

We conducted a retrospective cohort study using national Medicare claims (2008 through 2015). Among a 20% random sample of beneficiaries, we identified adults 65 years of age and older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a Medicare ACO. We then measured payments for surgical services made on their behalf. Finally, we fit multivariable regression models to evaluate the association between ACO alignment and spending for inpatient and outpatient surgical care.

RESULTS

We identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with a Medicare ACO. After adjustment for patient factors, ACO alignment was associated with $181 [95% confidence interval (CI), -$243 to -$118; P <0.001] lower spending per beneficiary-year. ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year [incidence rate ratio (IRR), 0.97; 95% CI, 0.96 to 0.98; P <0.001] but 2.3% more outpatient episodes per year (IRR, 1.02; 95% CI, 1.02 to 1.03; P <0.001). Among inpatient surgical episodes, average payments were $956 lower for ACO aligned beneficiaries (95%CI -$1218 to -$694, P <0.001).

CONCLUSIONS AND RELEVANCE

ACO alignment was associated with savings on surgical care. These savings resulted from increased outpatient surgery and reduced use of inpatient surgery as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control healthcare spending.

Rethinking the one-size-fits-most approach to venous thromboembolism prophylaxis after radical cystectomy

OBJECTIVES

Empirically dosed enoxaparin is routinely given in the postoperative period for venous thromboembolism (VTE) prophylaxis after radical cystectomy (RC). Patient-specific factors may alter its pharmacokinetics, and it is unclear whether this leads to levels sufficient for antithrombosis. We sought to evaluate variability of anti-factor Xa levels in a cohort of RC patients receiving perioperative enoxaparin prophylaxis.

MATERIAL AND METHODS

Patients undergoing RC at a single institution were placed on a postoperative pathway that included enoxaparin. An anti-factor Xa level was drawn 2 to 4 hours after the third dose. The target range for prophylaxis was 0.3 IU/ml to 0.5 IU/ml.

RESULTS

The primary outcome was anti-factor Xa level. Demographics, operative time, hospital course, and 30-days post-operative VTE were compared by anti-factor Xa level group using univariate and multivariable analyses. Between January 2018 and 2019, 107 RC patients remained on pathway and were included in our analysis. Sixty-five (61%) were below target range for VTE prophylaxis.  A single VTE event (0.9%) occurred in a subprophylactic individual. The subprophylactic group had a significantly higher body mass index (P < 0.01) than those within target range.

CONCLUSIONS

Higher body mass index was associated with subprophylactic enoxaparin dosing after RC. Nearly two-thirds of patients had below target anti-factor Xa levels. This suggests that dosing could be further individualized, but given the low incidence of VTE, implications of dose-adjusted prophylaxis on VTE prevention remain unknown.

Rapid organoid development, drug screening, and neoadjuvant chemotherapy response prediction for patients with locally advanced bladder cancer

543

Background: Neoadjuvant chemotherapy prior to radical cystectomy (RC) for muscle-invasive urothelial carcinoma (UCCx) is the standard of care though the absolute survival benefit is small, and some patients progress during chemotherapy. While progress has been made in the prediction of sensitivity to platinum-based chemotherapies, providing more accurate, personalized, and clinically-relevant chemotherapy response prediction is an unmet need. We present our early and ongoing experience with rapid, organoid-based drug-screening. Methods: one gram of tumor was procured from patients undergoing TURBT or RC and divided between DNA/RNA sequencing, organoid drug-screening, and patient-derived xenografts. Tissue was dissociated, filtered, and resuspended in organoid media for serial passage and drug screening. Drugs were tested at “Cmax” concentration, which is the maximum plasma concentration in human trials so as to provide physiologic relevance. Results were normalized to control such that a value of 100 indicated no drug effect compared to control, and a value of 0 indicated complete response. Number of drugs screened was dependent upon tissue available, but was often 20-30. Results: 25 patients have undergone rapid organoid development and drug testing to date. Clinical correlations with chemotherapy response are ongoing. Drug response analyses were available 5-10 days following procedure. Select drug response data from the 9 most recent patient organoid samples are presented in the Table. DNA and RNA sequencing and PDX models are in progress. Conclusions: This platform allows for the rapid determination of neoadjuvant chemotherapy response and may further guide selection of therapeutic agents in patients with locally advanced bladder cancer.[Table: see text]

Financial hardship among Medicare beneficiaries prescribed oral targeted therapies for advanced prostate cancer

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Background: Abiraterone and enzalutamide are increasingly being used to treat advanced prostate cancer. Understanding barriers to adhering to treatment is of paramount importance in ensuring continued access to these important therapies. Patients with limited resources or insufficient access to mechanisms that lower their out-of-pocket cost are likely to suffer from significant financial toxicity and may engage in coping mechanisms such as rationing or abandoning their medication. Methods: To address the variability in measures of financial hardship, we performed a retrospective cohort study on a 20% sample of patients eligible for Medicare Part D who received their first fill of abiraterone or enzalutamide between July 2013 and June 2015. Patients were assigned to a provider based on their first prescription, and a hospital referral region (HRR) based on their ZIP code. The primary outcomes were to determine the proportion of days covered (PDC), overall prescription adherence, and average monthly out-of-pocket cost to patients prescribed abiraterone or enzalutamide, all within the first six months of treatment. Results: From mid-2013 to mid-2015, 4529 patients filled abiraterone or enzalutamide through Medicare Part D, within 305 HRRs. There was substantial variability in PDC, adherence, and out-of-pocket cost to patients among HRRs. The mean PDC was 84% with mean adherence of 73%, which included the 393 (8.7%) of patients who abandoned oral therapy after 1-2 fills. The median standard monthly out-of-pocket cost was $707, ranging between $0 and $3505. Among patients with low-income subsidies, median out-of-pocket cost by HRR ranged from $0 to $2815. We observed that PDC tracked closely with socioeconomic status – HRRs that included a higher proportion of patients eligible for Medicaid had lower PDCs and adherence, but lower standard out-of-pocket cost. Conclusions: This investigation demonstrated significant variation in PDC, adherence, and out-of-pocket cost among different HRRs for patients prescribed abiraterone and enzalutamide and that much of the variability in financial hardship measures among HRRs may be due to socioeconomic variables and regional variability.

Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care

PURPOSE

To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer.

PATIENTS AND METHODS

We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types.

RESULTS

Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all P < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures.

CONCLUSION

Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer.

Understanding the Costs Associated With Surgical Care Delivery in the Medicare Population

BACKGROUND

Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood.

OBJECTIVE

To quantify the costs of inpatient and outpatient surgery in the Medicare population.

METHODS

We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008-2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpatient episode payments by surgical specialty. For inpatient episodes, we determined component payments related to the index hospitalization, readmissions, physician services, and postacute care. For outpatient episodes, we differentiated by the site of care (hospital outpatient department versus physician office versus ambulatory surgery center). We used linear regression to evaluate temporal trends in inpatient and outpatient surgical spending. Finally, we estimated the contribution of surgical care to overall Medicare expenditures.

RESULTS

Total Medicare payments for surgical care are substantial, representing 51% of Program spending in 2014. They declined modestly over the study period, from $133.1 billion in 2008 to $124.9 billion in 2014 (-6.2%, P = 0.085 for the temporal trend). While spending on inpatient surgery contributed the most to total surgical payments (69.4% in 2014), it declined over the study period, driven by decreases in index hospitalization (-16.7%, P = 0.002) and readmissions payments (-27.0%, P = 0.003). In contrast, spending on outpatient surgery increased by $8.5 billion (28.7%, P < 0.001). This increase was realized across all sites of care (hospital outpatient department: 36.6%, P < 0.001; physician office: 22.1%, P < 0.001; ambulatory surgery center: 36.6%, P < 0.001). Ophthalmology and hand surgery witnessed the greatest growth in surgical spending over the study period.

CONCLUSIONS AND RELEVANCE

Surgical care accounts for half of all Medicare spending. Our findings not only highlight the magnitude of spending on surgery, but also the areas of greatest growth, which could be targeted by future payment reforms.

Practice-Level Adoption of Conservative Management for Prostate Cancer

PURPOSE

We describe the longitudinal adoption of conservative management (ie, the absence of treatment) for prostate cancer among urology group practices in the United States and identify group practice features that influence this adoption.

METHODS

Using a 20% sample of Medicare claims, we identified men with incident prostate cancer from 2010 through 2014 and assigned each to his predominant urologist. We linked each urologist to a practice and characterized the practice's organization (eg, solo, single specialty, multispecialty) and ownership of intensity-modulated radiation therapy. For each group, we determined the rate of conservative management within 1 year of diagnosis. We then fit mixed-effects logistic regression models to assess relationships between practice organization and the adoption of conservative management over time, adjusted for patient characteristics.

RESULTS

We identified 22,178 men with newly diagnosed prostate cancer managed by 350 practices. Practices that increased use the most over time also used conservative management the most in 2010, whereas those that increased use the least used conservative management the least in 2010. Thus, the difference in average use of conservative management between highest- and lowest-use practices widened between 2010 and 2014. Urology groups increased their use of conservative management more rapidly than multispecialty groups. There was no difference in the rate of increase between intensity-modulated radiation therapy owning and nonowning groups.

CONCLUSION

There is increasing variation among group practices in the use of conservative management for prostate cancer. This underscores the need for a better understanding of practice-level factors that influence prostate cancer management.

Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery

OBJECTIVE

To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures.

SUMMARY BACKGROUND DATA

Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies.

METHODS

We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures.

RESULTS

Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided.

CONCLUSION

Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.

Urologist Practice Structure and Spending for Prostate Cancer Care

OBJECTIVE

To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership.

MATERIALS AND METHODS

We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics.

RESULTS

We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims.

CONCLUSION

Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest.

Variation in Physician-Specific Episode Payments for Major Cancer Surgery and Implications for the Merit-Based Incentive Program

BACKGROUND

Nearly 1.5 million clinicians in the United States will be affected by Centers for Medicare and Medicaid Services' (CMS) new payment program, the Merit-based Incentive Program (MIPS), where clinicians will be penalized or rewarded based on the health care expenditures of their patients. We therefore examined expenditures for major cancer surgery to understand physician-specific variation in episode payments.

METHODS

We used Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 y who underwent a prostatectomy, nephrectomy, lung, or colorectal resection for cancer from 2008 to 2012. We calculated 90-d episode payments, attributed each episode to a physician, and evaluated physician-level payment variation. Next, we determined which component (index admission, readmission, physician services, postacute care, hospice) drove differences in payments. Finally, we evaluated payments by geographic region, number of comorbidities, and cancer stage.

RESULTS

We identified 39,109 patients who underwent surgery by 1 of 7182 providers. There was wide variation in payments for each procedure (prostatectomy: $7046-$40,687; nephrectomy: $8855-$82,489; lung resection: $11,167-$223,467; colorectal resection: $9711-$199,480). The largest component difference in episode payments varied by condition: physician payments for prostatectomy (29%), postacute care for nephrectomy (38%) and colorectal resections (38%), and index hospital admission for lung resections (43%) but were fairly stable across region, comorbidity number, and cancer stage.

CONCLUSIONS

For patients undergoing major cancer surgery, 90-d episode payments vary widely across surgeons. The components driving such variation differ by condition but remain stable across region, number of comorbidities, and cancer stage. These data suggest that programs to reduce specific component payments may have advantages over those targeting individual physicians for decreasing health care expenditures.

The Stability of Physician-Specific Episode Costs for Urologic Cancer Surgery: Implications for Urologists Under the Merit-Based Incentive Program

OBJECTIVE

To evaluate the stability of physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy in the context of value-based purchasing programs, such as the merit-based incentive payment system.

METHODS

We utilized Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 who underwent a prostatectomy, nephrectomy, or cystectomy from 2008 to 2012. We calculated each surgeon's average 90-day episode payment by procedure. Next, we examined payment differences between the most and least expensive quartile providers. For the most expensive quartile of physicians in 2010, we examined their spending quartile in 2011. Finally, we evaluated the correlation in spending over time and across procedures.

RESULTS

We identified 14,585 patients who underwent surgery by one of 1895 unique clinicians. Differences in payments between the highest and lowest quartiles were $5881, $17,714, and $40,288 for prostatectomy, nephrectomy, and cystectomy, respectively. Only 39%, 16%, and 13% of physicians that were in the highest spending quartile for prostatectomy, nephrectomy, and cystectomy in 2010 were also in the most expensive quartile in 2011. Although we observed weak correlation in year-to-year spending for prostatectomy (0.108, P = .033 to .270, P < .001), annual payments for nephrectomy and cystectomy were not significantly correlated. Finally, there was minimal correlation in surgeon spending across procedures.

CONCLUSION

There is wide variation in physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy. However, physician spending patterns are not stable over time or across procedures, raising concerns about the ability of the cost-based measures in merit-based incentive payment system to change physician behavior and reliably distinguish those providing less efficient or lower quality care.

Utilization and Outcomes of Inpatient Surgery at Safety-Net Hospitals

Funding changes enacted with health care reform may compromise care and outcomes for vulnerable populations undergoing surgery in safety-net hospitals (SNHs). We performed a retrospective cohort study of surgical patients from 2007 through 2011. We examined the distribution of surgical procedures for SNHs (quartile of hospitals with the highest proportion of Medicaid plus self-pay discharges) vs. non-SNHs (lowest quartile). We fit multivariable models to compare in-hospital mortality, prolonged length of stay (LOS), and hospital costs at SNHs vs. non-SNHs. More gynecologic (C-section 10.6% of all procedures at SNH vs. 5.8% non-SNH, p &lt; .001) and fewer orthopedic procedures (joint replacement 4.4% vs. 9.9%, spinal fusion 4.3% vs. 7.1%, p &lt; .001) are performed at SNHs. Across nearly all procedures studied, adjusted inpatient mortality and prolonged LOS were higher at SNHs, while costs remained similar. Further reductions in funding as a consequence of health care reform may threaten access and exacerbate existing health disparities.

Costs of Cancer Care Across the Disease Continuum

Using SEER‐Medicare data, this article demonstrates that considerable differences exist in expenditures across phases of care and varying patient characteristics. These findings can help to provide a better understanding of the drivers of payment variation across patient and tumor characteristics to inform efforts to decrease costs and increase quality of cancer care.

Purpose.

The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity.

Materials and Methods.

We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis.

Results.

We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year.

Conclusion.

Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care.

Implications for Practice.

Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.

System-Level Health-Care Integration and the Costs of Cancer Care Across the Disease Continuum

PURPOSE

Policy reforms in the Affordable Care Act encourage health care integration to improve quality and lower costs. We examined the association between system-level integration and longitudinal costs of cancer care.

METHODS

We used linked SEER-Medicare data to identify patients age 66 to 99 years diagnosed with prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian cancer from 2007 to 2012. We attributed each patient to one or more phases of care (ie, initial, continuing, and end of life) according to time from diagnosis until death or end of study interval. For each phase, we aggregated all claims with the primary cancer diagnosis and identified patients treated in an integrated delivery network (IDN), as defined by the Becker Hospital Review list of the top 100 most integrated health delivery systems. We then determined if care provided in an IDN was associated with decreased payments across cancers and for each individual cancer by phase and across phases.

RESULTS

We identified 428,300 patients diagnosed with one of 10 common cancers. Overall, there were no differences in phase-based payments between IDNs and non-IDNs. Average adjusted annual payments by phase for IDN versus non-IDNs were as follows: initial, $14,194 versus $14,421, respectively ( P = .672); continuing, $2,051 versus $2,099 ( P = .566); and end of life, $16,257 versus $16,232 ( P = .948). However, in select cancers, we observed lower payments in IDNs. For bladder cancer, payments at the end of life were lower for IDNs ($11,041 v $12,331; P = .008). Of the four cancers with the lowest 5-year survival rates (ie, pancreatic, lung, esophageal, and liver), average expenditures during the initial and continuing-care phases were lower for patients with liver cancer treated in IDNs.

CONCLUSION

For patients with one of 10 common malignancies, treatment in an IDN generally is not associated with lower costs during any phase of cancer care.

Association of Delivery System Integration and Outcomes for Major Cancer Surgery

BACKGROUND

Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown.

METHODS

Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals.

RESULTS

The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status.

CONCLUSIONS

The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery.

Effects of the Medicare Modernization Act on Spending for Outpatient Surgery

OBJECTIVES

To examine the effects of Medicare's revised ambulatory surgery center (ASC) payment schedule on overall payments for outpatient surgery.

DATA SOURCES

Twenty percent sample of national Medicare beneficiaries.

STUDY DESIGN

We conducted a pre-post study of Medicare beneficiaries who underwent outpatient surgery in a hospital outpatient department (HOPD), ASC, or physician office between 2004 and 2011. Specifically, we used multivariable regression to compare temporal trends in outpatient surgery before and after implementation of Medicare's revised payment schedule in 2008, which reduced ASC facility payments to roughly two-thirds that of HOPDs. Our outcome measures included overall Medicare payments, utilization rates, per beneficiary spending, and average episode payments for outpatient surgery.

PRINCIPAL FINDINGS

Between the last quarters of 2007 and 2008, overall Medicare payments for outpatient surgery grew by $334 million-an amount nearly three times higher than would have been expected without the policy change (p < .001 for the difference). While utilization rates of outpatient surgery were attenuated, per beneficiary spending and average surgical episode payments increased by 10.4 percent and 7.8 percent, respectively, over the same period. By the end of 2011, Medicare payments for outpatient surgery reached $5.1 billion. Without the policy change, they would have totaled only $4.1 billion.

CONCLUSIONS

Despite lessening demand, reduced ASC facility payments did not curb spending for outpatient surgery. In fact, overall payments actually increased following the policy change, driven by higher average episode payments.

Accountable care organizations and prostate cancer care

Purpose

Accountable care organizations have the potential to increase the value of healthcare by improving population health and enhanced financial stewardship. How practice context modifies effects on a specialty-focused disease, such as prostate cancer care, has implications for their success.

Methods

We performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single-specialty, large single-specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12-month period after diagnosis according to accountable care organization alignment and practice affiliation.

Results

Of 15,640 patients with newly diagnosed prostate cancer, 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had similar use of curative treatment to those not in accountable care organizations (71.4% vs. 70.0%, respectively; p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations ($20,916 vs. $19,773, p=0.03); however, this relationship was independent of the practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p<0.05) but not with treatment (p=0.87).

Conclusions

Prostate cancer patients aligned with accountable care organizations had similar rates of treatment, but increased spending, in the year following diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Association Between Patient Satisfaction and Short-Term Outcomes After Major Cancer Surgery

OBJECTIVE

The aim of this study was to investigate whether patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is associated with short-term outcomes after major cancer surgery.

MATERIALS AND METHODS

We first used national Medicare claims to identify patients who underwent a major extirpative cancer surgery from 2011 to 2013. Next, we used Hospital Compare data to assign the HCAHPS score to the hospital where the patient underwent surgery. We then performed univariate statistical analyses and fit multilevel logistic regression models to evaluate the relationship between excellent patient satisfaction and short-term cancer surgery outcomes for all surgery types combined and then by each individual surgery type.

RESULTS

We identified 373,692 patients who underwent major cancer surgery for one of nine cancers at 2617 hospitals. In both unadjusted and adjusted analyses, hospitals with higher proportions of patients reporting excellent satisfaction had lower complication rates (p < 0.001), readmissions (p < 0.001), mortality (p < 0.001), and prolonged length of stay (p < 0.001) than hospitals with lower proportions of satisfied patients, but with modest differences. This finding held true broadly across individual cancer types for complications, mortality, and prolonged length of stay, but less so for readmissions.

CONCLUSIONS

Hospital-wide excellent patient satisfaction scores are associated with short-term outcomes after major cancer surgery overall, but are modest in magnitude.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care

BACKGROUND

Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care.

METHODS

Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses.

RESULTS

Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment.

CONCLUSIONS

The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.

Episode-based Payment Variation for Urologic Cancer Surgery

OBJECTIVE

To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures.

METHODS

Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation.

RESULTS

Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals.

CONCLUSION

Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care.

Understanding the relationship between the Centers for Medicare and Medicaid Services' Hospital Compare star rating, surgical case volume, and short-term outcomes after major cancer surgery

BACKGROUND

Both the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare star rating and surgical case volume have been publicized as metrics that can help patients to identify high-quality hospitals for complex care such as cancer surgery. The current study evaluates the relationship between the CMS' star rating, surgical volume, and short-term outcomes after major cancer surgery.

METHODS

National Medicare data were used to evaluate the relationship between hospital star ratings and cancer surgery volume quintiles. Then, multilevel logistic regression models were fit to examine the association between cancer surgery outcomes and both star rankings and surgical volumes. Lastly, a graphical approach was used to compare how well star ratings and surgical volume predicted cancer surgery outcomes.

RESULTS

This study identified 365,752 patients undergoing major cancer surgery for 1 of 9 cancer types at 2,550 hospitals. Star rating was not associated with surgical volume (P < .001). However, both the star rating and surgical volume were correlated with 4 short-term cancer surgery outcomes (mortality, complication rate, readmissions, and prolonged length of stay). The adjusted predicted probabilities for 5- and 1-star hospitals were 2.3% and 4.5% for mortality, 39% and 48% for complications, 10% and 15% for readmissions, and 8% and 16% for a prolonged length of stay, respectively. The adjusted predicted probabilities for hospitals with the highest and lowest quintile cancer surgery volumes were 2.7% and 5.8% for mortality, 41% and 55% for complications, 12.2% and 11.6% for readmissions, and 9.4% and 13% for a prolonged length of stay, respectively. Furthermore, surgical volume and the star rating were similarly associated with mortality and complications, whereas the star rating was more highly associated with readmissions and prolonged length of stay.

CONCLUSIONS

In the absence of other information, these findings suggest that the star rating may be useful to patients when they are selecting a hospital for major cancer surgery. However, more research is needed before these ratings can supplant surgical volume as a measure of surgical quality. Cancer 2017;123:4259-4267. © 2017 American Cancer Society.

Reimbursement and use of intensity-modulated radiation therapy for prostate cancer

The use of intensity-modulated radiation therapy (IMRT) for prostate cancer increased through the mid-2000s, in association with acquisition of the devices by large urology groups. More recently, reimbursement for IMRT in the office setting (generally representing freestanding facilities owned by physicians) has been declining. The aim of the study was to examine trends in IMRT use and related payments in the office versus hospital outpatient setting over time.In this retrospective cohort study, a total of 66,967 men aged 66 years or older, with newly diagnosed prostate cancer from 2007 through 2012 were identified in a 20% national sample of Medicare claims. IMRT use in the office versus hospital outpatient setting was examined over time, adjusted for patient characteristics using multivariable logistic regression models. Mean reimbursement for IMRT treatments and total IMRT-related payments were plotted by year.IMRT use increased from 28.6% to 38.0% of newly diagnosed men with prostate cancer over the study period, exclusively related to growth in the office setting. In particular, use in the office setting increased from 13.2% in 2007 to 22.1%, whereas use in the hospital outpatient setting remained essentially steady throughout the period around 15%. During the same period mean reimbursement for IMRT in the office setting declined from $504 per individual radiation treatment to $381, whereas it increased from $283 to $380 in the hospital outpatient setting. However, total IMRT-related payments in the office setting increased through 2011 due to increased utilization, falling only in 2012 (to $35.7 million from $48.3 million in 2011) related both to continued declines in reimbursement and a large reduction in new cases of prostate cancer.In conclusion, use of IMRT in the physician office setting in men diagnosed with prostate cancer has continued to increase in the face of declining reimbursement. Total payments for IMRT fell only in 2012, following a substantial reduction in new cases of prostate cancer.