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Faraj KS, Kaufman SR, Herrel LA, Maganty A, Oerline MK, Caram MEV, Shahinian VB, Hollenbeck BK. Urologist practice divestment from radiation vault ownership and treatment patterns for prostate cancer. Cancer 2024; 130:1609-1617. [PMID: 38146764 PMCID: PMC11009074 DOI: 10.1002/cncr.35168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/23/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
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.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan E. V. Caram
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Triner D, Daignault-Newton S, Singhal U, Sessine M, Dess RT, Caram MEV, Borza T, Ginsburg KB, Lane BR, Morgan TM. Variation in management of lymph node positive prostate cancer after radical prostatectomy within a statewide quality improvement consortium. Urol Oncol 2024:S1078-1439(24)00398-3. [PMID: 38570271 DOI: 10.1016/j.urolonc.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are at high risk of disease persistence and progression. Contemporary management trends of pN+ CaP are not well described. MATERIALS AND METHODS Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with clinically localized prostate cancer who underwent radical prostatectomy between 2012 and 2023 with cN0/pN+ disease were identified. The primary outcome was to evaluate patient and practice-level factors associated with time to secondary post-RP treatment. Secondary outcomes included practice-level variation in management of pN+ CaP and rates of secondary treatment modality. To assess factors associated with secondary treatment, a Cox proportional hazards model of a 60-day landmark analysis was performed. RESULTS We identified 666 patients with pN+ disease. Overall, 66% underwent secondary treatment within 12 months post-RP. About 19% of patients with detectable post-RP PSA did not receive treatment. Of patients receiving secondary treatment after 60-days post-RP, 34% received androgen deprivation therapy (ADT) alone, 27% received radiation (RT) alone, 36% received combination, and 4% received other systemic therapies. In the multivariable model, pathologic grade group (GG)3 (HR 1.5; 95%CI: 1.05-2.14), GG4-5 (HR 1.65; 95%CI: 1.16-2.34), positive margins (HR 1.46; 95%CI: 1.13-1.88), and detectable postoperative PSA ≥0.1 ng/ml (HR 3.46; 95%CI: 2.61-4.59) were significantly associated with secondary post-RP treatment. There was wide variation in adjusted practice-level 12-month secondary treatment utilization (28%-79%). CONCLUSIONS The majority pN+ patients receive treatment within 12 months post-RP which was associated with high-risk pathological features and post-RP PSA. Variation in management of pN+ disease highlights the uncertainty regarding the optimal management. Understanding which patients will benefit from secondary treatment, and which type, will be critical to minimize variation in care.
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Affiliation(s)
- Daniel Triner
- Department of Urology, Michigan Medicine, Ann Arbor, MI.
| | | | - Udit Singhal
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Department of Urology, Mayo Clinic, Rochester, MN
| | - Michael Sessine
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Robert T Dess
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, MI
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Brian R Lane
- Division of Urology, Corewell Health Hospital System, Grand Rapids, MI
| | - Todd M Morgan
- Department of Urology, Michigan Medicine, Ann Arbor, MI
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Maganty A, Kaufman SR, Oerline MK, Lai LY, Caram MEV, Shahinian VB, Hollenbeck BK. National Trends in Management of Newly Diagnosed Prostate Cancer. Clin Genitourin Cancer 2024; 22:10-17. [PMID: 37468340 DOI: 10.1016/j.clgc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Deciding whether to treat or conservatively manage patients with prostate cancer is challenging. Recent changes in guidelines, advances in treatment technologies, and policy can influence decision making surrounding management, particularly for those for whom the decision to treat is discretionary. Contemporary trends in management of newly diagnosed prostate cancer are unclear. METHODS Using national Medicare data, men with newly diagnosed prostate cancer were identified between 2014 and 2019. Patients were classified by 5- and 10-year noncancer mortality risk. Multinomial logistic regression models were fit to assess adjusted trends in management over time. The primary outcome was management of prostate cancer: local treatment (inclusive of surgery, radiation, brachytherapy, or cryotherapy), hormone therapy, or observation. RESULTS Local treatment was the most common form of management and stable across years (68%). Use of observation increased (21%-23%, P < .001) and use of hormone therapy decreased (11%-8%, P < 0.001). After stratifying by 10-year non-cancer mortality risk, observation increased among men with low (22.3%-26.1%, P < .001) and moderate (19.9%-23.5%, P < .001) mortality risk. Conversely, use of treatment increased among those with high (62.8%-68.0%, P = .004) and very high (45.5%-54.1%, P < .001) risk of noncancer mortality. These trends were similar across groups when stratified by 5-year noncancer mortality risk. CONCLUSION Nationally, use of local treatment remains common and was stable throughout the study period. However, while local treatment declined among men with a lower risk of noncancer mortality, it increased among men with a higher risk of non-cancer mortality.
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Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lillian Y Lai
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Brent K Hollenbeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Faraj KS, Kaufman SR, Oerline M, Herrel LA, Maganty A, Caram MEV, Shahinian VB, Hollenbeck BK. The 340B Program and oral specialty drugs for advanced prostate cancer. Cancer 2024. [PMID: 38395607 DOI: 10.1002/cncr.35262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan E V Caram
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Stensland KD, Caram MEV, Herr DJ, Burns JA, Sparks JB, Elliott DA, Shin C, Morgan TM, Zaslavsky A, Hollenbeck BK, Tsodikov A, Skolarus TA. National Long-term Survival Estimates After Radical Prostatectomy for Prostate Cancer. Urology 2024; 184:135-141. [PMID: 37951360 DOI: 10.1016/j.urology.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE To examine survival and disease control outcomes, including metastasis-related survival outcomes, in a large contemporary cohort of patients undergoing radical prostatectomy for localized prostate cancer. METHODS We conducted a retrospective study of men with localized prostate cancer treated with radical prostatectomy from 2005 to 2015 with follow-up through 2019 in the Veterans Health Administration. We defined biochemical recurrence (BCR) as a prostate-specific antigen ≥0.2 ng/mL. We used a validated natural language processing encoded dataset to identify incident metastatic prostate cancer. We estimated overall survival from time of surgery, time of BCR, and time of first metastasis using the Kaplan-Meier method. We then estimated time from surgery to BCR, BCR to metastatic disease, and prostate-cancer-specific survival from various time points using cumulative incidence considering competing risk of death. RESULTS Of 21,992 men undergoing radical prostatectomy, we identified 5951 (27%) who developed BCR. Of men with BCR, 677 (11%) developed metastases. We estimated the 10-year cumulative incidence of BCR and metastases after BCR were 28% and 20%, respectively. Median overall survival after BCR was 14years, with 10-year survival of 70%. From the time of metastasis, median overall survival approached 7years, with 10-year overall survival of 34%. Prostate cancer-specific survival for the entire cohort at 10years was 94%. CONCLUSION In this large contemporary national cohort, survival for men with biochemically recurrent prostate cancer is longer than historical cohorts. When counseling patients and designing clinical studies, these updated estimates may serve as more reliable reflections of current outcomes.
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Affiliation(s)
| | - Megan E V Caram
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel J Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Jennifer A Burns
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B Sparks
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - David A Elliott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Chris Shin
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | | | | | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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Maganty A, Kaufman SR, Oerline MK, Faraj KS, Caram MEV, Shahinian VB, Hollenbeck BK. Value-based payment models and management of newly diagnosed prostate cancer. Cancer Med 2023; 13:e6810. [PMID: 38146905 PMCID: PMC10807592 DOI: 10.1002/cam4.6810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. METHODS Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. RESULTS Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). CONCLUSIONS How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.
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Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Samuel R. Kaufman
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Mary K. Oerline
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Kassem S. Faraj
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- VA Health Services Research & Development, Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Vahakn B. Shahinian
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Division of Nephrology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Brent K. Hollenbeck
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
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Faraj KS, Kaufman SR, Herrel LA, Maganty A, Oerline M, Caram MEV, Shahinian VB, Hollenbeck BK. The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer. Cancer Med 2023; 12:22325-22332. [PMID: 38100144 PMCID: PMC10757152 DOI: 10.1002/cam4.6788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/22/2023] [Accepted: 11/23/2023] [Indexed: 12/31/2023] Open
Abstract
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.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan E V Caram
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Faraj KS, Kaufman SR, Herrel LA, Maganty A, Oerline M, Caram MEV, Shahinian VB, Hollenbeck BK. Acquisition of Urology Practices by Private Equity Firms and Performance in the Merit-based Incentive Payment System. Urol Pract 2023; 10:597-603. [PMID: 37856709 PMCID: PMC10593488 DOI: 10.1097/upj.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 10/21/2023]
Abstract
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.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
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Caram MEV. The perfect storm. Urol Oncol 2023; 41:361-362. [PMID: 37400354 DOI: 10.1016/j.urolonc.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/10/2023] [Indexed: 07/05/2023]
Affiliation(s)
- Megan E V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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Krampe N, Kaufman SR, Oerline MK, Hill D, Caram MEV, Shahinian VB, Hollenbeck BK, Maganty A. Health care delivery system contributions to management of newly diagnosed prostate cancer. Cancer Med 2023; 12:17346-17355. [PMID: 37475511 PMCID: PMC10501260 DOI: 10.1002/cam4.6349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear. METHODS Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups. RESULTS Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high-risk of noncancer mortality (range of practice-level rates of treatment for high: 57%-71% and very high: 41%-61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high-risk of noncancer mortality (26% and 40%, respectively). CONCLUSIONS Variation among urology practices in use of treatment was highest for men with high and very high-risk noncancer mortality. Practice characteristics explained a large share of this variation.
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Affiliation(s)
- Noah Krampe
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Samuel R. Kaufman
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Mary K. Oerline
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Dawson Hill
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Vahakn B. Shahinian
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Division of Nephrology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
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12
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Tsao PA, Burns J, Kumbier K, Sparks JB, Entenman S, Bloor LE, Bohnert ASB, Skolarus TA, Caram MEV. Mental health care utilization among men with castration-resistant prostate cancer receiving abiraterone or enzalutamide. Cancer Med 2023; 12:16490-16501. [PMID: 37325888 PMCID: PMC10469813 DOI: 10.1002/cam4.6237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Abiraterone and enzalutamide are castration-resistant prostate cancer (CRPC) therapies with potentially distinct associations with mental health symptoms given their differing antiandrogen targets. METHODS We used national Veterans Health Administration data to identify patients with CRPC who received first-line abiraterone or enzalutamide from 2010 to 2017. Using Poisson regression, we compared outpatient mental health encounters per 100 patient-months on drug between the abiraterone and enzalutamide cohorts adjusting for patient factors (e.g., age). We compared mental health encounters in the year before versus after starting therapy using the McNemar test. RESULTS We identified 2902 CRPC patients who received abiraterone (n = 1992) or enzalutamide (n = 910). We found no difference in outpatient mental health encounters between the two groups (adjusted incident rate ratio [aIRR] 1.04, 95% confidence interval [CI] 0.95-1.15). However, men with preexisting mental health diagnoses received 81.3% of the outpatient mental health encounters and had higher rates of these encounters with enzalutamide (aIRR 1.21, 95% CI 1.09-1.34). Among patients with ≥1 year of enrollment before and after starting abiraterone (n = 1139) or enzalutamide (n = 446), there was no difference in mental health care utilization before versus after starting treatment (17.0% of patients vs. 17.6%, p = 0.60, abiraterone; 16.4% vs. 18.4%, p = 0.26, enzalutamide). CONCLUSION We found no overall differences in mental health care utilization between CRPC patients who received first-line abiraterone versus enzalutamide. However, men with preexisting mental health diagnoses received the majority of mental health care and had more mental health visits with enzalutamide.
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Affiliation(s)
- Phoebe A. Tsao
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Jennifer Burns
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Kyle Kumbier
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Jordan B. Sparks
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Shami Entenman
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Lindsey E. Bloor
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of PsychiatryVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Amy S. B. Bohnert
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Department of Surgery, Section of UrologyUniversity of Chicago Pritzker School of MedicineChicagoIllinoisUSA
| | - Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
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13
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Hill D, Kaufman SR, Oerline MK, Faraj K, Caram MEV, Shahinian VB, Hollenbeck BK, Maganty A. In-office dispensing of oral targeted agents by urology practices in men with advanced prostate cancer. JNCI Cancer Spectr 2023; 7:pkad062. [PMID: 37643638 PMCID: PMC10555918 DOI: 10.1093/jncics/pkad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/26/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Management of men with advanced prostate cancer has evolved to include urologists, made possible by oral targeted agents (eg, abiraterone or enzalutamide) that can be dispensed directly to patients in the office. We sought to investigate whether this increasingly common model improves access to these agents, especially for Black men who are historically undertreated. METHODS We used 20% national Medicare data to perform a retrospective cohort study of men with advanced prostate cancer from 2011 through 2019, managed by urology practices with and without in-office dispensing. Using a difference-in-difference framework, generalized estimating equations were used to measure the effect of in-office dispensing on prescriptions for abiraterone and/or enzalutamide, adjusting for differences between patients, including race. RESULTS New prescription fills for oral targeted agents increased after the adoption of in-office dispensing (+4.4%, 95% confidence interval [CI] = 3.4% to 5.4%) relative to that for men managed by practices without dispensing (+2.4%, 95% CI = 1.4% to 3.4%). The increase in the postintervention period (difference-in-difference estimate) was 2% higher (95% CI = 0.6% to 3.4%) for men managed by practices adopting dispensing relative to men managed by practices without dispensing. The effect was strongest for practices adopting dispensing in 2015 (difference-in-difference estimate: +4.2%, 95% CI = 2.3% to 6.2%). The effect of dispensing adoption did not differ by race. CONCLUSION Adoption of in-office dispensing by urology practices increased prescription fills for oral targeted agents in men with advanced prostate cancer. This model of delivery may improve access to this important class of medications.
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Affiliation(s)
- Dawson Hill
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Kassem Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs (VA) Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
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14
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Maganty A, Hollenbeck BK, Kaufman SR, Oerline MK, Lai LY, Caram MEV, Shahinian VB. Practice Competition and Treatment of Newly Diagnosed Prostate Cancer. Urology 2023; 177:95-102. [PMID: 37146728 PMCID: PMC10524390 DOI: 10.1016/j.urology.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To examine the effect of urology practice market competition on use of treatment in men with newly diagnosed prostate cancer. METHODS We performed a retrospective national cohort study of 48,067 Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2018. The primary exposure was urology practice-level market competition. Markets were established by the flow of patients to a practice using a variable radius approach. Practice level competition was measured annually using the Herfindahl-Hirschman Index. The primary outcome was use of treatment for prostate cancer (ie, surgery, radiation, or cryotherapy) stratified by 10-year risk of noncancer mortality. RESULTS Between 2014 and 2018, there was a decrease in the total percent of urologists practicing in small single-specialty groups (49%-41%) with an increase in multispecialty practices (38%-47%). After adjusting for demographic and clinical characteristics, a lower percentage of men underwent treatment in practices with low competition relative to those managed in practices with high competition (70% vs 67.0%, P < .001). Among men with the highest risk of noncancer mortality, those managed in practices in the least competitive markets were less likely to receive treatment relative to men managed by practices in the most competitive markets (48% vs 60%, P-value<.001). CONCLUSION Reduction in competition between urology practices is not associated with greater use of treatment in men with newly diagnosed prostate cancer, particularly in those with a high risk of noncancer mortality.
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Affiliation(s)
- Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lillian Y Lai
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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15
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Caram MEV, Kumbier K, Burns J, Sparks JB, Tsao PA, Stensland KD, Washington SL, Hollenbeck BK, Shahinian V, Skolarus TA. Differential adoption of castration-resistant prostate cancer treatment across facilities in a national healthcare system. Cancer Med 2023; 12:6945-6955. [PMID: 36790037 PMCID: PMC10067072 DOI: 10.1002/cam4.5490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/15/2022] [Accepted: 11/17/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Over the past decade, abiraterone and enzalutamide have largely replaced ketoconazole as oral treatments for castration-resistant prostate cancer (CRPC). We investigated the differential adoption of abiraterone and enzalutamide across facilities in a national healthcare system to understand the impact a facility has on the receipt of these novel therapies. METHODS Using data from the VA Corporate Data Warehouse, we identified a cohort of men with CRPC who received the most common first-line therapies: abiraterone, enzalutamide, docetaxel, or ketoconazole between 2010 and 2017. We described variability in the adoption of abiraterone and enzalutamide across facilities by time period (2010-2013 or 2014-2017). We categorized facilities depending on the timing of adoption of abiraterone and enzalutamide relative to other facilities and described facility characteristics associated with early and late adoption. RESULTS We identified 4998 men treated with ketoconazole, docetaxel, abiraterone, or enzalutamide as first-line CRPC therapy between 2010 and 2017 at 125 national facilities. When limiting the cohort to oral therapies, most patients treated earlier in the study period (2010-2013) received ketoconazole. A dramatic shift was seen by the second half of the study period (2014-2017) with most men treated with first-line abiraterone (61%). Despite this shift and a new standard of care, some facilities persisted in the widespread use of ketoconazole in the later period, so-called late adopting facilities. After multivariable adjustment, patients who received treatment at a late adopting facility were more likely receiving care at a lower complexity, rural facility, with less urology and hematology/oncology workforce (all p < 0.01). CONCLUSION Many facilities persisted in their use of ketoconazole as first-line CRPC therapy, even when other facilities had adopted the new standard of care abiraterone and enzalutamide. Further work is needed to identify the effect of this late adoption on outcomes important to patients.
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Affiliation(s)
- Megan E. V. Caram
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Kyle Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jennifer Burns
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Phoebe A. Tsao
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | | | - Samuel L. Washington
- Department of UrologyUniversity of California San FranciscoCaliforniaSan FranciscoUSA
| | - Brent K. Hollenbeck
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Vahakn Shahinian
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of Chicago Pritzker School of MedicineIllinoisChicagoUSA
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16
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Abusamra SM, Solorzano MA, Luke M, Quarles J, Jacobs MF, Das S, Kasputis A, Okoth LA, Patel M, Seymore M, Caram MEV, Dunn RL, Merajver SD, Stoffel EM, Reichert ZR, Morgan TM. Satisfaction With Clinician-Led Germline Genetic Counseling in Patients With Prostate Cancer. J Urol 2022; 208:1007-1017. [PMID: 35930793 PMCID: PMC10544847 DOI: 10.1097/ju.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Indications for germline testing in prostate cancer patients have expanded substantially over the past decade. With a near-universal shortage of genetic counselors and increasing demand, increased access to genetic counseling is crucial. We sought to prospectively implement and assess a clinician-led approach to genetic counseling and testing. MATERIALS AND METHODS Patients with metastatic or localized prostate cancer meeting National Comprehensive Cancer Network® criteria for consideration of genetic testing were offered pre-test genetic counseling by their urologist or medical oncologist as part of their routine clinical care and concurrently approached for enrollment in the Germline Genetics in Prostate Cancer Study. Consented patients filled out a post-counseling survey using validated instruments to assess the quality of counseling. For patients who elected to undergo genetic testing, an additional validated questionnaire was completed following disclosure of results. The primary outcome was the proportion of patients undergoing testing, with a target >60% of patients. The secondary outcome was overall satisfaction with counseling, with a target >85% of patients. RESULTS A total of 275 patients enrolled, and 203 patients elected to undergo genetic testing. Post-counseling surveys were obtained from 265 patients, and post-genetic testing surveys were obtained from 132 patients. Patient satisfaction was high, with 98% of patients reporting being satisfied with the overall quality of pre-test counseling, and 74% of patients elected to undergo genetic testing. CONCLUSIONS These results support the effectiveness of clinician-led genetic counseling in prostate cancer. With clinician training, this approach can be utilized to expand access to appropriate germline genetic testing.
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Affiliation(s)
| | - Marissa A Solorzano
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Mallory Luke
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- School of Dentistry, University of Michigan, Ann Arbor, Michigan
| | | | - Michelle F Jacobs
- Department of Internal Medicine, Division of Genetic Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sanjay Das
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Amy Kasputis
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Linda A Okoth
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Milan Patel
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Mariana Seymore
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Megan E V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Rodney L Dunn
- Department of Urology, Dow Division of Health Services Research, University of Michigan, Ann Arbor, Michigan
| | - Sofia D Merajver
- Department of Internal Medicine, Division of Genetic Medicine, University of Michigan, Ann Arbor, Michigan
| | - Elena M Stoffel
- Department of Internal Medicine, Division of Genetic Medicine, University of Michigan, Ann Arbor, Michigan
| | - Zachery R Reichert
- Department of Internal Medicine, Hematology/Oncology Division, University of Michigan Medical School, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, Michigan
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17
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Maganty A, Hollenbeck BK, Kaufman SR, Oerline MK, Lai LY, Caram MEV, Shahinian VB. Implications of the Merit-Based Incentive Payment System for Urology Practices. Urology 2022; 169:84-91. [PMID: 35932872 PMCID: PMC9669102 DOI: 10.1016/j.urology.2022.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/04/2022] [Accepted: 05/08/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the implications of the merit-based incentive payment system (MIPS) for urology practices. MIPS is a Medicare payment model that determines whether a physician is financially penalized or receives bonus payment based on performance in four categories: quality, practice improvement, promotion of interoperability, and spending. METHODS We performed a cross-sectional analysis of urologist performance in MIPS for 2017 and 2019 using Medicare data. Urologist practice organization was categorized as single-specialty (small, medium, large) or multispecialty groups. MIPS scores were estimated by practice organization. Logistic regression models were used to examine the association between urology practice characteristics, including proportion of dual eligible beneficiaries, and bonus payment adjustment as defined by Medicare methodology. Rates of consolidation (movement from smaller to larger practices) between 2017 and 2019 were compared between those who were and those who were not penalized in 2017. RESULTS Urologists in small practices performed worse in MIPS and had a significantly lower adjusted odds ratio of receiving bonus payments in both 2017 and 2019 compared to larger group practices (odds ratio [OR] 0.04, 95% confidence interval [95%CI] 0.03-0.05 in 2017 and OR 0.37, 95%CI 0.30-0.47 in 2019). Increasing percent of dual eligible beneficiaries within a patient panel was associated with decreased odds of receiving bonus payment in both performance years. Urologists penalized in 2017 had higher rates of consolidation by 2019 compared to those who were not (14% vs 5%, P <.05). CONCLUSION Small urology practices and those caring for a higher proportion of dual eligible beneficiaries tended to perform worse in MIPS.
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Affiliation(s)
- Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI.
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Lillian Y Lai
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Megan E V Caram
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, MI
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18
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Lai LY, Oerline MK, Caram MEV, Tsao PA, Kaufman SR, Hollenbeck BK, Shahinian VB. Risk of metabolic and cardiovascular adverse events with abiraterone or enzalutamide among men with advanced prostate cancer. J Natl Cancer Inst 2022; 114:1127-1134. [PMID: 35417024 PMCID: PMC9360470 DOI: 10.1093/jnci/djac081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/27/2022] [Accepted: 04/04/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Abiraterone and enzalutamide are the most common oral agents for the treatment of men with advanced prostate cancer. To understand their safety profiles in real-world settings, we examined the association between the use of abiraterone or enzalutamide and the risk of metabolic or cardiovascular adverse events while on treatment. METHODS Men with advanced prostate cancer and their use of abiraterone or enzalutamide were identified in a 20% sample of the 2010-2017 national Medicare claims. The primary composite outcome was the occurrence of a major metabolic or cardiovascular adverse event, defined as an emergency room visit or hospitalization associated with a primary diagnosis of diabetes, hypertension, or cardiovascular disease. The secondary composite outcome was the occurrence of a minor metabolic or cardiovascular adverse event, defined as an outpatient visit associated with a primary diagnosis of the aforementioned conditions. Risks were assessed separately for abiraterone and enzalutamide using Cox regression. All statistical tests were 2-sided. RESULTS Compared to men not receiving abiraterone, men receiving abiraterone were at increased risk of both a major composite adverse event (HR 1.77, 95% CI 1.53-2.05, P<0.001) and a minor composite adverse event (HR 1.24, 95% CI 1.05-1.47, P=0.01). Compared to men not receiving enzalutamide, men receiving enzalutamide were at an increased risk of a major composite adverse event (HR 1.22, 95% CI 1.01-1.48, P=0.04) but not a minor composite adverse event (HR 1.04, 95% CI 0.83-1.30, P=0.75). CONCLUSION Careful monitoring and management of men on abiraterone or enzalutamide through team-based approaches are critical.
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Affiliation(s)
- Lillian Y Lai
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Mary K Oerline
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Megan E V Caram
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Phoebe A Tsao
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Samuel R Kaufman
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Vahakn B Shahinian
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, United States.,Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
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19
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Tsao PA, Ross RD, Bohnert ASB, Mukherjee B, Caram MEV. Depression, Anxiety, and Patterns of Mental Health Care Among Men With Prostate Cancer Receiving Androgen Deprivation Therapy. Oncologist 2022; 27:314-322. [PMID: 35298660 DOI: 10.1093/oncolo/oyab033] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/01/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Androgen deprivation therapy (ADT) use is associated with an increased risk of developing depression and anxiety. Little is known about how the mental health of these men is treated. MATERIALS AND METHODS We identified men with prostate cancer who received ADT between 2001 and 2015 using Optum's de-identified Clinformatics Data Mart Database. We determined the incidence of depression or anxiety diagnoses, mental health treatments, and the specialty of providers initiating psychotropic medications, after the start of ADT. Outcomes were compared with those of men with prostate cancer not receiving ADT and men without prostate cancer. RESULTS Of 37 388 men with prostate cancer treated with ADT, 3964 (10.6%) received a new diagnosis of depression or anxiety. Of those 3964 men, 1892 (47.7%) did not receive a documented treatment, 10 (0.3%) received psychotherapy, 1321 (33.3%) a selective serotonin reuptake inhibitor, and 744 (18.8%) a benzodiazepine. The median time from initiation of ADT to a depression or anxiety diagnosis was 9.3 months. Primary care physicians were the most common prescribers of psychotropic medications (72.2%). The proportion of men not receiving mental health treatments of interest (47.7%) was similar compared to men without prostate cancer (49.1%), but statistically significantly lower compared to men with prostate cancer not receiving ADT (52.7%). CONCLUSIONS In men with prostate cancer receiving ADT with a new diagnosis of depression or anxiety, nearly half are not receiving mental health care while one in five is introduced to a benzodiazepine. Further investigation toward improving the mental health care for men on ADT is needed.
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Affiliation(s)
- Phoebe A Tsao
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research & Development, Center for Clinical Management and Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute of Health Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ryan D Ross
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute of Health Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Institute of Health Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research & Development, Center for Clinical Management and Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute of Health Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA
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Lai LY, Oerline MK, Kaufman SR, Herrel LA, Skolarus TA, Dusetzina SB, Ellimoottil C, Shahinian VB, Hollenbeck BK, Caram MEV. Promotional Payments to Medical Oncologists and Urologists and Prescriptions for Abiraterone and Enzalutamide. Urology 2022; 161:50-58. [PMID: 34861316 PMCID: PMC8940668 DOI: 10.1016/j.urology.2021.10.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/04/2021] [Accepted: 10/04/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Lillian Y Lai
- Departments of Urology, University of Michigan, Ann Arbor, MI.
| | - Mary K Oerline
- Departments of Urology, University of Michigan, Ann Arbor, MI
| | | | | | - Ted A Skolarus
- Departments of Urology, University of Michigan, Ann Arbor, MI; Veterans Affairs Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN; Vanderbilt-Ingram Cancer Center, Nashville, TN
| | | | - Vahakn B Shahinian
- Departments of Urology, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Megan E V Caram
- Veterans Affairs Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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21
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Townsend TN, Salz T, Haffajee RL, Caram MEV, Chino F, Bohnert ASB. Has Declining Opioid Dispensing to Cancer Patients Been Tailored to Risk of Opioid Harms? J Pain Symptom Manage 2022; 63:179-188. [PMID: 34656655 PMCID: PMC8816811 DOI: 10.1016/j.jpainsymman.2021.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Opioid prescribing to cancer patients is declining, but it is unknown whether reductions have been tailored to those at highest risk of opioid-related harms. OBJECTIVES Examine whether declines in opioid dispensing to patients receiving active cancer treatment are sharper in patients with substance use disorder (SUD) or mental health diagnoses. METHODS We used 2008-2018 national, commercial healthcare claims data to examine adjusted and unadjusted trends in opioid dispensing (receipt of ≥1 fill; average daily dosage; receipt of high-dose opioids; receipt of concurrent opioids and benzodiazepines) to patients ages ≥18 receiving treatment for one of four cancer types (breast; colorectal; head and neck; sarcoma; N = 324,789 patients). To compare declines across subgroups with varying risk of opioid-related harms, we stratified by SUD and mental health diagnosis. To address potential confounding, we estimated subgroup-specific trends using generalized estimating equations, adjusting for covariates. RESULTS Across groups, rate of ≥1 opioid fill per quarter fell 32.5% (95% CI: 31.8%-33.2%) from 2008 to 2018; daily dose among those receiving opioids fell 37.6% (95% CI: 36.7%-38.6%). In most cases, these declines were not sharper in subgroups at greater risk of opioid-related harms. For example, patients with opioid use disorder experienced the smallest declines in dispensing frequency, and there was no evidence that declines were sharper in patients with mental health diagnoses. CONCLUSION Sharp declines in opioid prescribing during the drug overdose crisis have affected a wide range of patients undergoing cancer treatment and may not have been sufficiently tailored to patient characteristics. Research on implications for opioid-related harms and pain management is needed.
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Affiliation(s)
- Tarlise N Townsend
- University of Michigan, Department of Health Management and Policy (T.N.T., R.L.H.), Ann Arbor, Michigan, USA; NYU Rory Meyers College of Nursing (T.N.T.), New York, New York, USA; Center for Opioid Epidemiology and Policy (T.N.T.), NYU Grossman School of Medicine Department of Population Health, New York, New York, USA.
| | - Talya Salz
- Memorial Sloan Kettering Cancer Center Health Outcomes Research Group (T.S.), New York, New York, USA
| | - Rebecca L Haffajee
- University of Michigan, Department of Health Management and Policy (T.N.T., R.L.H.), Ann Arbor, Michigan, USA; RAND Corporation (R.L.H.), Boston, Massachusetts, USA
| | - Megan E V Caram
- University of Michigan Department of Internal Medicine (M.E.V.C), Ann Arbor, Michigan, USA; VA Center for Clinical Management Research (M.E.V.C., A.S.B.B.), Ann Arbor, Michigan, USA
| | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology (F.C.), New York, New York, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (M.E.V.C., A.S.B.B.), Ann Arbor, Michigan, USA; University of Michigan, Department of Anesthesiology (A.S.B.B.), Ann Arbor, Michigan, USA
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22
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Lai LY, Kaufman SR, Oerline MK, Caram MEV, Maganty A, Hollenbeck BK, Shahinian VB. OUP accepted manuscript. JNCI Cancer Spectr 2022; 6:6544596. [PMID: 35603854 PMCID: PMC8973404 DOI: 10.1093/jncics/pkac023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/22/2021] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
Urologists are increasingly prescribing oral targeted therapies to patients with advanced prostate cancer. Concurrent with this trend, urology practices are allowing patients to fill their prescription onsite or through a pharmacy established by the practice. We examined prescription patterns for abiraterone or enzalutamide between eventually dispensing single-specialty urology practices, nondispensing single-specialty urology practices, and multispecialty practices using a 20% random sample of the 2013-2017 national Medicare claims. We determined physician dispensing through manual search of publicly available information. From 2015 through 2017, higher percentages of patients managed by eventually dispensing single-specialty urology practices had a filled prescription of abiraterone or enzalutamide compared with patients managed in nondispensing single-specialty urology practices (eg, in 2017, 8.9%, 95% confidence interval = 7.3% to 10.9%, vs 5.9%, 95% confidence interval = 5.0% to 7.0%, respectively; 2-sided P < .001). Insofar as physician dispensing is associated with higher use of abiraterone or enzalutamide, it may represent a means to improve treatment access.
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Affiliation(s)
- Lillian Y Lai
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Correspondence to: Lillian Y. Lai, MD, MS, Department of Urology, University of Michigan, 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109-2800, USA (e-mail: )
| | - Samuel R Kaufman
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Mary K Oerline
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Megan E V Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Avinash Maganty
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | - Vahakn B Shahinian
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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23
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Lai LY, Shahinian VB, Oerline MK, Kaufman SR, Skolarus TA, Caram MEV, Hollenbeck BK. Understanding Active Surveillance for Prostate Cancer. JCO Oncol Pract 2021; 17:e1678-e1687. [PMID: 33830822 PMCID: PMC9810129 DOI: 10.1200/op.20.00929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To assess how active surveillance for prostate cancer is apportioned across specialties and how testing patterns and transition to treatment vary by specialty. METHODS We used a 20% national sample of Medicare claims to identify men diagnosed with prostate cancer from 2010 through 2016 initiating surveillance (N = 13,048). Patients were assigned to the physician responsible for the bulk of surveillance care based on billing patterns. Freedom from treatment was assessed by specialty of the responsible physician (urology, radiation oncology, medical oncology, and primary care). Multinomial logistic regression models were used to examine associations between specialty and treatment patterns. RESULTS Urologists were responsible for surveillance in 93.7% of patients in 2010 and 96.2% of patients in 2016 (P for trend = .01). Testing patterns varied by specialty. For example, patients of medical oncologists had more frequent prostate-specific antigen testing compared with patients of urologists (1.85 v 2.39 tests per year, respectively; P < .01). Three years after diagnosis, a significantly smaller proportion of patients managed by radiation oncologists (64.3%) remained on surveillance compared with patients managed by other physicians (75.8%-79.5%; P < .01). Although radiation was the most common treatment among all men who transitioned to treatment, a disproportionate percentage of patients followed by radiation oncologists (28.9%) ultimately underwent radiation compared with patients followed by other physicians (15.1%-15.4%; P < .01). CONCLUSION Nontrivial percentages of patients on active surveillance are managed by physicians outside of urology. Given the interspecialty variations observed, efforts to strengthen the evidence underlying surveillance pathways and to engage other specialties in guideline development are needed.
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Affiliation(s)
- Lillian Y. Lai
- Department of Urology, University of Michigan, Ann Arbor, MI,Lillian Y. Lai, MD, Dow Division for Health Services Research, Department of Urology, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, MI 48109-2800; e-mail:
| | - Vahakn B. Shahinian
- Department of Urology, University of Michigan, Ann Arbor, MI,Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mary K. Oerline
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Ted A. Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI,Veterans Affairs Ann Arbor Healthcare System, HSR&D, Center for Clinical Management Research, Ann Arbor, MI
| | - Megan E. V. Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Veterans Affairs Ann Arbor Healthcare System, HSR&D, Center for Clinical Management Research, Ann Arbor, MI
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24
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Marchetti KA, Oerline M, Hollenbeck BK, Kaufman SR, Skolarus TA, Shahinian VB, Caram MEV, Modi PK. Urology Workforce Changes and Implications for Prostate Cancer Care Among Medicare Enrollees. Urology 2021; 155:77-82. [PMID: 33610652 PMCID: PMC8374001 DOI: 10.1016/j.urology.2020.12.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/28/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize national trends in urologist workforce, practice organization, and management of incident prostate cancer. METHODS Using Medicare claims data from 2010 to 2016, we identified all urologists billing Medicare and the practice with which they were affiliated. We characterized groups as solo, small single specialty, large single specialty, multispecialty, specialist, or hospital-owned practices. Using a 20% sample of national Medicare claims, we identified all patients with incident prostate cancer and identified their primary treatment. RESULTS The number of urologists increased from 9,305 in 2010 to 9,570 in 2016 (P = .03), while the number of practices decreased from 3,588 to 2,861 (P < .001). The proportion of urologists in multispecialty groups increased from 17.1% in 2010 to 28.2% in 2016, while those within solo practices declined from 26.2% to only 15.8% over the same time period. A higher proportion of patients at hospital-owned practices were treated with observation (P < .001) and surgery (P < .001), while a higher proportion of patients at large single specialty practices were treated with radiation therapy (P < .001). CONCLUSION We characterized shifts in urologist membership from smaller, independent groups to larger, multispecialty or hospital-owned practices. This trend coincides with higher utilization of observation and surgical treatment for prostate cancer.
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Affiliation(s)
- Kathryn A Marchetti
- Division of Health Services Research, Department of Urology, University of Michigan.
| | - Mary Oerline
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Brent K Hollenbeck
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Ted A Skolarus
- Division of Health Services Research, Department of Urology, University of Michigan; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Parth K Modi
- Division of Health Services Research, Department of Urology, University of Michigan
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25
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Cobain EF, Wu YM, Vats P, Chugh R, Worden F, Smith DC, Schuetze SM, Zalupski MM, Sahai V, Alva A, Schott AF, Caram MEV, Hayes DF, Stoffel EM, Jacobs MF, Kumar-Sinha C, Cao X, Wang R, Lucas D, Ning Y, Rabban E, Bell J, Camelo-Piragua S, Udager AM, Cieslik M, Lonigro RJ, Kunju LP, Robinson DR, Talpaz M, Chinnaiyan AM. Assessment of Clinical Benefit of Integrative Genomic Profiling in Advanced Solid Tumors. JAMA Oncol 2021; 7:525-533. [PMID: 33630025 PMCID: PMC7907987 DOI: 10.1001/jamaoncol.2020.7987] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Question What is the clinical utility of genomic profiling for patients with advanced solid tumors? Findings In this cohort study of 1015 patients who underwent integrative genomic profiling, a high rate of pathogenic germline variants and a subset of patients who derive substantial clinical benefit from sequencing information were identified. Meaning These findings support (1) directed germline testing for inherited cancer predisposition in all patients with advanced cancer and (2) use of integrative genomic profiling as a component of standard of care for patients with cancer of unknown origin and other rare malignant neoplasms. Importance Use of next-generation sequencing (NGS) to identify clinically actionable genomic targets has been incorporated into routine clinical practice in the management of advanced solid tumors; however, the clinical utility of this testing remains uncertain. Objective To determine which patients derived the greatest degree of clinical benefit from NGS profiling. Design, Setting, and Participants Patients in this cohort study underwent fresh tumor biopsy and blood sample collection for genomic profiling of paired tumor and normal DNA (whole-exome or targeted-exome capture with analysis of 1700 genes) and tumor transcriptome (RNA) sequencing. Somatic and germline genomic alterations were annotated and classified according to degree of clinical actionability. Results were returned to treating oncologists. Data were collected from May 1, 2011, to February 28, 2018, and analyzed from May 1, 2011, to April 30, 2020. Main Outcomes and Measures Patients’ subsequent therapy and treatment response were extracted from the medical record to determine clinical benefit rate from NGS-directed therapy at 6 months and exceptional responses lasting 12 months or longer. Results During the study period, NGS was attempted on tumors from 1138 patients and was successful in 1015 (89.2%) (MET1000 cohort) (538 men [53.0%]; mean [SD] age, 57.7 [13.3] years). Potentially clinically actionable genomic alterations were discovered in 817 patients (80.5%). Of these, 132 patients (16.2%) received sequencing-directed therapy, and 49 had clinical benefit (37.1%). Exceptional responses were observed in 26 patients (19.7% of treated patients). Pathogenic germline variants (PGVs) were identified in 160 patients (15.8% of cohort), including 49 PGVs (4.8% of cohort) with therapeutic relevance. For 55 patients with carcinoma of unknown primary origin, NGS identified the primary site in 28 (50.9%), and sequencing-directed therapy in 13 patients resulted in clinical benefit in 7 instances (53.8%), including 5 exceptional responses. Conclusions and Relevance The high rate of therapeutically relevant PGVs identified across diverse cancer types supports a recommendation for directed germline testing in all patients with advanced cancer. The high frequency of therapeutically relevant somatic and germline findings in patients with carcinoma of unknown primary origin and other rare cancers supports the use of comprehensive NGS profiling as a component of standard of care for these disease entities.
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Affiliation(s)
- Erin F Cobain
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Yi-Mi Wu
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Pankaj Vats
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Rashmi Chugh
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Francis Worden
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - David C Smith
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott M Schuetze
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mark M Zalupski
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Vaibhav Sahai
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Ajjai Alva
- Department of Internal Medicine, University of Michigan, Ann Arbor.,Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Anne F Schott
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Megan E V Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Daniel F Hayes
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Elena M Stoffel
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Chandan Kumar-Sinha
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Xuhong Cao
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Rui Wang
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - David Lucas
- Department of Pathology, University of Michigan, Ann Arbor
| | - Yu Ning
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Erica Rabban
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Janice Bell
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | | | - Aaron M Udager
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Marcin Cieslik
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Robert J Lonigro
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Lakshmi P Kunju
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Dan R Robinson
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor
| | - Moshe Talpaz
- Department of Internal Medicine, University of Michigan, Ann Arbor.,Rogel Cancer Center, University of Michigan, Ann Arbor
| | - Arul M Chinnaiyan
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor.,Department of Pathology, University of Michigan, Ann Arbor.,Rogel Cancer Center, University of Michigan, Ann Arbor.,Department of Urology, University of Michigan, Ann Arbor.,Howard Hughes Medical Institute, University of Michigan, Ann Arbor
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26
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Yu Y, Zhang M, Shi X, Caram MEV, Little RJA, Mukherjee B. A comparison of parametric propensity score-based methods for causal inference with multiple treatments and a binary outcome. Stat Med 2021; 40:1653-1677. [PMID: 33462862 DOI: 10.1002/sim.8862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 11/07/2022]
Abstract
We consider comparative effectiveness research (CER) from observational data with two or more treatments. In observational studies, the estimation of causal effects is prone to bias due to confounders related to both treatment and outcome. Methods based on propensity scores are routinely used to correct for such confounding biases. A large fraction of propensity score methods in the current literature consider the case of either two treatments or continuous outcome. There has been extensive literature with multiple treatment and binary outcome, but interest often lies in the intersection, for which the literature is still evolving. The contribution of this article is to focus on this intersection and compare across methods, some of which are fairly recent. We describe propensity-based methods when more than two treatments are being compared, and the outcome is binary. We assess the relative performance of these methods through a set of simulation studies. The methods are applied to assess the effect of four common therapies for castration-resistant advanced-stage prostate cancer. The data consist of medical and pharmacy claims from a large national private health insurance network, with the adverse outcome being admission to the emergency room within a short time window of treatment initiation.
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Affiliation(s)
- Youfei Yu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Xu Shi
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Veterans Affairs (VA) Health Services Research and Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Roderick J A Little
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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27
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Caram MEV, Oerline MK, Dusetzina S, Herrel LA, Modi PK, Kaufman SR, Skolarus TA, Hollenbeck BK, Shahinian V. Adherence and out-of-pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer. Cancer 2020; 126:5050-5059. [PMID: 32926427 DOI: 10.1002/cncr.33176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Megan E V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan.,Ann Arbor VA Center for Clinical Management Research, VA Health Services Research and Development, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Mary K Oerline
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Stacie Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsey A Herrel
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Parth K Modi
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ted A Skolarus
- Ann Arbor VA Center for Clinical Management Research, VA Health Services Research and Development, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Vahakn Shahinian
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
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28
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Hollenbeck BK, Oerline M, Kaufman SR, Caram MEV, Dusetzina SB, Ryan AM, Shahinian VB. Promotional Payments Made to Urologists by the Pharmaceutical Industry and Prescribing Patterns for Targeted Therapies. Urology 2020; 148:134-140. [PMID: 33075381 DOI: 10.1016/j.urology.2020.08.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/29/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To measure the association between market-level promotional payments to urologists by the manufacturers of abiraterone and enzalutamide and national prescribing patterns. METHODS A 20% national sample of the 2015 Part D event file was used to identify patients filling their first prescription for abiraterone and enzalutamide and their prescribing physicians. The 2015 Open Payments data were used to characterize promotional payments made to physicians at the market level. Generalized linear models were then used to measure the relationship between market-level payments to urologists and the physician specialty prescribing abiraterone or enzalutamide for the first time RESULTS: In 2015, 2318 men filled a prescription for abiraterone or enzalutamide by a urologist or medical oncologist. Increasing market-level promotional payments to urologists for abiraterone or enzalutamide was strongly associated with a urologist prescribing either drug-24.3% versus 5.8% of those residing in the markets with highest and lowest level of promotional payments to urologists, respectively (P <.01). Neither the number of urologists residing in a market nor other promotional payment measures (ie, to medical oncologists for these drugs, or to all physicians for all other drugs) were associated with a urologist prescribing either drug. CONCLUSION Promotional payments to urologists at the market level are strongly associated with the specialty of the physician prescribing abiraterone or enzalutamide for the first time. Future work should elucidate the effects of the shift in prescribing patterns on quality of care and financial hardship for men with advanced prostate cancer.
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Affiliation(s)
| | - Mary Oerline
- Departments of Urology, University of Michigan, Ann Arbor, MI
| | | | | | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Andy M Ryan
- Health Management and Policy, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Departments of Urology, University of Michigan, Ann Arbor, MI; Medicine, University of Michigan, Ann Arbor, MI
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Jiang CY, El-Kouri NT, Elliot D, Shields J, Caram MEV, Frankel TL, Ramnath N, Passero VA. Telehealth for Cancer Care in Veterans: Opportunities and Challenges Revealed by COVID. JCO Oncol Pract 2020; 17:22-29. [PMID: 32970512 DOI: 10.1200/op.20.00520] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The Veterans Health Administration system is one of the largest integrated health care providers in the United States, delivering medical care to > 9 million veterans. Barriers to delivering efficient health care include geographical limitations as well as long wait times. Telehealth has been used as a solution by many different health care services. However, it has not been as widely used in cancer care. In 2018, the US Department of Veterans Affairs (VA) Pittsburgh Healthcare System expanded the use of telehealth to provide antineoplastic therapies to rural patients by creating a clinical video telehealth clinic of the Virtual Cancer Care Network. This allows oncologists located at the tertiary center to virtually deliver care to remote sites. The recent COVID-19 pandemic forced oncologists across the VA system to adopt telehealth to provide continuity of care. On the basis of our review and personal experience, we have outlined opportunities for telehealth to play a role in every step of the cancer care journey from diagnosis to therapy to surveillance to clinical trials for medical, surgical, and radiation oncology. There are many advantages, such as decreased travel time and potential cost savings; however, there continues to be challenges with veterans having access to devices and the Internet as well as understanding how to use telehealth equipment. The lessons learned from this assessment of the VA telehealth system for cancer care can be adopted and integrated into other health systems. In the future, there needs to be evaluation of how telehealth can be further incorporated into oncology, satisfaction of veterans using telehealth services, overcoming telehealth barriers, and defining metrics of success.
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Affiliation(s)
- Cindy Y Jiang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - David Elliot
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI.,VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Timothy L Frankel
- Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Nithya Ramnath
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI.,VA Ann Arbor Healthcare System, Ann Arbor, MI
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Chapman CH, Caram MEV, Radhakrishnan A, Tsodikov A, Deville C, Burns J, Zaslavsky A, Chang M, Leppert JT, Hofer T, Sales AE, Hawley ST, Hollenbeck BK, Skolarus TA. Association between PSA values and surveillance quality after prostate cancer surgery. Cancer Med 2019; 8:7903-7912. [PMID: 31691526 PMCID: PMC6912050 DOI: 10.1002/cam4.2663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although prostate-specific antigen (PSA) testing is used for prostate cancer detection and posttreatment surveillance, thresholds in these settings differ. The screening cutoff of 4.0 ng/mL may be inappropriately used during postsurgery surveillance, where 0.2 ng/mL is typically used, creating missed opportunities for effective salvage radiation treatment. We performed a study to determine whether guideline concordance with annual postoperative PSA surveillance increases when PSA values exceed 4 ng/mL, which represents a screening threshold that is not relevant after surgery. METHODS We used US Veterans Health Administration data to perform a retrospective longitudinal cohort study of men diagnosed with nonmetastatic prostate cancer from 2005 to 2008 who underwent radical prostatectomy. We used logistic regression to examine the association between postoperative PSA levels and receipt of an annual PSA test. RESULTS Among 10 400 men and 38 901 person-years of follow-up, annual guideline concordance decreased from 95% in year 1 to 79% in year 7. After adjustment, guideline concordance was lower for the youngest and oldest men, Black, and unmarried men. Guideline concordance significantly increased as PSA exceeded 4 ng/mL (adjusted odds ratio 2.20 PSA > 4-6 ng/mL vs PSA > 1-4 ng/mL, 95% confidence interval 1.20-4.03; P = .01). CONCLUSIONS Guideline concordance with prostate cancer surveillance increased when PSA values exceeded 4 ng/mL, suggesting a screening threshold not relevant after prostate cancer surgery, where 0.2 ng/mL is considered treatment failure, is impacting cancer surveillance quality. Clarification of PSA thresholds for early detection vs cancer surveillance, as well as emphasizing adherence for younger and Black men, appears warranted.
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Affiliation(s)
- Christina Hunter Chapman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Megan E V Caram
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Alexander Tsodikov
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer Burns
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Michael Chang
- Hunter Holmes McGuire Veterans Affairs Healthcare System, Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - John T Leppert
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System and the Department of Urology, Stanford University, Stanford, CA, USA
| | - Timothy Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anne E Sales
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Caram MEV, Kaufman SR, Modi PK, Herrel L, Oerline M, Ross R, Skolarus TA, Hollenbeck BK, Shahinian V. Adoption of Abiraterone and Enzalutamide by Urologists. Urology 2019; 131:176-183. [PMID: 31136769 PMCID: PMC6711811 DOI: 10.1016/j.urology.2019.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the adoption of abiraterone and enzalutamide by urologists. Abiraterone and enzalutamide are oral therapies approved for the treatment of metastatic castration-resistant prostate cancer, a disease most commonly treated by medical oncologists. METHODS Using the Medicare Part D Public Use Files from 2013 to 2016, we identified total abiraterone and enzalutamide prescriptions 2013-2016 and urologists who prescribed moderate to high volumes of these drugs. We then characterized the urologist practices of those urologists according to practice context (eg, single-specialty group) using data from the Centers for Medicare and Medicaid Services, and the geographic distribution of those providers. RESULTS We found abiraterone prescriptions increased from 71,423 in 2013 to a peak of 100,371 in 2015 and enzalutamide prescriptions continued to increase from 29,572 in 2013 to 100,980 in 2016. Prescriptions by urologists increased between 2013 and 2016 while prescriptions by other specialties plateaued. The number of moderate-high prescribing urologists increased from 98 (abiraterone) and 22 (enzalutamide) in 2013, to 301 (abiraterone) and 671 (enzalutamide) by 2016 with 1063 unique urologists prescribing moderate-high volumes of either drug between 2013 and 2016. Among urologists who prescribe androgen deprivation therapy, 5% were moderate-high prescribers of abiraterone and 12% of enzalutamide in 2016. The majority of moderate-high prescribing urologists were in single-specialty groups (70%). CONCLUSION Urologists are increasingly prescribing oral therapies for metastatic castration-resistant prostate cancer. Understanding the distribution of urologists specializing in castration-resistant prostate cancer therapeutics will help guide future interventions to optimize the care for this important patient population.
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Affiliation(s)
- Megan E V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
| | - Samuel R Kaufman
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Parth K Modi
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Lindsey Herrel
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Mary Oerline
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Ryan Ross
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Ted A Skolarus
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Vahakn Shahinian
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Department of Urology, University of Michigan Medical School, Ann Arbor, MI
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Caram MEV, Ross R, Lin P, Mukherjee B. Factors Associated With Use of Sipuleucel-T to Treat Patients With Advanced Prostate Cancer. JAMA Netw Open 2019; 2:e192589. [PMID: 31002323 PMCID: PMC6481456 DOI: 10.1001/jamanetworkopen.2019.2589] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/04/2019] [Indexed: 12/19/2022] Open
Abstract
Importance Sipuleucel-T is an immunotherapy that has been approved for use in patients with asymptomatic or minimally symptomatic metastatic castration-resistant prostate cancer (mCRPC). However, sipuleucel-T may not be available to some patients because of logistics, cost, and practice structure. Objective To identify factors associated with the adoption of sipuleucel-T across the United States. Design, Setting, and Participants In this retrospective cohort study, patients with prostate cancer who received therapy for mCRPC (docetaxel, abiraterone acetate, enzalutamide, cabazitaxel, radium 223, or sipuleucel-T) from January 1, 2010, through June 30, 2016, were identified in a large claims database of commercially insured patients. Patients who received sipuleucel-T were compared with patients who received any of the other treatments for mCRPC but did not receive sipuleucel-T. Data were analyzed from May 3, 2018, to February 24, 2019. Exposures Sipuleucel-T treatment. Main Outcomes and Measures Patterns of treatment that involved the use of sipuleucel-T were elucidated, and binomial logistic regression was conducted to determine patient and physician factors that were associated with the use of sipuleucel-T and whether patients received sipuleucel-T in isolation or concurrently with other therapies. Results Among 7272 patients who received a treatment for mCRPC, 730 (10.0%) received sipuleucel-T. Mean (SD) age of patients in the entire cohort was 73.2 (9.2) years; 6739 (92.7%) were non-Hispanic and 975 (13.4%) were black. In multivariable analysis, patients who were Hispanic (odds ratio [OR], 0.57; 95% CI, 0.38-0.86) or lived in the Pacific region (OR, 0.66; 95% CI, 0.45-0.97) had lower odds of receiving sipuleucel-T than patients who were not Hispanic or who lived in the South Atlantic region. Patients with higher incomes had greater odds of receiving sipuleucel-T than patients with incomes of less than $50 000 (OR, 1.29 [95% CI, 1.04-1.61] for $50 000-$99 000; OR, 1.43 [95% CI, 1.10-1.85] for >$99 000). Patients treated by a urologist had greater odds of receiving sipuleucel-T than patients not treated by a urologist (OR, 8.89; 95% CI, 7.10-11.11). Sixty-seven patients received concurrent therapies with sipuleucel-T, most commonly abiraterone or enzalutamide, but no factors were independently associated with patients receiving sipuleucel-T concurrent with other therapies for mCRPC. Conclusions and Relevance In this study, 1 of 10 patients with prostate cancer who were treated for mCRPC received sipuleucel-T, with several variables associated with its use. Identifying disparities in receipt of sipuleucel-T may affect future access to this and other highly specialized cancer therapies by defining barriers to treatment that could be addressed in future studies.
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Affiliation(s)
- Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
| | - Ryan Ross
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
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Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram MEV, Hollenbeck BK, Makarov DV, Leppert JT, Shelton JB, Shahinian V, Srinivasaraghavan S, Sales AE. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implement Sci 2018; 13:144. [PMID: 30486836 PMCID: PMC6262964 DOI: 10.1186/s13012-018-0833-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 01/27/2023] Open
Abstract
Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA. .,Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Kevin Zhu
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Megan E V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York City, NY, USA.,VA New York Harbor Healthcare System, 423 E. 23rd St, New York City, NY, 10010, USA
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Grant Building, S-287, 300 Pasteur Drive, Stanford, CA, 94305, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Jeremy B Shelton
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Vahakn Shahinian
- Division of Nephrology, University of Michigan Medical School, Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | | | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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Kirk PS, Borza T, Caram MEV, Shumway DA, Makarov DV, Burns JA, Shelton JB, Leppert JT, Chapman C, Chang M, Hollenbeck BK, Skolarus TA. Characterising potential bone scan overuse amongst men treated with radical prostatectomy. BJU Int 2018; 124:55-61. [PMID: 30246937 DOI: 10.1111/bju.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown. PATIENTS AND METHODS We identified 12 269 patients with prostate cancer treated with RP between 2005 and 2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding prostate-specific antigen (PSA) levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post-RP bone scan use. RESULTS At a median follow-up of 6.8 years, one in five men (22%) underwent a post-RP bone scan at a median PSA level of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen-deprivation or radiation therapy. After adjustment, post-RP bone scan was associated with a prior bone scan (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.32-1.84), positive surgical margin (aOR 1.68, 95% CI 1.40-2.01), preoperative PSA level (aOR 1.02, 95% CI 1.01-1.03), as well as Hispanic ethnicity, Black race, and increasing D'Amico risk category, but not with age or comorbidity. CONCLUSION We found a substantial rate of bone scan utilisation after RP. The majority were performed for PSA levels of <1 ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post-RP setting.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Megan E V Caram
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Dean A Shumway
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York, NY, USA.,Veterans Affairs (VA) New York Healthcare System, New York, NY, USA
| | - Jennifer A Burns
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Christina Chapman
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Chang
- Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Kirk PS, Borza T, Dupree JM, Wei JT, Ellimoottil C, Caram MEV, Burkhardt M, Heidelbaugh JJ, Hollenbeck BK, Skolarus TA. Potential Savings in Medicare Part D for Common Urological Conditions. Urol Pract 2018; 5:351-359. [PMID: 30555855 DOI: 10.1016/j.urpr.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction Millions of patients take prescription medications each year for common urological conditions. Generic and brand-name drugs have widely divergent pricing despite similar therapeutic benefit and side effect profiles. We examined prescribing patterns across provider types for generic and brand-name drugs used to treat 3 common urological conditions, and estimated economic implications for Medicare Part D spending. Methods We extracted 2014 prescription claims and payments from Medicare Part D and categorized oral medications used to treat 3 urological conditions, namely benign prostatic hyperplasia, erectile dysfunction and overactive bladder. We examined claims and payments for each medication among urologists and nonurologists. Lastly, we estimated potential savings by selecting a low cost or generic drug as a cost comparator for each class. Results There were significant differences in prescribing patterns across these conditions, with urologists prescribing more brand-name and expensive medications (p <0.001). The total potential savings related to prescriptions of more expensive and nongeneric drugs in 2014 was $1 billion (benign prostatic hyperplasia $348,454,910, erectile dysfunction $10,211,914 and overactive bladder $698,130,833). These potential savings comprised 53% of the total spending for these medications in 2014. Conclusions Within Medicare Part D the potential savings associated with generic substitution for higher cost and nongeneric drugs for 3 common urological conditions surpassed $1 billion, with urologists more likely to prescribe brand-name and more expensive drugs. Increasing low cost and generic drug use where available evidence of efficacy is equivocal represents a promising policy target to optimize prescription drug spending.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John T Wei
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Megan E V Caram
- Division of Hematology & Oncology, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Mary Burkhardt
- University of Michigan Health System, Pharmacy Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Joel J Heidelbaugh
- Department of Family Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology VA Ann Arbor Healthcare System, Ann Arbor, Michigan, VA Health Services Research & Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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Caram MEV, Estes JP, Griggs JJ, Lin P, Mukherjee B. Temporal and geographic variation in the systemic treatment of advanced prostate cancer. BMC Cancer 2018; 18:258. [PMID: 29510667 PMCID: PMC5840834 DOI: 10.1186/s12885-018-4166-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/26/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Several systemic treatments have been shown to increase survival for patients with metastatic castration-resistant prostate cancer. This study sought to characterize variation in use of the six "focus drugs" (docetaxel, abiraterone, enzalutamide, sipuleucel-T, radium-223, and cabazitaxel) that have been approved by the Food and Drug Administration for the treatment of metastatic castration-resistant prostate cancer during the years 2010-2015. We hypothesized that the use of these treatments would vary over time and by region of the country. METHODS We used Clinformatics DataMart™ Database (OptumInsight, Eden Prairie, MN), a de-identified claims database from a national insurance provider. Our sample included patients with prostate cancer who received any of the six drugs. We describe changes in usage patterns over time and geographic region of the United States via detailed descriptive statistics. We explore both patterns of first line therapy and sequence of treatments in our database. RESULTS Our final analysis included 4275 patients with a mean age of 74 years. Docetaxel was the most commonly used first-line therapy in 2010 (97%), 2011 (66%), and 2012 (49%). Abiraterone was the most commonly used first-line therapy in 2013 (56%), 2014 (46%), and 2015 (34%). Approximately 14% of our study cohort received ≥3 of the 6 drugs throughout their disease course. There was marked geographic variation in use of each of the drugs. CONCLUSION Variation in treatment patterns were found with respect to both time and geographic location. Prescription rates of abiraterone outpaced docetaxel as the most commonly prescribed drug after 2013 when it became widely available. However, some regions of the country still lagged behind and prescribed less than would be expected.
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Affiliation(s)
- Megan E. V. Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI USA
- Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, MI USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI USA
| | - Jason P. Estes
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Jennifer J. Griggs
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Paul Lin
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI USA
| | - Bhramar Mukherjee
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI USA
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI USA
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Caram MEV, Miller DC. Treating Advanced Prostate Cancer-the Human Factor. Eur Urol 2017; 73:212-214. [PMID: 28733088 DOI: 10.1016/j.eururo.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - David C Miller
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
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Caram MEV, Skolarus TA, Cooney KA. Limitations of Prostate-specific Antigen Testing After a Prostate Cancer Diagnosis. Eur Urol 2016; 70:209-10. [PMID: 26776937 DOI: 10.1016/j.eururo.2015.12.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
Prostate-specific antigen (PSA) is frequently used in isolation to guide treatment decisions in men with recurrent prostate cancer, a practice discouraged by prostate cancer working groups and guidelines. Instead, PSA should be used with imaging and other factors to make treatment decisions.
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Affiliation(s)
- Megan E V Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA; Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Ted A Skolarus
- Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kathleen A Cooney
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
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Caram MEV, Guo C, Leja M, Smerage J, Henry NL, Giacherio D, Rubenfire M, Schott A, Davis M, Hayes DF, Van Poznak C, Cooney KA, Hertz DL, Banerjee M, Griggs JJ. Doxorubicin-induced cardiac dysfunction in unselected patients with a history of early-stage breast cancer. Breast Cancer Res Treat 2015; 152:163-172. [PMID: 26050157 DOI: 10.1007/s10549-015-3454-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 10/23/2022]
Abstract
Cardiomyopathy is a known complication of anthracycline-based adjuvant chemotherapy and is more commonly reported in population-based studies of breast cancer survivors than in clinical trials. This study prospectively evaluated the prevalence of elevated cardiac biomarkers in unselected patients who had been treated with doxorubicin for early-stage breast cancer and the prevalence of reduced LVEF in patients with an elevated biomarker. All participants underwent an examination, symptom inventory, medical record review, and biomarker analysis for BNP, troponin, and plasma and urine NT-proBNP. Patients who had one or more elevated biomarkers were referred for echocardiogram; systolic dysfunction was defined as LVEF less than 55 %. Multivariable logistic regression was used to determine the associations between age, BMI, cumulative dose of doxorubicin, diabetes, hypertension, and left-sided radiation therapy and the risk of reduced LVEF. Among the 269 patients who underwent lab testing (mean age 56 years, mean time since completion of doxorubicin-based chemotherapy 6 years), 192 (72 %) had one or more elevated biomarker. Among the 166 patients who completed an echocardiogram, 11.5 % had a LVEF < 55 %. After adjusting for covariates known to affect cardiac function, multivariable logistic regression revealed plasma NT-proBNP to be the only measured cardiac biomarker associated with systolic dysfunction. There is a relationship between NT-proBNP and the frequency of reduced LVEF in women treated with doxorubicin for curative intent; further study of NT-proBNP as a potential biomarker for subclinical cardiac dysfunction after exposure to anthracyclines is warranted.
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Affiliation(s)
- Megan E V Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States.
| | - Cui Guo
- Department of Biostatistics, University of Michigan School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, United States
| | - Monika Leja
- Department of Internal Medicine, Division of Cardiology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive; Cardiovascular Center, Ann Arbor, MI, 48109, United States
| | - Jeffrey Smerage
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Donald Giacherio
- Department of Pathology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Melvyn Rubenfire
- Department of Internal Medicine, Division of Cardiology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive; Cardiovascular Center, Ann Arbor, MI, 48109, United States
| | - Anne Schott
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Melinda Davis
- Department of Internal Medicine, Division of Cardiology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive; Cardiovascular Center, Ann Arbor, MI, 48109, United States
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Catherine Van Poznak
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Kathleen A Cooney
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States.,Department of Urology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States
| | - Daniel L Hertz
- Department of Pharmacology, College of Pharmacy, University of Michigan , 428 Church Street, Ann Arbor, MI, 48104-1065, United States
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, United States
| | - Jennifer J Griggs
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, United States.,Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, 48109, United States
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