Physician and facility drivers of spending variation in locoregional prostate cancer

• Published in: Cancer 2020-04, Vol.126 (8), p.1622-1631
• Main Authors: Rodin, Danielle, Chien, Alyna T., Ellimoottil, Chad, Nguyen, Paul L., Kakani, Pragya, Mossanen, Matthew, Rosenthal, Meredith, Landrum, Mary Beth, Sinaiko, Anna D.
• Format: Article
• Language: English
• Subjects: Brachytherapy; cancer cost of care; Cancer therapies; Decision making; Demography; Epidemiology; Government programs; health economics; Health risks; health services research; Medical treatment; Medicare; Oncology; Patients; Physicians; practice variation; Prostate cancer; Radiation; Radiation therapy; Robotic surgery; Surgery; Urology; Variation
• ISSN: 0008-543X; 1097-0142
• DOI: 10.1002/cncr.32719

Background Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown. Methods In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee‐for‐service and were included in the Surveillance, Epidemiology, and End Results‐Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient‐level spending, and differences between those that were high‐spending and low‐spending were examined. Results Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists. Conclusions Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels. In an evaluation of the drivers of spending variation in the treatment of localized prostate cancer, the highest spending urologists and radiation oncologists spent 46% more and 43% more, respectively, than the lowest on men with similar individual and disease characteristics. Differences in primary treatment modalities and discretionary decision making for similar patients are the most important drivers of spending variation, and, to improve value, interventions should target decision making along the primary treatment pathway and should be directed at both individual physicia