Patterns of Care for Medicare Beneficiaries With Metastatic Prostate Cancer.

INTRODUCTION: Therapeutic options for men with metastatic prostate cancer have increased in the past decade. We studied recent treatment patterns for men with metastatic prostate cancer and how treatment patterns have changed over time. METHODS: Using the Surveillance, Epidemiology, and End Results‒Medicare database, we identified fee-for-service Medicare beneficiaries who either were diagnosed with metastatic prostate cancer or developed metastases following diagnosis, as indicated by the presence of claims with diagnoses codes for metastatic disease, between 2007 and 2017. We evaluated treatment patterns using claims. RESULTS: We identified 29,800 men with metastatic disease, of whom 4721 (18.8%) had metastatic disease at their initial diagnosis. The mean age was 77 years, and 77.9% of patients were non-Hispanic White. The proportion receiving antineoplastic agents within 3 years of the index date increased over time (from 9.7% in 2007 to 25.9% in 2017; P < .001). Opioid use within 3 years of prostate cancer diagnosis was stable during 2007 to 2013 (around 73%) but decreased through 2017 to 65.5% (P < .001). Patients diagnosed during 2015 to 2017 had longer median survival (32.6 months) compared to those diagnosed during 2007 to 2010 (26.6 months; P < .001). CONCLUSIONS: Most metastatic prostate cancer patients do not receive life-prolonging antineoplastic therapies. Improved adoption of effective cancer therapies when appropriate may increase length and quality of survival among metastatic prostate cancer patients.

Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act.

BACKGROUND: Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for PCa men is unknown. METHODS: Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis. Cochran-Armitage test measured annual trends in delays, and joinpoint regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. RESULTS: Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p < 0.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p < 0.001) patients had higher odds of delay. Compared to uninsured, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = 0.31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p < 0.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p < 0.001) had lower odds of delay. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p < 0.001); 2014 was associated with a significant inflection for increase in rates of major delays. CONCLUSIONS: Non-White and Medicaid-insured men with localized PCa are at risk of treatment delays in the United States. Treatment delays have been consistently rising, particularly after implementation of the ACA.

The cost burden of metastatic prostate cancer in the US populations covered by employer-sponsored health insurance.

BACKGROUND: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance. METHODS: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars. RESULTS: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars. CONCLUSIONS: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

Patterns of multispecialty care for low- and intermediate-risk prostate cancer in the use of active surveillance.

BACKGROUND: Multidisciplinary models of care have been advocated for prostate cancer (PC) to promote shared decision-making and facilitate quality care. Yet, how this model applies to low-risk disease where the preferred management is expectant remains unclear. Accordingly, we examined recent practice patterns in specialty visits for low/intermediate-risk PC and resultant use of active surveillance (AS). METHODS: Using SEER-Medicare, we ascertained whether patients saw urology and radiation oncology (i.e., multispecialty care) versus urology alone, based on self-designated specialty codes, for newly diagnosed PC from 2010 to 2017. We also examined the association with AS, defined as the absence of treatment within 12 months of diagnosis. Time trends were analyzed using Cochran-Armitage test. Chi-squared and logistic regression analyses were applied to compare sociodemographic and clinicopathologic characteristics between these models of care. RESULTS: The proportion of patients seeing both specialists was 35.5% and 46.5% for low- and intermediate-risk patients respectively. Trend analysis showed a decline in multispecialty care in low-risk patients (44.1% to 25.3% years 2010-2017; P < 0.001). Between 2010 and 2017, the use of AS increased 40.9% to 68.6% (P < 0.001) and 13.1% to 24.6% (P < 0.001) for patients seeing urology and those seeing both specialists respectively. Age, urban residence, higher education, SEER region, co-morbidities, frailty, Gleason score, predicted receipt of multispecialty care (all P < 0.02). CONCLUSIONS: Uptake of AS among men with low-risk PC has occurred primarily under the purview of urologists. While selection is certainly at play, these data suggest that multispecialty care may not be required to promote the utilization of AS for men with low-risk PC.

Use of expectant management based on prostate cancer risk and health status: How far are we from a risk-adapted approach?

OBJECTIVES: While active surveillance, a form of expectant management (EM), is preferred for patients with low-risk prostate cancer (PCa), some favor a more risk-adapted approach that recognizes patient preferences and condition-specific factors. However, previous research has shown non-patient-related factors often drive PCa treatment. In this context, we characterized trends in AS with respect to disease risk and health status. METHODS AND MATERIALS: Using SEER-Medicare data, we identified men 66 years and older diagnosed with localized low- and intermediate-risk PCa from 2008 to 2017 and examined receipt of EM, defined as the absence of treatment (i.e., surgery, cryotherapy, radiation, chemotherapy, and androgen deprivation therapies) within 1 year of diagnosis. We performed bivariable analysis to compare trends in use for EM vs. treatment, stratified by disease risk (i.e., Gleason 3+3, 3+4, 4+3; PSA<10, 10-20) and health status (i.e., NCI Comorbidity Index (NCI), frailty, life expectancy). We then ran a multivariable logistic regression model to examine determinants of EM. RESULTS: Within this cohort, 26,364 (38%) were categorized as low-risk (i.e., Gleason 3+3 and PSA<10) and 43,520 (62%) as intermediate-risk (i.e., all others). Over the study period, use of EM significantly increased across all risk groups, except for Gleason 4+3 (P = 0.662), as well across all health status groups. However, linear trends did not differ significantly between frail vs. nonfrail patients for both those categorized as low-risk (P = 0.446) and intermediate-risk (P = 0.208). Trends also did not differ between NCI 0 vs. 1 vs. >1 for low-risk PCa (P = 0.395). In the multivariable models, EM was associated with increasing age and being frail for men with both low- and intermediate risk disease. Conversely, EM selection was negatively associated with higher comorbidity score. CONCLUSIONS: EM increased significantly over time for patients with low- and favorable intermediate-risk disease, with the most notable differences based on age and Gleason score. In contrast, trends in uptake of EM did not differ substantively by health status, suggesting that physicians may not be effectively incorporating patient health into PCa treatment decisions. Additional work is needed to develop interventions that recognize health status as an essential component of a risk-adapted approach.

The Cost of Metastatic Prostate Cancer in the United States.

INTRODUCTION: We sought to estimate per patient and annual aggregate health care costs related to metastatic prostate cancer. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified fee-for-service Medicare beneficiaries ages 66 and older diagnosed with metastatic prostate cancer or claims with diagnosis codes for metastatic disease (indicating tumor progression following diagnosis) between 2007 and 2017. We measured annual health care costs and compared costs between cases and a sample of beneficiaries without prostate cancer. RESULTS: We estimate that per-patient annual costs attributable to metastatic prostate cancer are $31,427 (95% CI: $31,219-$31,635; 2019 dollars). Annual attributable costs rose over time, from $28,311 (95% CI: $28,047-$28,575) in 2007-2013 to $37,055 (95% CI: $36,716-$37,394) in 2014-2017. In aggregate, health costs attributable to metastatic prostate cancer are $5.2 to $8.2 billion per year. CONCLUSIONS: The per patient annual health care costs attributable to metastatic prostate cancer are substantial and have increased over time, corresponding to the approval of new oral therapies used in treating metastatic prostate cancer.

Prolonged Opioid Use Following Bladder Tumor Resection for Opioid-naïve Patients.

INTRODUCTION: Bladder cancer patients represent a high-risk group for opioid dependence due to the frequency of surgical procedures. Using MarketScan insurance commercial claims and Medicare-eligible databases, we sought to identify whether filling an opioid prescription following initial transurethral resection of bladder tumor resulted in increased odds of prolonged opioid use. METHODS: We analyzed 43,741 commercial claims and 45,828 Medicare-eligible opioid-naïve patients with a new diagnosis of bladder cancer from 2009 to 2019. Multivariable analyses were completed to assess the odds of prolonged opioid use at 3-6 months based on initial exposure to opioids and initial opioid dose quartile. We performed subgroup analyses by sex and eventual treatment modality. RESULTS: Those who filled an opioid prescription following initial transurethral resection of bladder tumor had greater odds of persistent opioid use (commercial claims: 27% vs 12%, OR 2.14, 95% CI 1.84-2.45; Medicare-eligible: 24% vs 12%, OR 1.95, 95% CI 1.70-2.22). Increasing dosage quartile of opioids was associated with increased odds of prolonged opioid use. Those going on to radical therapy had the highest rates of an initial opioid prescription (31% commercial claims and 23% Medicare eligible). Men and women had similar rates of initial prescriptions, but female sex was associated with higher odds of persistent opioid use at 3-6 months in the Medicare-eligible group (OR 1.08, 95% CI 1.01-1.16). CONCLUSIONS: Opioids following initial transurethral resection of bladder tumor increase the odds of continued use at 3-6 months, with the greatest odds in those prescribed the highest initial doses. These data suggest that short-term prescriptions have long-term effects, and additional research on opioid use and bladder cancer outcomes is merited.

Trends in Urethral Suspension With Robotic Prostatectomy Procedures Following Medicare Payment Policy Changes.

Importance: In 2016, the Centers for Medicare and Medicaid Services cut payments for robotic prostatectomy performed for Medicare beneficiaries. Although regulations mandate that billing for urethral suspension is only acceptable for preexisting urinary incontinence, reductions in reimbursement may incentivize billing for the use of this procedure in other scenarios. Objective: To assess trends and geographic variations in payments for urethral suspension with robotic prostatectomy in the context of Medicare payment policy. Design, Setting, and Participants: This US population-based retrospective cohort study analyzed data from the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental Database for men with employer-based insurance (primary commercial or Medicare supplemental coverage) who underwent robotic prostatectomy (Current Procedural Terminology [CPT] code 55866) between 2009 and 2019. Exposures: Time period and metropolitan statistical area of patient residence. Main Outcomes and Measures: Payment for urethral suspension (CPT code 51990) with robotic prostatectomy. Results: We identified 87 774 men with prostate cancer treated with robotic prostatectomy; 3352 (3.8%) had undergone urethral suspension. The mean (SD) patient age was 59.7 (6.5) years; 16 870 patients (19.2%) had Medicare supplemental coverage. From 2015 to 2016, median payments for robotic prostatectomy changed by -$358 (-17.0%) for Medicare beneficiaries vs -$9 (0%) for commercially insured patients. With urethral suspension vs without, median (IQR) episode payments for robotic prostatectomy were higher for commercially insured men ($3678 [$3090-$4503] vs $3322 [$2601-$4306]) and Medicare beneficiaries ($2927 [$2450-$3909] vs $2379 [$2014-$3512]). Compared with men treated between 2013 and 2015, those treated between 2016 and 2017 were twice as likely to undergo urethral suspension (8.5% vs 4.1%; odds ratio, 2.17 [95% CI, 1.96-2.38]). The proportion of patients who underwent urethral suspension was stable for 2018 to 2019 and 2016 to 2017 (8.5% vs 9.0%; odds ratio, 1.06 [95% CI, 0.96-1.18]). From 2015 to 2019, the proportion of patients who underwent urethral suspension was highest in Charleston, South Carolina (92.0%), Knoxville, Tennessee (66.0%), and Columbia, South Carolina (58.0%). These regions neighbored high-volume areas without patients who underwent prostatectomy with urethral suspension (eg, 146 patients in Greenville, South Carolina, and 173 in Nashville, Tennessee). Conclusions and Relevance: In this study, urethral suspension was associated with increased costs for patients with both commercial insurance and Medicare. Patients treated between 2016 and 2017 were more likely than those treated between 2013 and 2015 to undergo this procedure. Geographic variation in use exceeded what was expected for the preexisting condition for which billing is permitted for Medicare beneficiaries. Policy statements from professional societies highlighting appropriate billing for urethral suspension may have tempered, but not reversed, the broad adoption of this procedure.

Longitudinal impact of bladder cancer diagnosis on common psychiatric disorders.

BACKGROUND: The presence of psychiatric disorders in patients with cancer is associated with increased morbidity and poorer outcomes. We sought to determine the impact of a new bladder cancer diagnosis on the incidence of depression and anxiety. METHODS: We used a database of billing claims (MarketScan®) to identify patients newly diagnosed with bladder cancer between 2009 and 2018. Patients with preexisting psychiatric disorders or use of anxiolytics/antidepressants were excluded. We matched cases to patients without a bladder cancer or psychiatric diagnosis. Our primary outcome was a new diagnosis of depression, anxiety, or use of anxiolytics/antidepressants. Other exposures of interest included gender and treatment received. We used multivariable regression to estimate odds ratios for these exposures. RESULTS: We identified 65,846 cases with a new diagnosis of bladder cancer (31,367 privately insured; 34,479 Medicare-eligible). Compared to controls, bladder cancer patients were more likely to develop new-onset depression/anxiety at 6 months (privately insured: 6.9% vs. 3.4%, p < 0.001; Medicare-eligible: 5.7% vs. 3.4%, p < 0.001) and 36 months (privately insured: 19.2% vs. 13.5%, p < 0.001; Medicare-eligible: 19.3% vs. 16.0%, p < 0.001). Women (vs. men, privately insured: OR 1.65, 95%CI 1.53-1.78; Medicare-eligible: OR 1.63, 95%CI 1.50-1.76) and those receiving cystectomy and chemotherapy (vs. no treatment, privately insured: OR 4.94, 95%CI 4.13-5.90; Medicare-eligible: OR 2.35, 95%CI 1.88-2.94) were more likely to develop significant depression/anxiety. CONCLUSION: A new diagnosis of bladder cancer was associated with increased burden of significant depression/anxiety compared with matched controls. Women and patients receiving more radical treatments had higher rates of depression and anxiety.

Disparities in magnetic resonance imaging of the prostate for traditionally underserved patients with prostate cancer.

BACKGROUND: Prebiopsy magnetic resonance imaging (MRI) of the prostate improves detection of significant tumors, while decreasing detection of less-aggressive tumors. Therefore, its use has been increasing over time. In this study, the use of prebiopsy MRI among Medicare beneficiaries with prostate cancer was examined. It was hypothesized that patients of color and those in isolated areas would be less likely to undergo this approach for cancer detection. METHODS: Using cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries, men with nonmetastatic prostate cancer were identified from 2010 through 2015 with prostate-specific antigen (PSA) <30 ng/mL. Outcome was prebiopsy MRI of the prostate performed within 6 months before diagnosis (ie, Current Procedural Terminology 72197). Exposures were patient race/ethnicity and rural/urban status. Multivariable regression estimated the odds of prebiopsy prostate MRI. Post hoc analyses examined associations with the registry-level proportion of non-Hispanic Black patients and MRI use, as well as disparities in MRI use in registries with data on more frequent use of prostate MRI. RESULTS: There were 50,719 men identified with prostate cancer (mean age, 72.1 years). Overall, 964 men (1.9% of cohort) had a prebiopsy MRI. Eighty percent of patients with prebiopsy MRI lived in California, New Jersey, or Connecticut. Non-Hispanic Black men (0.6% vs 2.1% non-Hispanic White; odds ratio [OR], 0.28; 95% CI, 0.19-0.40) and men in less urban areas (1.1% vs 2.2% large metro; OR, 0.65; 95% CI, 0.44-0.97) were less likely to have prebiopsy MRI of the prostate. CONCLUSIONS: Non-Hispanic Black patients with prostate cancer and those in less urban areas were less likely to have prebiopsy MRI of the prostate during its initial adoption as a tool for improving prostate cancer detection.

The value of new drugs for advanced prostate cancer.

BACKGROUND: The US Food and Drug Administration has recently approved a number of new cancer drugs. The clinical trials that serve as the basis for new cancer drug approvals may not reflect how the drugs will perform in routine practice and do not measure the impact of the drugs on spending. The authors sought to evaluate the real-world effectiveness and value of drugs recently approved for advanced prostate cancer. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, the authors identified fee-for-service Medicare beneficiaries aged 65 years or older who began treatment with a drug approved for metastatic castration-resistant prostate cancer in 2007-2009, when only 1 drug was approved for metastatic castration-resistant prostate cancer, and in 2014-2016, when 5 additional drugs were approved. They calculated life expectancy and lifetime medical costs (ie, Medicare reimbursements) for each group. RESULTS: Between 2007-2009 and 2014-2016, life expectancy increased by 12.6 months. Lifetime medical costs increased by $87,000. The incremental cost per life-year gained was $83,000. CONCLUSION: The release of 5 new drugs coincided with increases in survival rates and spending. This study's estimates indicate that the new drugs collectively were cost-effective.

Association of State-Level Medicaid Expansion With Treatment of Patients With Higher-Risk Prostate Cancer.

Importance: The Patient Protection and Affordable Care Act broadened insurance coverage, partially through voluntary state-based Medicaid expansion. Objective: To determine whether patients with higher-risk prostate cancer residing in Medicaid expansion states were more likely to receive treatment after expansion compared with patients in states electing not to pursue Medicaid expansion. Design, Setting, and Participants: This population-based cohort study included 15 332 patients diagnosed with higher-risk prostate cancer (ie, grade group >2; grade group 2 with prostate-specific antigen levels >10 ng/mL; or grade group 1 with prostate-specific antigen levels >20 ng/mL) from January 2010 to December 2016 aged 50 to 64 years who were candidates for definitive treatment. Patients residing in states that partially expanded Medicaid coverage before 2010 (ie, California and Connecticut) and those with diagnosis not confirmed by histology were excluded. Data were collected from the Surveillance, Epidemiology, and End Results Program. Data were analyzed between August and December 2019. Exposure: State-level Medicaid expansion status. Main Outcomes and Measures: Insurance status before and after expansion, treatment with prostatectomy or radiation therapy (including brachytherapy), treatment trends over time. Results: Of 15 332 patients, 7811 (50.9%) lived in expansion states (mean [SD] age, 59.1 [3.8] years; 5532 [71.9%] non-Hispanic White), and 7521 (49.1%) lived in nonexpansion states (mean [SD] age, 59.0 [3.9] years; 3912 [52.1%] non-Hispanic White). Residence in an expansion state was associated with higher pre-expansion levels of Medicaid coverage (292 [8.1%] vs 161 [3.8%]; odds ratio [OR], 2.12; 95% CI, 1.78 to 2.53) and lower likelihood of being uninsured (136 [3.2%] vs 38 [1.1%]; OR, 0.28; 95% CI, 0.15 to 0.54). After expansion, there was no difference in trends in treatment receipt between expansion and nonexpansion states (change, -0.39%; 95% CI, -0.11% to 0.28%; P = .25). Patients with private or Medicare coverage were more likely to receive treatment vs those with Medicaid or no coverage across racial/ethnic groups (eg, Black patients with coverage: OR, 2.30; 95% CI, 1.68 to 3.10; Black patients with no coverage: OR, 1.48; 95% CI, 1.09 to 2.00; P < .001). Medicaid patients were not more likely to be treated compared with those without insurance (737 [78.8%] vs 435 [79.5%]; OR, 0.97; 95% CI, 0.76 to 1.25). Conclusions and Relevance: In this cohort study, state-level expansion of Medicaid was associated with increased Medicaid coverage for men with higher-risk prostate tumors but did not appear to affect treatment patterns at a population level. This may be related to the finding that Medicaid coverage was not associated with increased treatment rates compared with those without insurance.

Contemporary Patterns of Third-line Treatments for Privately Insured Individuals With Overactive Bladder in the United States.

OBJECTIVE: To evaluate utilization of third-line overactive bladder (OAB) treatments including percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and intradetrusor botulinum toxin A (BTX) among privately insured patients and examine factors associated with their use. MATERIALS AND METHODS: Using MarketScan claims (2015-2017), we identified patients who underwent third-line OAB treatments based on procedure codes. Factors of interest included location, age, health plan, among others. We fit multivariable logistic regression models to estimate associations between pertinent factors with receipt of PTNS and SNS relative to BTX and associations between provider type and practice location with each treatment modality. RESULTS: We identified 7383 patients (mean age 50.9) in our cohort. SNS was used most frequently (n = 3602, 48.8%), while PTNS was used least frequently (n = 955, 12.9%). PTNS patients were more likely to reside in metropolitan areas (vs BTX: OR 1.6, 95%CI 1.3-2.1; vs SNS: OR 2.2, 95%CI 1.7-2.8), be aged 55 years or older (vs BTX: 54% vs 47%, OR 1.6, 95%CI 1.2-2.1; vs SNS: 54% vs 45%, OR 1.6, 95%CI 1.2-2.0), and be covered under a health maintenance organization (vs BTX: 17% vs 10%; vs SNS: 17% vs 10%, P <.01). Urologists were most likely to perform SNS, and gynecologists were most likely to perform BTX. 91% of PTNS procedures were performed in office settings. CONCLUSION: Among patients receiving third-line OAB treatment, PTNS was used infrequently. PTNS utilization was concentrated within urban areas, and among older patients and those covered by cost-conscious health maintenance organizations.

Payments and Patient Cost Sharing for Prostate Biopsies According to Image Guidance, Practice Site and Use of Anesthesia.

INTRODUCTION: Use of magnetic resonance imaging for prostate biopsies has increased and more biopsies are performed in nonoffice based settings. These changes will likely impact payments related to prostate biopsies. METHODS: Using private insurance claims from 2009 to 2015 we identified men who underwent transrectal ultrasound guided (CPT 55700) or transperineal (CPT 55706) prostate biopsies. We assumed any magnetic resonance imaging of the pelvis within 3 months prior to biopsy was for image based guidance. We assigned biopsy site as being performed in the office, ambulatory surgical center or hospital. Use of anesthesia was based on CPT codes 00100-01999. Our primary outcome was aggregate payments for anesthesia, pathology, imaging and procedural services. We also studied patient out-of-pocket costs. Multivariable regression was used to generate predicted payments based on magnetic resonance imaging performance, anesthesia and site of biopsy. RESULTS: We identified 304,388 biopsy episodes, of which 2.2% were magnetic resonance imaging guided and 0.7% were transperineal. Median cost of magnetic resonance imaging guided biopsies was greatest at $4,396 (IQR $2,784-$7,127) compared to the costs of transperineal and transrectal ultrasound guided biopsies. Imaging accounted for the greatest share of magnetic resonance imaging guided biopsy costs (median $1,704, IQR $975-$3,043). Magnetic resonance imaging guided biopsies in a hospital with anesthesia had the highest cost at $5,832 per episode (95% CI $5,732-$5,934). There was a fivefold difference in patient cost sharing between the least expensive (transperineal, office and no anesthesia $168) and most expensive (magnetic resonance imaging guided, ambulatory surgical center with anesthesia $891) modality. CONCLUSIONS: Total and out-of-pocket costs for prostate biopsies vary substantially based on modality, location and anesthesia use.

Multiparametric Magnetic Resonance Imaging Is Associated with Increased Medicare Spending in Prostate Cancer Active Surveillance.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) may improve prostate cancer risk stratification and decrease the need for repeat biopsies in men on prostate cancer active surveillance (AS). However, the impact of mpMRI on AS-related healthcare spending has not been established. OBJECTIVE: To characterize the impact of mpMRI on AS-related Medicare expenditures. DESIGN, SETTING, AND PARTICIPANTS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare files, we identified men ≥66 yr old with localized prostate cancer diagnosed during 2008-2013. OUTCOME MEASURES AND STATISTICAL ANALYSIS: With a validated algorithm, we classified men into AS with and without mpMRI groups. We then determined Medicare spending on AS in each group using inflation-adjusted, price-standardized Medicare payments for AS-related procedures (ie, prostate-specific antigen [PSA] tests, prostate biopsies, biopsy complications, and mpMRI). Multivariable median regression compared Medicare spending on AS for men who received mpMRI and those who did not. RESULTS AND LIMITATIONS: We identified 9081 men on AS with a median follow-up of 45 mo (interquartile range 29-64 mo). Thirteen percent (N = 1225) received mpMRI. On multivariable median regression, receipt of mpMRI was associated with an additional $447 (95% confidence interval $409-487) in Medicare spending per year. We observed greater frequency of AS-related procedures and higher spending for identical procedures (eg, PSA or prostate biopsy) in the mpMRI group than in the non-mpMRI group (all p < 0.001). CONCLUSIONS: Among Medicare beneficiaries on AS, mpMRI is associated with additional annual Medicare spending. Future studies are needed to determine optimal use of mpMRI during AS to maximize value. PATIENT SUMMARY: Prostate magnetic resonance imaging (MRI) helps physicians determine which prostate cancers are aggressive and which can be monitored safely. We studied whether using MRI during prostate cancer monitoring (also called active surveillance) resulted in increased healthcare spending. There was a modest increase in spending, but this may be worthwhile if the use of MRI allows physicians to monitor prostate cancer more accurately.

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries.

Importance: Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries. Objective: To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists. Design, Setting, and Participants: This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019. Main Outcomes and Measures: Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified. Results: Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist. Conclusions and Relevance: Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Use of Office Versus Ambulatory Surgery Center Setting and Associated Ancillary Services on Healthcare Cost Burden for Vasectomy Procedures.

OBJECTIVE: To analyze variation in total healthcare costs for vasectomies performed in the United States, based on procedure setting and use of ancillary pathology services. METHODS: We queried the MarketScan Commercial Claims database using CPT, ICD, and HCPCS codes to identify men who underwent vasectomy between 2009 and 2015, either in the office or ambulatory surgical center (ASC) setting, with or without use of pathology services. All payments for each treatment episode were calculated based on relevant claims. Patient out-of-pocket expenses were defined as the sum of copayments, coinsurance, and deductibles for each claim. Trends in vasectomy use, and differences in procedure costs by practice setting were compared over the study period. RESULTS: 453,492 men underwent a vasectomy between 2009 and 2015. The number of procedures decreased from 76,197 in 2009 to 37,575 in 2015 (P = .002). Average procedural costs increased from $870 in 2009 to $938 in 2015 (P = .001). Overall, 82.6% and 17.4% of procedures were performed in the office vs ASCs, respectively. In-office procedures were associated with lower total healthcare costs ($707 vs $1851) and lower patient out-of-pocket expenses ($173 vs $356) than those performed in ASCs. Vasal segments were submitted for pathologic evaluation in 40% of cases, which increased average payments by 55%. The use of ASCs and ancillary pathology services for vasectomies performed during the study period increased vasectomy-associated costs by $64 million. CONCLUSION: The unnecessary use of ASCs and ancillary pathology services for vasectomy may lead to tens of millions of dollars in potentially avoidable healthcare costs annually.

Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance.

OBJECTIVE: To characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. mpMRI has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established. METHODS: Using Surveillance, Epidemiology, and End Results registry data linked to Medicare claims data, we identified men with localized prostate cancer diagnosed between 2008 and 2013 and managed with active surveillance. We classified men into 2 treatment groups: active surveillance without mpMRI and active surveillance with mpMRI. We then fit a multivariable logistic regression models to examine changing mpMRI utilization over time, and factors associated with the receipt of mpMRI. RESULTS: We identified 9467 men on active surveillance. Of these, 8178 (86%) did not receive mpMRI and 1289 (14%) received mpMRI. The likelihood of receiving mpMRI over the entire study period increased by 3.7% (P = .004). On multivariable logistic regression, patients who were younger, white, had lower comorbidity burden, lived in the northeast and west, had higher incomes and lived in more urban areas had greater odds of receiving mpMRI (all P < .05). CONCLUSION: From 2008 to 2013, use of mpMRI in active surveillance increased gradually but significantly. Receipt of mpMRI among men on surveillance for prostate cancer varied significantly across demographic, geographic, and socioeconomic strata. Going forward, studies should investigate causes for this variation and define ideal strategies for equitable, cost-effective dissemination of mpMRI technology.

Assigning value to preparation for prostate cancer decision making: a willingness to pay analysis.

BACKGROUND: The Personal Patient Profile-Prostate (P3P) is a web-based decision support system for men newly diagnosed with localized prostate cancer that has demonstrated efficacy in reducing decisional conflict. Our objective was to estimate willingness-to-pay (WTP) for men's decisional preparation activities. METHODS: In a multicenter, randomized trial of P3P, usual care group participants received typical preparation for decision making plus referral to publicly-available, educational websites. Intervention group participants received the same, plus online P3P educational media specific to the user's personal preferences and values, and a communication coaching component tailored to race\ethnicity, age and language. WTP data were collected one week after physician consultation. An iterative bidding direct contingent valuation survey format was used, randomly assigning participants to high or low starting values (SV). Tobit models were used to explore associations between SV-adjusted WTP and age, education, marital and work-status, insurance, decision-control preference and decision-making stage. RESULTS: Of 392 participants enrolled, 141 P3P and 107 usual care (UC) provided a WTP value. Men were willing to pay a median $25 (IQR $10-100) for P3P in addition to usual care preparation materials. In the final multivariable tobit regression model, SV, marital status, stage of decision making and income were significantly associated with WTP for P3P. Decision control preference was considered marginally significant (p = 0.11). Men were WTP a median $30 (IQR $10-$200) for usual care material alone. In the final multivariable model, SV, education, and stage of decision making were significantly associated with WTP in usual care. CONCLUSION: WTP was similar for UC and for the addition of P3P to UC decision preparation. The WTP values were associated with demographic and preference variables. Findings can help focus decision support on future patients who would benefit most: those without strong support systems, at earlier stages of decision making, and open to a shared-decision style. TRIAL REGISTRATION: NCT NCT01844999 . Registered May 3, 2013.