Association between hospital competition and quality of prostate cancer care.

BACKGROUND: Hospitals account for approximately 6% of United States' gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association. METHODS: Retrospective study using Surveillance, Epidemiology, and End Results (SEER) - Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias. RESULTS: Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15-1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans. CONCLUSIONS: Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.

Racial Disparity in Outcomes Among Prostate Cancer Patients in the Post-Affordable Care Act Period.

INTRODUCTION: Our objective was to assess whether Medicaid expansion is associated with reduced racial disparity in quality of care measured as 30-day mortality, 90-day mortality, and 30-day readmission in prostate cancer patients receiving surgery. METHODS: We used the National Cancer Database to extract a cohort of African American and White men diagnosed with prostate cancer between 2004 and 2015 and surgically treated. We used 2004-2009 data to observe preexisting racial disparity in outcomes. We used 2010-2015 data to assess racial disparity in outcomes and the interaction of race and Medicaid expansion status. RESULTS: Between 2004 and 2009, 179,762 men met our criteria. In this period, African American patients reported higher hazard of 30- and 90-day mortality and higher odds of 30-day readmission compared to White patients. Between 2010 and 2015, 174,985 men met our criteria. Of these 84% were White and 16% were African American. Main effects models showed that compared to White men, African American men had higher odds of 30-day mortality (OR=1.96, 95% CI = 1.46, 2.67), 90-day mortality (OR=1.40, 95% CI = 1.11, 1.77), and 30-day readmission (OR=1.28, 95% CI = 1.19, 1.38).The interactions between race and Medicaid expansion were not significant (P = .1306, .9499, and .5080, respectively). CONCLUSIONS: Improved access to care via Medicaid expansion may not translate into reduced racial disparity in quality-of-care outcomes in prostate cancer patients treated surgically. System-level factors such as availability of and referrals to care, and complex socioeconomic structure may also play a role in improving quality of care and reducing disparities.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients.

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial.

OBJECTIVES: Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy. MATERIALS AND METHODS: We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively. RESULTS: Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support. CONCLUSIONS: While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.

Effectiveness of postoperative radiotherapy after radical cystectomy for locally advanced bladder cancer.

BACKGROUND: Local-regional failure (LF) for locally advanced bladder cancer (LABC) after radical cystectomy (RC) is common even with chemotherapy and is associated with high morbidity/mortality. Postoperative radiotherapy (PORT) can reduce LF and may enhance overall survival (OS) but has no defined role. We hypothesized that the addition of PORT would improve OS in LABC in a large nationwide oncology database. METHODS: We identified ≥ pT3pN0-3M0 LABC patients in the National Cancer Database diagnosed 2004-2014 who underwent RC ± PORT. OS was calculated using Kaplan-Meier and Cox proportional hazards regression modeling was used to identify predictors of OS. Propensity matching was performed to match RC patients who received PORT vs those who did not. RESULTS: 15,124 RC patients were identified with 512 (3.3%) receiving PORT. Median OS was 20.0 months (95% CI, 18.2-21.8) for PORT vs 20.8 months (95% CI, 20.3-21.3) for no PORT (P = 0.178). In multivariable analysis, PORT was independently associated with improved OS: hazard ratio 0.87 (95% CI, 0.78-0.97); P = 0.008. A one-to-three propensity match yielded 1,858 patients (24.9% receiving PORT and 75.1% without). In the propensity-matched cohort, median OS was 19.8 months (95% CI, 18.0-21.6) for PORT vs 16.9 months (95% CI, 15.6-18.1) for no PORT (P = 0.030). In the propensity-matched cohort of urothelial carcinoma patients (N = 1,460), PORT was associated with improved OS for pT4, pN+, and positive margins (P < 0.01 all). CONCLUSION: In this observational cohort, PORT was associated with improved OS in LABC. While the data should be interpreted cautiously, these results lend support to the use of PORT in selected patients with LABC, regardless of histology. Prospective trials of PORT are warranted.

Patient-Centered Preference Assessment to Improve Satisfaction With Care Among Patients With Localized Prostate Cancer: A Randomized Controlled Trial.

PURPOSE: To study the effectiveness of the Patient Preferences for Prostate Cancer Care (PreProCare) intervention in improving the primary outcome of satisfaction with care and secondary outcomes of satisfaction with decision, decision regret, and treatment choice among patients with localized prostate cancer. METHODS: In this multicenter randomized controlled study, we randomly assigned patients with localized prostate cancer to the PreProCare intervention or usual care. Outcomes were satisfaction with care, satisfaction with decision, decision regret, and treatment choice. Assessments were performed at baseline and at 3, 6, 12, and 24 months, and were analyzed using repeated measures. We compared treatment choice across intervention groups by prostate cancer risk categories. RESULTS: Between January 2014 and March 2015, 743 patients with localized prostate cancer were recruited and randomly assigned to receive PreProCare (n = 372) or usual care (n = 371). For the general satisfaction subscale, improvement at 24 months from baseline was significantly different between groups (P < .001). For the intervention group, mean scores at 24 months improved by 0.44 (SE, 0.06; P < .001) from baseline. This improvement was 0.5 standard deviation, which was clinically significant. The proportion reporting satisfaction with decision and no regret increased over time and was higher for the intervention group, compared with the usual care group at 24 months (P < .05). Among low-risk patients, a higher proportion of the intervention group was receiving active surveillance, compared with the usual care group (P < .001). CONCLUSION: Our patient-centered PreProCare intervention improved satisfaction with care, satisfaction with decision, reduced regrets, and aligned treatment choice with risk category. The majority of our participants had a high income, with implications for generalizability. Additional studies can evaluate the effectiveness of PreProCare as a mechanism for improving clinical and patient-reported outcomes in different settings.

Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer.

BACKGROUND: Substance use disorder in patients with cancer has implications for outcomes. The objective of this study was to analyze the effects of the type and timing of substance use on outcomes in elderly Medicare recipients with advanced prostate cancer. METHODS: This was an observational cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000 to 2009. Among men who were diagnosed with advanced prostate cancer between 2001 and 2004, we identified those who had a claim for substance use disorder in the year before cancer diagnosis, 1 year after cancer diagnosis, and an additional 4 years after diagnosis. The outcomes investigated were use of health services, costs, and mortality. RESULTS: The prevalence of substance use disorder was 10.6%. The category drug psychoses and related had greater odds of inpatient hospitalizations (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.8), outpatient hospital visits (OR, 2.6; 95% CI, 1.9-3.6), and emergency room visits (OR, 1.7; 95% CI, 1.2-2.4). Substance use disorder in the follow-up phase was associated with greater odds of inpatient hospitalizations (OR, 2.0; 95% CI, 1.8-2.2), outpatient hospital visits (OR, 2.0; 95% CI, 1.7-2.4), and emergency room visits (OR, 1.7; 95% CI, 1.5-2.1). Compared with men who did not have substance use disorder, those in the category drug psychoses and related had 70% higher costs, and those who had substance use disorder during the follow-up phase had 60% higher costs. The hazard of all-cause mortality was highest for patients in the drug psychoses and related category (hazard ratio, 1.3; 95% CI, 1.1-1.7) and the substance use disorder in treatment phase category (hazard ratio, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS: The intersection of advanced prostate cancer and substance use disorder may adversely affect outcomes. Incorporating substance use screening and treatments into prostate cancer care guidelines and coordination of care is desirable.

The burden of depression in prostate cancer.

OBJECTIVE: We sought to analyze the prevalence and incremental burden of depression among elderly with prostate cancer. METHODS: We adopted a retrospective cohort design using the Surveillance, Epidemiology and End Results-Medicare linked database between 1995 and 2003. Patients with prostate cancer diagnosed between 1995 and 1998 were identified and followed retrospectively for 1 year pre-diagnosis and up to 8 years post diagnosis. In this cohort of patients with prostate cancer, depression during treatment phase (1 year after diagnosis of prostate cancer) or in the follow-up phase was identified using the International Classification of Diseases-Ninth Revision depression-related codes. Poisson, general linear (log-link) and Cox regression models were used to determine the association between depression status during treatment and follow-up phases and outcomes-health resource utilization, cost and mortality. RESULTS: Of the 50,147 patients newly diagnosed with prostate cancer, 4285 (8.54%) had a diagnosis of depression. A diagnosis of depression during treatment phase was associated with higher odds of emergency room visits (odds ratio (OR) = 4.45, 95% CI = 4.13, 4.80), hospitalizations (OR = 3.22, CI = 3.08, 3.37), outpatient visits (OR = 1.71, CI = 1.67, 1.75) and excess risk of death over the course of the follow-up interval (hazard ratio = 2.82, CI = 2.60, 3.06). Health care costs associated with depression remained elevated compared with costs for men without depression, over the course of the follow-up. CONCLUSIONS: Depression during the treatment phase was associated with significant health resource utilization, costs and mortality among men with prostate cancer. These findings emphasize the need to effectively identify and treat depression in the setting of prostate cancer.

The burden of out-of-pocket and indirect costs of prostate cancer.

BACKGROUND: Out-of-pocket and indirect (OPI) costs play an important role in prostate cancer (PCa) outcomes research. We sought to analyze OPI costs of newly diagnosed PCa patients receiving either radical prostatectomy (RP) or external beam radiation therapy (EBRT). METHODS: Prospective cohort design was used to recruit 512 newly diagnosed PCa patients from urology clinics of an urban academic hospital and a Veterans Administration medical center. Participants provided demographic information and completed self-reported generic and prostate-specific Health Related Quality of Life (HRQoL) and indirect-cost surveys at baseline and at 3, 6, 12, and 24 months follow-up. Linear mixed models were applied to study the association between OPI costs, treatment and HRQoL outcomes. Propensity scores adjusted for potential confounders and Bonferroni correction was used to account for multiple testing. RESULTS: Total mean OPI costs varied between RP group and EBRT group at 3-month ($5576 vs. $2010), 6-month ($1776 vs. $2133), 12-month ($757 vs. $774), and at 24-month follow-up ($458 vs. $871). Linear mixed models indicated that RP was associated with lower medication costs (OR = 0.61, CI = 0.48-0.89) and total OPI costs (OR = 0.71, CI = 0.64-0.92). Total OPI costs were inversely related to most of the generic HRQoL items. Similarly, prostate-specific HRQoL items of urinary function (OR = 0.72; adjusted-CI = 0.58-0.84), bowel function (OR = 0.96; adjusted-CI = 0.78-0.98), sexual function (OR = 0.85; adjusted-CI = 0.72-0.92), urinary bother (OR = 0.79; adjusted-CI = 0.67-0.83), and sexual bother (OR = 0.88; adjusted-CI = 0.76-0.93) were inversely related to OPI costs. CONCLUSIONS: OPI costs of PCa care are substantial and vary across time and treatment.

Association between utility and treatment among patients with prostate cancer.

PURPOSE: To analyze the association between utility, treatment, and generic and prostate-specific health-related quality of life (HRQoL) among patients with prostate cancer. METHODS: In this longitudinal cohort study, we recruited 201 (>or=45 years) newly diagnosed patients with prostate cancer from urology clinics of an urban academic hospital. Participants completed Quality of Wellbeing (QWB-SA), generic (SF-36), and prostate-specific (UCLA-PCI) HRQoL surveys prior to treatment and up to 24 months post-treatment. Clinical and demographic data were obtained via medical chart review, and utility scores were computed using QWB-SA. To analyze the relationship between treatment and utility, we used linear mixed effects models, after adjusting for covariates and propensity score. Similar models were used to examine the association between generic and prostate-specific HRQoL and utility. RESULTS: Mean baseline utility was comparable between radical prostatectomy (RP) and external beam radiation therapy (EBRT) groups (0.73 vs. 0.69, P=0.1750). Mixed effects models indicated that RP was associated with higher utility at 24 month (OR=1.12, P=0.027), after controlling for covariates. RP was associated with improved functioning for role physical, role emotional, vitality, mental health and bodily pain, and impaired urinary function. Higher scores on generic health subscales were indicative of higher utility. Also, for prostate-specific HRQoL, higher scores on bowl function, sexual function, urinary bother, and bowel bother were associated with higher utility. CONCLUSIONS: Treatment appears to have significant association with post-treatment utility. Thus, utility assessment provides an important quantitative tool to support patient and physician clinical treatment decision-making process in prostate cancer care.

Racial and ethnic variation in health resource use and cost for prostate cancer.

OBJECTIVE: To analyse the racial and ethnic variation in health resource use (HRU) and direct medical care (DMC) cost in elderly men with prostate cancer. PATIENTS AND METHODS: This was a retrospective case-control study using the linked Surveillance, Epidemiology, and End Results Medicare database. Patients with prostate cancer diagnosed between 1995 and 1998 (50 147 men) were identified and followed retrospectively for 1 year before and 5 years after the diagnosis. Phase-specific HRU and DMC costs were compared between racial and ethnic groups using parametric and nonparametric analysis. To compute the incremental cost of prostate cancer, a matched non-cancer control group was extracted from Medicare database. Poisson and general linear models (log-link) were used to identify the association of race and ethnicity with HRU and DMC cost, after controlling for potentially influential clinical and demographic covariates. RESULTS: The African-American group was more likely to have emergency-room visits (odds ratio 1.19, 95% confidence interval 1.12-1.28) and less likely to have outpatient visits (0.96, 0.96-0.97) than whites. However, the Hispanic group was more likely to have inpatient and outpatient visits (odds ratio 0.88, 0.83-0.91; and 0.93, 0.91-0.95) than whites. Adjusted DMC cost showed racial and ethnic variation in all phases except the treatment and terminal phases. Factors associated with DMC cost varied among racial and ethnic groups. CONCLUSION: The incremental burden of prostate cancer remains significant in the long term. Overall, the cost of prostate cancer care was higher among African-American men than white and Hispanic men. This indicates the need for further research on care-level factors to comprehend the racial and ethnic disparity in HRU and cost.

Predictors of patient reported outcomes and cost of care in younger men with newly diagnosed prostate cancer.

BACKGROUND: The proportion of younger men (<65 years) diagnosed with prostate cancer (PCa) has increased significantly. We sought to analyze the association between race/ethnicity, biochemical recurrence risk and outcomes in younger men with PCa. METHODS: In this prospective cohort study, we recruited 318 younger men with newly diagnosed PCa. Participants completed generic and prostate-specific Health Related Quality of Life (HRQoL), out-of-pocket cost and satisfaction with care surveys at baseline and at 3, 6, 12, and 24 months of follow-up. Health resource utilization and cost data were obtained from the hospital based administrative databases. We compared time to return to baseline (RTB) of HRQoL scores across groups. Survival curves were used to compare mean time to RTB across groups. Linear mixed effects (LMEs) and generalized linear (GLM) models were used to analyze the association of race/ethnicity and biochemical recurrence groups with outcomes. RESULTS: African Americans reported lower generic and prostate-specific HRQoL scores at diagnosis and required more time to RTB values for generic HRQoL. The results of LME models showed that low risk of biochemical recurrence was associated with better physical function, vitality, mental health, and general health. For prostate-specific HRQoL items, low risk of biochemical recurrence was associated with impaired urinary function and better bowel function and bowel bother. GLM model showed that treatment, hospital type and comorbidity were associated with cost. CONCLUSIONS: Biochemical recurrence risk and treatment groups, not ethnicity, were associated poorer post-treatment outcomes. This information is important in planning for and communicating with patients about post-treatment care.

Health related quality of life and direct medical care cost in newly diagnosed younger men with prostate cancer.

PURPOSE: We evaluated health related quality of life (HRQOL) and the direct medical care cost (DMC) in young men receiving radical prostatectomy. MATERIALS AND METHODS: In this prospective cohort study, 40 newly diagnosed patients with prostate cancer (PCa) who were younger than 65 years were matched with 40 cancer-free men. Participants completed the Medical Outcome Study Short Form and UCLA-PCa Index surveys prior to treatment, and at 3, 6, 12 and 24-month followup. Cost data were obtained from a hospital based administrative database and clinical data were obtained via structured medical chart review. Demographics and HRQOL were compared using the t, Fisher exact and chi-square tests. The Wilcoxon and log-T tests were used to compare DMC. Multivariate regression models were used to assess the incremental cost of PCa and predictors of 24-month prostate specific HRQOL. RESULTS: Patients with PCa had a mean annual DMC of 4,160 dollars for the treatment year with a mean length of stay of 3.5 days. They had 3-fold higher DMC than controls. At 12 months, generic HRQOL values were similar to baseline values. Sexual function showed trends toward improvement 6 months after surgery. Urinary function improved significantly by 6 months, although it decreased thereafter. Bowel function and bother returned to baseline values by 3 months. On multivariate regression marital status was a significant predictor of 5 domains of prostate specific HRQOL at 24 months. CONCLUSIONS: Patients with PCa reported weaker sexual function, urinary function and sexual bother at 2 years after treatment compared with their baseline values. There exists an opportunity for improving prostate specific HRQOL in men with early stage PCa.

Medical care cost of patients with prostate cancer.

OBJECTIVE: To analyze variations in direct medical care cost of patients with prostate across two racial groups after controlling for age, disease stage, and comorbidity. METHODS: In this retrospective cohort control study, we randomly selected 120 newly diagnosed prostate cancer patients (60 African Americans and 60 White) from the administrative database of a large urban academic hospital. Medical care costs data and clinical data were obtained. The control group consisted of 240 men without cancer, and matched by age and race. Demographics, clinical variables and treatment patterns were compared across race using t-test and chi2. Mean medical care costs for prostate cancer patients were compared by race, using bootstrap and log t-test. Regression models were used to estimate the incremental cost of prostate cancer, and to analyze the association between race and direct medical care cost. RESULTS: Whites were more likely to receive radical prostatectomy, whereas African Americans were more likely to receive radiation therapy. The incremental cost of prostate cancer was 1.30 times higher than controls. Charlson comorbidity was a significant predictor of type of treatment received and cost. Race was not associated with total direct medical care cost after controlling for age, Charlson comorbidity and stage of cancer at diagnosis. CONCLUSIONS: Charlson Comorbidity score was a predictor of type of treatment and direct medical care cost. While analyzing the association between race and cost of care, potential bias-inducing factors such as clinical characteristics at diagnosis and provider characteristics (physician and hospital) must be addressed.

Interest in services among prostate cancer patients receiving androgen deprivation therapy.

Treatment side effects and decreased quality of life associated with androgen deprivation therapy (ADT) suggest the need for supportive services for prostate cancer (PC) patients receiving ADT. Nonetheless, uptake of services is low, suggesting that PC patients' preferences are not being addressed. We examined interest in supportive services and predictors of interest among 118 PC patients receiving ADT. Overall interest in services was associated with lower quality of life (p = 0.01). The majority of participants expressed interest in informational services (70%), with a minority (22%) expressing interest in psychosocial services. Interest in psychosocial services was associated with younger age (p = 0.02), and shorter duration of ADT (p < 0.04), but was unrelated to psychological distress or social support. Although most men (68%) reported that they would prefer not to take medication for depression, 75% would do so if advised by their physician. Overall, results suggest that PC patients on ADT prefer individualized informational support. Substantial interest (61%) in Oncolink, an internet-based informational resource, suggests the Internet may provide an acceptable mode of service delivery. Health care providers should consider integrating increased informational support into routine care and, more generally, consider patient preferences in prioritizing and designing support services.