Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians.

This cross-sectional study compares the prescribing practices among urologists and advanced practice clinicians who received vs did not receive payment from drug manufacturers.

Industry Payments to Urologists and Urologic Advanced Practice Providers in 2021.

OBJECTIVE: To compare industry payments from drug and medical device companies to urologists and urologic advanced practice providers (APPs) in 2021. METHODS: We used the 2020 Medicare Data on Provider Practice and Specialty file to identify single-specialty urology practices, defined as those where the majority of physicians were urologists. We then used the Open Payments Program Year 2021 data to summarize the value and number of industry payments to urologists and APPs, including nurse practitioners and physician assistants, in these practices. We calculated the total value and number of payments and median total value and number of payments per provider for urologists and urologic APPs. RESULTS: We identified 4418 urologists and 1099 APPs working in single-specialty urology practices in 2021 (Table 1). Of these, 3646 (87%) urologists received at least one industry payment, totaling $14,755,003 from 116,039 payments, and 954 urologic APPs (87%) received at least one industry payment, including 463 nurse practitioners (85%), totaling $401,283 from 13,035 payments, and 491 physician assistants (89%), totaling $543,429 from 14,626 payments. We observed significantly greater median total value and number of payments per provider for urologists ($620 and 24 payments) compared to urologic APPs ($473 and 21 payments; P < .001 and P = .017, respectively). CONCLUSION: A similar percentage of urologists and urologic APPs received industry payments in 2021. While urologists received a higher total number and total value of payments in 2021, urologic APPs were a common target of industry marketing payments.

Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities.

PURPOSE: Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer. METHODS: Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations. RESULTS: We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05). CONCLUSION: Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

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

OBJECTIVE: To understand the influence of drug manufacturers on the prescribing patterns of medical oncologists and urologists, we examined the relationship between promotional payments from the manufacturers of abiraterone and enzalutamide and prescriptions for either drug by medical oncologists and urologists. METHODS: Promotional payments for abiraterone or enzalutamide made to medical oncologists and urologists between January 2014 and December 2017 reported through the Open Payments Program were categorized as $0, $1$999, and $1000 or more. Prescriptions filled between January 2013 and December 2017 were identified in the Medicare Part D File. Associations between promotional payments and prescribing were assessed using generalized linear models. RESULTS: From 2013 through 2017, the number of medical oncologists and urologists prescribing abiraterone or enzalutamide increased by 38% - 298%, respectively. The odds of prescribing among medical oncologists receiving $1--$999 and those receiving $1,000 or more were 1.69 (95%CI:1.59--1.79) and 2.61 (95% CI: 2.14--3.18) times that of medical oncologists receiving no payments. Among urologists receiving $1--$999 and those receiving $1,000 or more, the odds of prescribing were 4.04 (95%CI: 3.59--4.54) and 13.57 (95%CI: 9.69--19.0) times that of urologists receiving no payments. CONCLUSION: Increasing promotional payments were associated with prescribing among medical oncologists and urologists, with a stronger relationship evident for urologists. Prescribing patterns for abiraterone and enzalutamide, particularly among urologists, may be influenced by payments from drug manufacturers.

Understanding Active Surveillance for Prostate Cancer.

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.

Urology Workforce Changes and Implications for Prostate Cancer Care Among Medicare Enrollees.

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.

Aligning Urology Residency Training With Real-World Workforce Needs.

OBJECTIVE: Research suggests recently graduated urology residents do not feel ready for independent practice. We conducted a study to determine if Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements, resident case logs, and graduating resident perceived readiness for practice are aligned with the procedural demand and needs of the current urology workforce. DESIGN: Correlative study comparing the association between (1) workforce demand and ACGME case requirements, and (2) workforce demand and perceived resident competency. Three distinct datasets were used; (1) the 2017 Medicare Part B National Summary Data File; (2) the 2017 National Data Report published by the ACGME; and (3) a graduating resident survey from Okhunov et al. SETTING: N/A. PARTICIPANTS: N/A. RESULTS: In 2017, there were a total of 6,784,696 urologic cases performed through Medicare. We found nonsignificant positive associations between resident case logs (rho = 0.16, p = 0.5784), ACGME minimum procedure requirements (rho = 0.42, p = 0.1255), and Medicare procedural demand. Our 15 index procedures accounted for 21.1% (n = 1,431,775) of all Medicare cases, with a median number of 7706 procedures. Endopyelotomy was the least common procedure (n = 98), while cystoscopy was the most common (n = 980,623). Medicare case volume was positively correlated with graduating residents' procedural confidence (r = 0.86, p < 0.0001). We identified four categories with varied alignment of training and demand: (1) high volume and high confidence, (2) high volume and low confidence, (3) low volume and high confidence, and (4) low volume and low confidence. CONCLUSIONS: Optimizing urology residency training is time-sensitive and important. Using national Medicare data coupled with recently graduated urology resident survey results, we provide a guiding framework for improving the alignment of training with workforce demand. Informed by these results, we recommend altering training requirements to reflect these needs.

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

BACKGROUND: Abiraterone and enzalutamide are high-cost oral therapies that increasingly are used to treat patients with advanced prostate cancer; these agents carry the potential for significant financial consequences to patients. In the current study, the authors investigated coping and material measures of the financial hardship of these therapies among patients with Medicare Part D coverage. METHODS: The authors performed a retrospective cohort study on a 20% sample of Medicare Part D enrollees who underwent treatment with abiraterone or enzalutamide between July 2013 and June 2015. The authors described the variability in adherence rates and out-of-pocket payments among hospital referral regions in the first 6 months of therapy and determined whether adherence and out-of-pocket payments were associated with patient factors and the socioeconomic characteristics of where a patient was treated. RESULTS: There were 4153 patients who filled abiraterone or enzalutamide prescriptions through Medicare Part D in 228 hospital referral regions. The mean adherence rate was 75%. The median monthly out-of-pocket payment for abiraterone and enzalutamide was $706 (range, $0-$3505). After multilevel, multivariable adjustment for patient and regional factors, adherence was found to be lower in patients who were older (69% for patients aged ≥85 years vs 76% for patients aged <70 years; P < .01) and in those with low-income subsidies (69% in those with a subsidy vs 76% in those without a subsidy; P < .01). Both Hispanic ethnicity and living in a hospital referral region with a higher percentage of Hispanic beneficiaries were found to be independently associated with higher out-of-pocket payments for abiraterone and enzalutamide. CONCLUSIONS: There were substantial variations in the adherence rate and out-of-pocket payments among Medicare Part D beneficiaries who were prescribed abiraterone and enzalutamide. Sociodemographic patient and regional factors were found to be associated with both adherence and out-of-pocket payments.

The Impact of the COVID-19 Pandemic on Genitourinary Cancer Care: Re-envisioning the Future.

CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic necessitated rapid changes in medical practice. Many of these changes may add value to care, creating opportunities going forward. OBJECTIVE: To provide an evidence-informed, expert-derived review of genitourinary cancer care moving forward following the initial COVID-19 pandemic. EVIDENCE ACQUISITION: A collaborative narrative review was conducted using literature published through May 2020 (PubMed), which comprised three main topics: reduced in-person interactions arguing for increasing virtual and image-based care, optimisation of the delivery of care, and the effect of COVID-19 in health care facilities on decision-making by patients and their families. EVIDENCE SYNTHESIS: Patterns of care will evolve following the COVID-19 pandemic. Telemedicine, virtual care, and telemonitoring will increase and could offer broader access to multidisciplinary expertise without increasing costs. Comprehensive and integrative telehealth solutions will be necessary, and should consider patients' mental health and access differences due to socioeconomic status. Investigations and treatments will need to maximise efficiency and minimise health care interactions. Solutions such as one stop clinics, day case surgery, hypofractionated radiotherapy, and oral or less frequent drug dosing will be preferred. The pandemic necessitated a triage of those patients whose treatment should be expedited, delayed, or avoided, and may persist with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in circulation. Patients whose demographic characteristics are at the highest risk of complications from COVID-19 may re-evaluate the benefit of intervention for less aggressive cancers. Clinical research will need to accommodate virtual care and trial participation. Research dissemination and medical education will increasingly utilise virtual platforms, limiting in-person professional engagement; ensure data dissemination; and aim to enhance patient engagement. CONCLUSIONS: The COVID-19 pandemic will have lasting effects on the delivery of health care. These changes offer opportunities to improve access, delivery, and the value of care for patients with genitourinary cancers but raise concerns that physicians and health administrators must consider in order to ensure equitable access to care. PATIENT SUMMARY: The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the care provided to many patients with genitourinary cancers. This has necessitated a transition to telemedicine, changes in threshold or delays in many treatments, and an opportunity to reimagine patient care to maintain safety and improve value moving forward.

Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy.

OBJECTIVE: To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS: Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS: Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION: Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.

Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer.

BACKGROUND: We use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making. PATIENTS AND METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy. Propensity of receiving neoadjuvant chemotherapy was determined using gradient boosted models. Inverse probability of treatment weighted survival curves were adjusted for 13 demographic, socioeconomic, temporal, and oncologic covariates. RESULTS: We identified 1342 patients who received neoadjuvant (n = 676) or adjuvant chemotherapy (n = 666) with a median follow-up of 23 months (interquartile range, 9-55 months). Inverse probability of treatment weighted adjustment allows comparison of the groups head-to-head as well as counterfactual scenarios (eg, effect if those getting one treatment were to receive the other). The average treatment effect (ie, "head-to-head" comparison) of adjuvant compared with neoadjuvant on OS was not significant (hazard ratio, 1.14; 95% confidence interval, 0.99-1.31). However, the average treatment effect of the treated (ie, the effect if the neoadjuvant patients were to receive adjuvant instead) was associated with a 33% increase in risk of mortality if they were given adjuvant therapy instead (hazard ratio, 1.33; 95% confidence interval, 1.12-1.57). CONCLUSION: Significant treatment selection bias was noted in peri-cystectomy timing, which limits the ability to discriminate differential efficacy of these 2 approaches with observational data. However, patients with higher propensity to receive neoadjuvant therapy were predicted to have increased OS with approach, in keeping with existing paradigms from trial data.

Resurrecting immortal-time bias in the study of readmissions.

OBJECTIVE: To compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods. DATA SOURCES: 20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014. STUDY DESIGN: Retrospective cohort study comparing 30-day readmission rates. DATA COLLECTION/EXTRACTION METHODS: Patients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified. PRINCIPAL FINDINGS: Cystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal-time bias. CONCLUSIONS: We found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.

Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program.

Importance: The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. Objective: To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. Design, Setting, and Participants: Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. Exposures: Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. Main Outcomes and Measures: The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. Results: Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. Conclusions and Relevance: This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

Trends and appropriateness of perioperative chemotherapy for muscle-invasive bladder cancer.

INTRODUCTION: Contemporary guidelines recommend cystectomy with neoadjuvant or adjuvant cisplatin-based chemotherapy given with curative intent for patients with resectable muscle-invasive bladder cancer (MIBC). However, rates and appropriateness of perioperative chemotherapy utilization remain unclear. We therefore sought to characterize use of perioperative chemotherapy in older radical cystectomy MIBC patients and examine factors associated with use. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified patients with MIBC diagnosed between 2004 and 2013 and treated with radical cystectomy. We classified patients into 3 treatment groups: cystectomy alone, neoadjuvant, or adjuvant chemotherapy. Chemotherapy was classified by regimen. We then fit a multinomial multivariable logistic regression model to assess association between patient factors with the receipt of each treatment. RESULTS: We identified 3,826 eligible patients. The majority (484; 65%) received cystectomy alone. Neoadjuvant (676; 18% overall, 69% cisplatin-based), and adjuvant chemotherapy (666, 17% overall, 55% cisplatin-based) were used in similar proportions of cystectomy patients. Over the study period, the odds of receiving adjuvant chemotherapy decreased by 7.5%, whereas neoadjuvant therapy increased by 27.5% (both P < 0.001). There was an increase in use of cisplatin-based regimens in the neoadjuvant setting (35 to 72%, P < 0.001), but not the adjuvant setting. Female gender, lower comorbidity, married status, and lower stage disease were associated with greater odds of receiving neoadjuvant chemotherapy (all P < 0.05). CONCLUSION: From 2004 to 2013 use of neoadjuvant chemotherapy for MIBC increased while use of adjuvant chemotherapy decreased. Future studies examining barriers to appropriate chemotherapy use, and the comparative effectiveness of neoadjuvant versus adjuvant chemotherapy are warranted.

Adoption of Abiraterone and Enzalutamide by Urologists.

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.

Urologist Practice Structure and Spending for Prostate Cancer Care.

OBJECTIVE: To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership. MATERIALS AND METHODS: We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics. RESULTS: We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims. CONCLUSION: Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest.

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

OBJECTIVE: To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. SUMMARY BACKGROUND DATA: Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. METHODS: We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. RESULTS: Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. CONCLUSION: Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.

Variation in prostate cancer treatment and spending among Medicare shared savings program accountable care organizations.

BACKGROUND: Accountable care organizations (ACOs) have been shown to reduce prostate cancer treatment among men unlikely to benefit because of competing risks (ie, potential overtreatment). This study assessed whether the level of engagement in ACOs by urologists affected rates of treatment, overtreatment, and spending. METHODS: A 20% sample of national Medicare data was used to identify men diagnosed with prostate cancer between 2012 and 2014. The extent of urologist engagement in an ACO, as measured by the proportion of patients in an ACO managed by an ACO-participating urologist, served as the exposure. The use of treatment, potential overtreatment (ie, treatment in men with a ≥75% risk of 10-year noncancer mortality), and average payments in the year after diagnosis for each ACO were modeled. RESULTS: Among 2822 men with newly diagnosed prostate cancer, the median rates of treatment and potential overtreatment by an ACO were 71.3% (range, 23.6%-79.5%) and 53.6% (range, 12.4%-76.9%), respectively. Average Medicare payments among ACOs in the year after diagnosis ranged from $16,523.52 to $34,766.33. Stronger urologist-ACO engagement was not associated with treatment (odds ratio, 0.87; 95% confidence interval, 0.6-1.2; P = .4) or spending (9.7% decrease in spending; P = .08). However, urologist engagement was associated with a lower likelihood of potential overtreatment (odds ratio, 0.29; 95% confidence interval, 0.1-0.86; P = .03). CONCLUSIONS: ACOs vary widely in treatment, potential overtreatment, and spending for prostate cancer. ACOs with stronger urologist engagement are less likely to treat men with a high risk of noncancer mortality, and this suggests that organizations that better engage specialists may be able to improve the value of specialty care. Cancer 2018. © 2018 American Cancer Society.

Predictors and Cost of Readmission in Total Knee Arthroplasty.

BACKGROUND: The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. METHODS: We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. RESULTS: We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. CONCLUSIONS: A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.