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The American Journal of Managed Care September 2016
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Implications of Evolving Delivery System Reforms for Prostate Cancer Care
Brent K. Hollenbeck, MD, MS; Maggie J. Bierlein, MS; Samuel R. Kaufman, MS; Lindsey Herrel, MD; Ted A. Skolarus, MD, MPH; David C. Miller, MD, MPH; and Vahakn B. Shahinian, MD
Cost-Benefit of Appointment-Based Medication Synchronization in Community Pharmacies
Julie A. Patterson, BS; David A. Holdford, PhD, MS, BSPharm; and Kunal Saxena, PhD, MS
Geographic Variation in Surgical Outcomes and Cost Between the United States and Japan
Michael P. Hurley, MD, MS; Lena Schoemaker, BA; John M. Morton, MD, MPH; Sherry M. Wren, MD; William B. Vogt, PhD; Sachiko Watanabe, RN, MHSA, MAE; Aki Yoshikawa, PhD; and Jay Bhattacharya, MD, PhD
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Farzad Mostashari, MD, ScM, and Travis Broome, MPH
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Maria Salinas, PhD; Maite López-Garrigós, PhD; Emilio Flores, PhD; Maria Leiva-Salinas, MD, PhD; Alberto Asencio, MD; Javier Lugo, MD; and Carlos Leiva-Salinas, MD, PhD
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Vivian Ho, PhD; Timothy K. Allen, PhD; Urie Kim, BBA; William P. Keenan, BA; Meei-Hsiang Ku-Goto, MA; and Mark Sanderson, PhD
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Robert S. Rudin, PhD; Eric C. Schneider, MD, MSc; Zachary Predmore, BA; and Courtney A. Gidengil, MD, MPH
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Implications of Evolving Delivery System Reforms for Prostate Cancer Care

Brent K. Hollenbeck, MD, MS; Maggie J. Bierlein, MS; Samuel R. Kaufman, MS; Lindsey Herrel, MD; Ted A. Skolarus, MD, MPH; David C. Miller, MD, MPH; and Vahakn B. Shahinian, MD
Healthcare integration was associated with small declines in treatment, but no change in overtreatment of prostate cancer. Integrated care delivery alone may be insufficient to curtail overtreatment.
ABSTRACT

Objectives: Prostate cancer treatment is a significant source of morbidity and healthcare spending. Evolving clinical data have supported expanding surveillance as a means to “right-size” treatment. Integrated delivery systems afford the possibility of hastening this objective.

Study Design: Retrospective cohort study of Medicare beneficiaries.

Methods: We used a 20% sample of national Medicare claims to assess the impact of healthcare integration on rates of treatment and potential overtreatment in men newly diagnosed with prostate cancer between 2007 and 2011. Rates were measured according to the extent of integration within a market (ie, none, low, intermediate, and high). Generalized estimating equations were used to assess the relationship between integration and utilization, adjusting for confounders.

Results: Rates of treatment declined across all markets (P <.01 for overall time trend), but the rate of decline was similar for the 4 market types (P = .27). In the most integrated markets, the rate decreased by 28.8%, or from 55.5 per 10,000 population in 2007 to 39.5 per 10,000 in 2011. After adjusting for confounders, men residing in the most integrated markets were 2.1% less likely to be treated with curative intent compared with those living in areas without integrated delivery systems (P = .04). However, rates of potential overtreatment were similar across all markets regardless of the level of integration (P = .21).

Conclusions: Healthcare integration was associated with small declines in prostate cancer treatment in newly diagnosed men, but not with potential overtreatment. Integrated care alone may be insufficient to curtail potential overtreatment of prostate cancer.

 Am J Manag Care. 2016;22(9):569-575
Take-Away Points
  • Integration was associated with a small decrease in the treatment of prostate cancer. 
  • Integration was not associated with treatment among men least likely to benefit (ie, those with a high risk of noncancer mortality). 
  • Integration alone may be insufficient to promote optimal care for prostate cancer. 
  • Financial risk, implied by evolving delivery system reforms, may help to promote better stewardship of preference-sensitive diseases, such as prostate cancer.
Prostate cancer is among the most common malignancies in men in the United States.1 Ongoing uncertainties about how best to treat the disease, coupled with the availability of multiple options, have led to wide variations in both the quantity and quality of care.2,3 Prostate cancer spending has increased by 11% annually over the last decade, outpacing rates for other common conditions (such as cardiovascular and pulmonary diseases) and resulting in $12 billion in yearly expenditures.4,5 Although the merits of screening are a subject of ongoing debate in the field, consensus is growing that some newly diagnosed men with prostate cancer stand to gain little from treatment.6-8
 
Improving the efficiency of the delivery system and eliminating wasteful spending have long been priorities for payers and policy makers, and many hope that accountable care organizations (ACOs) and related components of healthcare reform will do just that. By encouraging closer alignment between hospitals and caregivers, ACOs aim to focus on improving quality and cutting costs—both of which may affect prostate cancer care. To a large extent, ACOs are extensions of integrated delivery systems that, due to their emphasis on evidence-based medicine and minimizing unnecessary healthcare, are associated with providing higher quality.9-12 Thus, understanding the implications of integrated delivery systems for prostate cancer care will help us to anticipate the likely effect of evolving reforms of the Affordable Care Act.
 
For this reason, we performed a national study to determine the impact of healthcare integration on the management of prostate cancer. We hypothesized that the most integrated markets would be more selective in the use of curative treatment for prostate cancer, particularly among those unlikely to benefit from intervention.
 
METHODS

Using a 20% sample of Medicare claims, we performed a retrospective cohort study of fee-for-service beneficiaries newly diagnosed with prostate cancer between January 1, 2007, and December 31, 2011. We limited our study to men continuously enrolled in Parts A and B for at least the 12-month periods prior to and after the prostate cancer diagnosis. To ensure that we had complete claims on all patients, we excluded patients in risk-bearing Medicare managed care plans. Patients were followed through December 31, 2012.
 
To identify incident prostate cancer cases in national Medicare claims, we developed an algorithm and validated it using Surveillance Epidemiology and End Results (SEER) cancer registry data. Briefly, we used a 5% sample of Medicare beneficiaries residing in a catchment area of a SEER registry in the years 2003 to 2005. We selected men with at least 2 “Evaluation and Management” visit codes in which the line diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code was 185 for prostate cancer. We further required that all incident cases underwent prostate biopsy within 180 days of the first visit code associated with a prostate cancer diagnosis. Men with any claim in the preceding 12-month period that was associated with an ICD-9-CM diagnosis code of 185 (prostate cancer) or V10.46 (personal history of malignant neoplasm of prostate) were excluded. Finally, we validated this approach against the Patient Entitlement Denominator Summary File, which identifies all incident cases in SEER regions, and found our algorithm to have specificity and positive predictive values of 99.8% and 88.7%, respectively. We then implemented this algorithm in our 20% national sample of Medicare claims to identify incident cases, which compose our study population.
 
We used hospital referral regions (HRRs), as described by the Dartmouth Atlas,13 to reflect distinct healthcare markets. There are 306 HRRs in the United States, each of which represents a collection of zip codes in which Medicare patients receive the bulk of their healthcare. We determined each market’s level of integration by measuring the proportion of hospital discharges occurring from an integrated delivery system, which were identified from public reports based on data from IMS Health14 and have been used in a similar context.15 These data provide information on delivery system relationships, including affiliations between hospitals and physician practices. Each health system is rated for 33 attributes in 8 domains: overall integration, integrated technology, hospital utilization, financial stability, services, access, contract capabilities, and physicians. Domain-specific scores are summed to yield an overall score for the delivery system, with higher scores reflecting a greater degree of integration.
 


 
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