Temporal and geographic variation in the systemic treatment of advanced prostate cancer

Abstract Background Several systemic treatments have been shown to increase survival for patients with metastatic castration-resistant prostate cancer. This study sought to characterize variation in use of the six “focus drugs” (docetaxel, abiraterone, enzalutamide, sipuleucel-T, radium-223, and cabazitaxel) that have been approved by the Food and Drug Administration for the treatment of metastatic castration-resistant prostate cancer during the years 2010–2015. We hypothesized that the use of these treatments would vary over time and by region of the country. Methods We used Clinformatics DataMart™ Database (OptumInsight, Eden Prairie, MN), a de-identified claims database from a national insurance provider. Our sample included patients with prostate cancer who received any of the six drugs. We describe changes in usage patterns over time and geographic region of the United States via detailed descriptive statistics. We explore both patterns of first line therapy and sequence of treatments in our database. Results Our final analysis included 4275 patients with a mean age of 74 years. Docetaxel was the most commonly used first-line therapy in 2010 (97%), 2011 (66%), and 2012 (49%). Abiraterone was the most commonly used first-line therapy in 2013 (56%), 2014 (46%), and 2015 (34%). Approximately 14% of our study cohort received ≥3 of the 6 drugs throughout their disease course. There was marked geographic variation in use of each of the drugs. Conclusion Variation in treatment patterns were found with respect to both time and geographic location. Prescription rates of abiraterone outpaced docetaxel as the most commonly prescribed drug after 2013 when it became widely available. However, some regions of the country still lagged behind and prescribed less than would be expected.https://deepblue.lib.umich.edu/bitstream/2027.42/142724/1/12885_2018_Article_4166.pd

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

Abstract Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680 , First Posted July 6, 2018.https://deepblue.lib.umich.edu/bitstream/2027.42/146541/1/13012_2018_Article_833.pd

Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies

Peer reviewe

A comparison of parametric propensity score‐based methods for causal inference with multiple treatments and a binary outcome

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/1/sim8862.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/2/sim8862-sup-0001-supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/3/sim8862_am.pd

A comparison of parametric propensity score‐based

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/1/sim8862.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/2/sim8862-sup-0001-supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167067/3/sim8862_am.pd

Value‐based payment models and management of newly diagnosed prostate cancer

Abstract Objective To examine the effect of urologist participation in value‐based payment models on the initial management of men with newly diagnosed prostate cancer. Methods Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow‐up, were assigned to their primary urologist, each of whom was then aligned to a value‐based payment model (the merit‐based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed‐effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non‐cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price‐standardized prostate cancer spending in the 12 months after diagnosis. Results Treatment did not vary by payment model, both overall (MIPS—67% [95% CI 66%–68%], ACOs without risk—66% [95% CI 66%–68%], ACOs with risk—66% [95% CI 64%–68%]). Similarly, treatment did not vary among men with very high risk of non‐cancer mortality by payment model (MIPS—52% [95% CI 50%–55%], ACOs without risk—52% [95% CI 50%–55%], ACOs with risk—51% [95% CI 45%–56%]). Adjusted spending was similar across payment models (MIPS—$16,501 [95$16,222–$16,780], ACOs without risk—$16,140 [95% CI $15,852–$16,429], ACOs with risk—$16,117 [95$15,585–$16,649]). Conclusions How urologists participate in value‐based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease

Health care delivery system contributions to management of newly diagnosed prostate cancer

Abstract Background Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear. Methods Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups. Results Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high‐risk of noncancer mortality (range of practice‐level rates of treatment for high: 57%–71% and very high: 41%–61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high‐risk of noncancer mortality (26% and 40%, respectively). Conclusions Variation among urology practices in use of treatment was highest for men with high and very high‐risk noncancer mortality. Practice characteristics explained a large share of this variation

The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer

Abstract Introduction Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer. Methods We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference‐in‐differences design. Results There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference‐in‐differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference‐in‐differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference‐in‐differences −5.5%, p = 0.12) and those managed conservatively (difference‐in‐differences −2.0%, p = 0.82). Conclusions In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon

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

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/3/cncr33176.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/2/cncr33176-sup-0001-FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/1/cncr33176_am.pd

Factors influencing treatment of veterans with advanced prostate cancer

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168287/1/cncr33485.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168287/2/cncr33485_am.pd