Local Coverage Determination Policy and the Use of Stereotactic Body Radiation Therapy for Prostate Cancer

Abstract

IntroductionLocal coverage determinations are local decisions that regulate health care coverage. We evaluated the impact of local coverage determinations as well as patient, tumor and market characteristics on the adoption of stereotactic body radiation therapy for prostate cancer. MethodsUsing SEER-Medicare data we identified men treated with stereotactic body radiation treatment, intensity modulated radiotherapy and robotic prostatectomy. We compared demographics, clinical characteristics and market factors among these 3 treatments. Our primary exposure was local coverage determination policy. Using the Medicare Coverage Database we categorized local coverage determinations as favorable (stereotactic body radiation treatment covered), neutral (stereotactic body radiation treatment covered in the context of a clinical trial or registry), unfavorable (stereotactic body radiation treatment not covered) or absent (ie stereotactic body radiation treatment not governed by a local coverage determination at the time of treatment). We fit a multivariable multinomial logistic regression model and generated predicted probabilities to examine the relationship between local coverage determinations and stereotactic body radiation treatment. ResultsDuring this early period of stereotactic body radiation treatment adoption, intensity modulated radiotherapy was the most common of the 3 treatments, followed by robotic prostatectomy and stereotactic body radiation treatment. Stereotactic body radiation treatment use was high when governed by favorable and neutral local coverage determinations, and lowest when governed by unfavorable local coverage determinations. Compared with favorable local coverage determinations, areas where local coverage determinations were absent were associated with higher stereotactic body radiation treatment use compared with intensity modulated radiotherapy (OR 1.56, 95% CI 1.07–2.25) and robotic prostatectomy (OR 1.84, 95% CI 1.25–2.69). ConclusionsWhen present, local coverage determinations appear to regulate the early adoption of stereotactic body radiation treatment, but when absent are associated with increased stereotactic body radiation treatment use. Although stereotactic body radiation treatment use was uncommon, it varied across a wide range of patient, tumor and market characteristics.