Abstract
Background: External beam radiation therapy is an important aspect of multidisciplinary care for patients with metastatic bone disease. Referral to radiation oncology is within the control of the orthopaedic surgeon and has the potential to serve as a quality benchmark. Methods: This is a retrospective cohort study. Patients with metastatic disease of the femur who underwent prophylactic femoral stabilization or fixation of a pathologic femur fracture from 2010-2015 at a single academic medical center or within the Veterans Health Administration (VHA) were included. A total of 950 VHA patients and 130 academic medical center patients were enrolled. The main outcome was the proportion of patients receiving a referral to radiation oncology by six weeks after the date of surgery. Results are presented for each institution and are stratified by type of procedure (prophylactic stabilization versus pathologic fixation). The study further evaluates regional differences within the VHA. Results: The majority of patients received a referral for radiation after prophylactic stabilization (VHA: 290/361 patients [80% 95% CI: 76% - 84%]; academic medical center: 81/89 patients [91%, 95% CI: 85%, 97%]). The proportion referred was higher at the academic medical center (odds ratio [OR]: 2.5, 95% CI: [1.15, 5.36], P =0.027). After fracture fixation, 428/589 (73%, 95% CI: [69%, 77%]) of VHA patients and 30/41 (73%, 95% CI [59%, 87%]) of patients at the academic medical center received a referral to radiation. Receiving a referral was not associated with healthcare system (OR: 1.0; 95% CI: [0.50, 2.10])). Within the VHA, the proportion of patients referred varied by geographic location (Pearson’s chi-squared test, P =0.004 for prophylactic stabilization and P <0.001 for pathologic fixation). Conclusion: Referral rates at both institutions were moderate to high. The observed regional variation within the VHA highlights the importance of establishing quality benchmarks.
Highlights
Metastatic bone disease is relatively prevalent and currently affects over 300,000 people in the United States [1, 2]
Referral to radiation oncology is within the control of the orthopaedic surgeon and has the potential to serve as a quality benchmark
In the prophylactic stabilization cohorts, patients at the academic medical center had an average age of 64 years compared to an average age within the Veteran’s Health Administration (VHA) of 67 years (t-test, P=0.045)
Summary
Metastatic bone disease is relatively prevalent and currently affects over 300,000 people in the United States [1, 2]. Several national radiology and oncology societies conclude that patients presenting with metastatic bone disease and lesions concerning impending pathologic fracture should: i) be seen by an orthopaedic surgeon for possible stabilization and ii) receive palliative EBRT regardless of whether surgery occurred [9,10,11,12,13,14]. Patients with metastatic disease of the femur who underwent prophylactic femoral stabilization or fixation of a pathologic femur fracture from 2010-2015 at a single academic medical center or within the Veterans Health Administration (VHA) were included. Results: The majority of patients received a referral for radiation after prophylactic stabilization (VHA: 290/361 patients [80% 95% CI: 76% - 84%]; academic medical center: 81/89 patients [91%, 95% CI: 85%, 97%]). 428/589 (73%, 95% CI: [69%, 77%]) of VHA patients and 30/41 (73%, 95% CI [59%, 87%]) of patients at the academic medical center received a referral to radiation. The observed regional variation within the VHA highlights the importance of establishing quality benchmarks
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