Male Medicare Beneficiaries Research Articles

Cost-Effectiveness of Annual Prostate MRI and Potential MRI-Guided Biopsy After Prostate-Specific Antigen Test Results

Magnetic resonance imaging (MRI) and potential MRI-guided biopsy enable enhanced identification of clinically significant prostate cancer. Despite proven efficacy, MRI and potential MRI-guided biopsy remain costly, and there is limited evidence regarding the cost-effectiveness of this approach in general and for different prostate-specific antigen (PSA) strata. To examine the cost-effectiveness of integrating annual MRI and potential MRI-guided biopsy as part of clinical decision-making for men after being screened for prostate cancer compared with standard biopsy. Using a decision analytic Markov cohort model, an economic evaluation was conducted projecting outcomes over 10 years for a hypothetical cohort of 65-year-old men in the US with 4 different PSA strata (<2.5 ng/mL, 2.5-4.0 ng/mL, 4.1-10.0 ng/mL, >10 ng/mL) identified by screening through Monte Carlo microsimulation with 10 000 trials. Model inputs for probabilities, costs in 2020 US dollars, and quality-adjusted life-years (QALYs) were from the literature and expert consultation. The model was specifically designed to reflect the US health care system, adopting a federal payer perspective (ie, Medicare). Magnetic resonance imaging with potential MRI-guided biopsy and standard biopsy. Incremental cost-effectiveness ratios (ICERs) using a willingness-to-pay threshold of $100 000 per QALY was estimated. One-way and probabilistic sensitivity analyses were performed. For the 3 PSA strata of 2.5 ng/mL or greater, the MRI and potential MRI-guided biopsy strategy was cost-effective compared with standard biopsy (PSA 2.5-4.0 ng/mL: base-case ICER, $21 131/QALY; PSA 4.1-10.0 ng/mL: base-case ICER, $12 336/QALY; PSA >10.0 ng/mL: base-case ICER, $6000/QALY). Results varied depending on the diagnostic accuracy of MRI and potential MRI-guided biopsy. Results of probabilistic sensitivity analyses showed that the MRI and potential MRI-guided biopsy strategy was cost-effective at the willingness-to-pay threshold of $100 000 per QALY in a range between 76% and 81% of simulations for each of the 3 PSA strata of 2.5 ng/mL or more. This economic evaluation of a hypothetical cohort suggests that an annual MRI and potential MRI-guided biopsy was a cost-effective option from a US federal payer perspective compared with standard biopsy for newly eligible male Medicare beneficiaries with a serum PSA level of 2.5 ng/mL or more.

Risk of Severe COVID-19 in Prevalent Users of Alpha-1 Adrenergic Receptor Antagonists: A National Case-Control Study of Medicare Beneficiaries

BackgroundAlpha-1 adrenergic receptor antagonists prevent cytokine storm in mouse sepsis models. This led to the hypothesis that alpha-1 blockers may prevent severe coronavirus disease 2019 (COVID-19), which is characterized by hypercytokinemia and progressive respiratory failure. MethodsWe performed an observational case-control study in male Medicare beneficiaries aged 65 years or older, with or without benign prostatic hyperplasia (BPH), and treated with alpha-1 receptor blockers or 5-alpha reductase inhibitors. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated for outcomes of uncomplicated and severe COVID-19 hospitalization (intensive care unit admission, invasive mechanical ventilation, or death). ResultsThere were 20,963 cases of hospitalized COVID-19 matched to 101,161 controls on calendar date and neighborhood of residence. In the primary analysis (males with BPH), there was no difference in risk of uncomplicated COVID-19 hospitalization (aOR 1.08, 95% CI 0.996-1.17) or hospitalization with severe complications (aOR 0.97, 95% CI 0.88-1.08). In the secondary analysis (males with or without BPH), the corresponding aORs were 1.02 (95% CI, 0.96-1.09) (uncomplicated) and 0.99 (95% CI, 0.91-1.07) (complicated), respectively. Subgroup and sensitivity analyses yielded similar results. Of note, there was no difference in risk of severe COVID-19 hospitalization when comparing non-selective vs selective alpha-1 blocker use (aOR 0.98, 95% CI 0.86-1.10), higher- vs lower-dose alpha-1 blocker use (aOR 0.96, 95% CI 0.86-1.08), or current vs remote alpha-1 blocker use (aOR 1.04, 95% CI 0.91-1.18). ConclusionsPrevalent use of alpha-1 receptor blockers was not associated with a protective or harmful effect on risk of uncomplicated or severe hospitalized COVID-19.

Sex differences in Medicare beneficiaries' experiences by low-income status.

Medicare beneficiaries dually eligible for Medicaid are a low-income group who are often in poor health. Little research has examined sex differences in patient experience by dual/low-income subsidy (LIS) status. Cross-sectional comparison by sex and low-income status. We used linear regression to compare 6 case mix-adjusted patient experience measures (on a 0-100 scale) by sex within non-dual/LIS and dual/LIS beneficiary groups among 549,603 respondents 65 years and older to the 2016-2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys of beneficiary experience with Medicare (mail with telephone follow-up of nonrespondents, 42% response rate). Dual/LIS male beneficiaries reported worse patient experiences on all 6 measures than female beneficiaries, with scores 1 to 2 percentage points lower for 3 measures and less than 1 percentage point lower for the other 3 measures. For 4 of the 6 measures, sex differences among dual/LIS beneficiaries were significantly larger than those among non-dual/LIS beneficiaries. In all 4 instances, the gaps between men and women among dual/LIS beneficiaries favored women; P < .05 for all differences discussed. Low-income male Medicare beneficiaries are more likely to report poor patient experiences, possibly because of lower health literacy, less patient activation, and smaller social networks, along with provider responses to these characteristics. Efforts to address these patient-level factors should happen in parallel with structural-level approaches to train and prepare providers to ensure attentive, respectful patient-centered care for all patients. Additionally, targeted use of ombudsmen and interventions may help reduce inequities.

Re: Treatment of Male Hypogonadism Partially Reverses Oxidative Stress in Patients with Hypogonadism.

No AccessJournal of UrologyUrological Survey1 Dec 2020Re: Treatment of Male Hypogonadism Partially Reverses Oxidative Stress in Patients with Hypogonadism Allen D. SeftelMD Allen D. SeftelAllen D. Seftel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001274.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Treatment of Male Hypogonadism Partially Reverses Oxidative Stress in Patients with Hypogonadism." The Journal of Urology, 204(6), p. 1363 Suggested Reading : Trends and patterns of testosterone therapy among U.S. male Medicare beneficiaries, 1999 to 2014. J Urol 2020; 203: 1184. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 6December 2020Page: 1363-1363 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Allen D. Seftel More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP27-04 ECONOMIC COST OF URINARY INCONTINENCE FOR INSURED ADULT MEN IN THE UNITED STATES: FINDINGS FROM THE UROLOGICAL DISEASES IN AMERICA PROJECT

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures (MP27)1 Apr 2020MP27-04 ECONOMIC COST OF URINARY INCONTINENCE FOR INSURED ADULT MEN IN THE UNITED STATES: FINDINGS FROM THE UROLOGICAL DISEASES IN AMERICA PROJECT Kathleen C. Kobashi*, Julia B. Ward, Lydia Feinstein, Kevin C. Abbott, Tamara Bavendam, Ziya Kirkali, Erline Martinez-Miller, Brian R. Matlaga, and Alvaro Lucioni Kathleen C. Kobashi*Kathleen C. Kobashi* More articles by this author , Julia B. WardJulia B. Ward More articles by this author , Lydia FeinsteinLydia Feinstein More articles by this author , Kevin C. AbbottKevin C. Abbott More articles by this author , Tamara BavendamTamara Bavendam More articles by this author , Ziya KirkaliZiya Kirkali More articles by this author , Erline Martinez-MillerErline Martinez-Miller More articles by this author , Brian R. MatlagaBrian R. Matlaga More articles by this author , and Alvaro LucioniAlvaro Lucioni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000866.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary incontinence (UI) is a prevalent, yet underappreciated condition in men of all ages. However, its economic impact is not well understood. We examined insurer expenditures on UI services among a national sample of insured adult men in the United States from 2004-2013. METHODS: Urinary incontinence (UI) is a prevalent, yet underappreciated condition in men of all ages. However, its economic impact is not well understood. We examined insurer expenditures on UI services among a national sample of insured adult men in the United States from 2004-2013. RESULTS: From 2004-2013, annual per-person UI-related expenditures in the Medicare population increased from $149 to $194; however, these expenditures varied by race. Among White male Medicare beneficiaries, per patient expenditures increased from $140 in 2004 to $202 in 2013. Among Black male Medicare beneficiaries, expenditures decreased from $156 in 2004 to $150 in 2013. For privately insured patients, per-person expenditures decreased from $580 in 2004 to $472 in 2013. In most study years, expenditures in this privately insured sector were higher for White and Black men than Hispanic and Asian men. While expenditures decreased for all race/ethnic groups among privately insured men, the decrease was largest among Black men (50%) than White (16%), Hispanic (4%), and Asian (36%) men. The service location for expenditures shifted drastically over time in the Medicare UI population. Inpatient expenditures made up 12% of total expenditures in 2004, decreasing to 5% by 2013. Physician office expenditures also decreased from 46% to 23%. Correspondingly, outpatient expenditures increased from 32% in 2004 to 67% in 2013. The shift was less pronounced among privately insured patients, with inpatient expenditures decreasing from 18% of total expenditures in 2004 to 16% in 2013, while outpatient expenditures increased from 56% to 66%. CONCLUSIONS: We provide one of the most comprehensive examinations of UI expenditures among an insured adult male population to date, demonstrating racial/ethnic disparities in spending trends and a shift to outpatient treatment. Better understanding of the healthcare expenditures for UI provides a platform upon which to potentially improve utilization of resources and selection of therapeutic options for patients. Source of Funding: Funded by the NIH via a contract to Social & Scientific Systems. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e410-e410 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathleen C. Kobashi* More articles by this author Julia B. Ward More articles by this author Lydia Feinstein More articles by this author Kevin C. Abbott More articles by this author Tamara Bavendam More articles by this author Ziya Kirkali More articles by this author Erline Martinez-Miller More articles by this author Brian R. Matlaga More articles by this author Alvaro Lucioni More articles by this author Expand All Advertisement PDF downloadLoading ...

PD29-04 EVOLUTION OF HEALTHCARE COSTS FOR LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Epidemiology & Evaluation (PD29)1 Apr 2020PD29-04 EVOLUTION OF HEALTHCARE COSTS FOR LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA Charles Welliver*, Julia B. Ward, Lydia Feinstein, Kevin C. Abbott, Tamara Bavendam, Ziya Kirkali, Erline Martinez-Miller, Brian R. Matlaga, and Kevin McVary Charles Welliver*Charles Welliver* More articles by this author , Julia B. WardJulia B. Ward More articles by this author , Lydia FeinsteinLydia Feinstein More articles by this author , Kevin C. AbbottKevin C. Abbott More articles by this author , Tamara BavendamTamara Bavendam More articles by this author , Ziya KirkaliZiya Kirkali More articles by this author , Erline Martinez-MillerErline Martinez-Miller More articles by this author , Brian R. MatlagaBrian R. Matlaga More articles by this author , and Kevin McVaryKevin McVary More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000893.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Evolving management of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) has changed the distribution of healthcare spending. Our understanding of recent trends in LUTS/BPH management costs is incomplete given prior studies have been limited to older men, small datasets, and inpatient procedures. We characterized LUTS/BPH-related Medicare and private insurance expenditures over 10 years. METHODS: As part of the Urologic Diseases in America project, we analyzed two insurance claims databases: the Centers for Medicare & Medicaid Services Medicare 5% Sample for male Medicare beneficiaries aged ≥65 years with LUTS/BPH (N≈147,800 annually) and the Optum© de-identified Clinformatics® Data Mart Database (CDM) for privately insured males aged 40-64 years with LUTS/BPH (N≈100,300 annually). Annual LUTS/BPH-related expenditures from 2004-2013 were examined by service location: inpatient, hospital-based outpatient, and physician office. RESULTS: The average annual LUTS/BPH-related expenditures were $305 and $248 per LUTS/BPH patient in CDM and Medicare, respectively. Over the 10-year study period, inpatient care accounted for a decreasing percentage of total dollars spent on managing LUTS/BPH by Medicare (30% to 15%) and private insurance (37% to 15%). Outpatient LUTS/BPH-related expenditures rose for both insurer groups, especially for private insurance (61% to 83%). Expenditures for hospital-based outpatient care rose over the study period and exceeded physician office expenditures from 2007 onward for patients with private insurance, and from 2010 onward for Medicare patients (Figure). CONCLUSIONS: The distribution of healthcare expenditures for LUTS/BPH shifted across practice settings from 2004-2013, with increasing outpatient relative to inpatient expenditures. Hospital-based outpatient expenses exceeded physician office expenses, likely due to increased use of ambulatory surgical procedures for LUTS/BPH. In-office minimally invasive surgical therapies will likely lead to higher physician office costs in the future. Differences in expenditures between the study populations may be due to differential reimbursement practices between private insurance and Medicare. Source of Funding: Funded by the NIH via a contract to Social & Scientific Systems. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e619-e619 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Welliver* More articles by this author Julia B. Ward More articles by this author Lydia Feinstein More articles by this author Kevin C. Abbott More articles by this author Tamara Bavendam More articles by this author Ziya Kirkali More articles by this author Erline Martinez-Miller More articles by this author Brian R. Matlaga More articles by this author Kevin McVary More articles by this author Expand All Advertisement PDF downloadLoading ...

PD33-06 NATIONAL PRESCRIBING TRENDS IN LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA

INTRODUCTION AND OBJECTIVE: Lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) is a chronic disease causing significant morbidity and quality of life impairment among adult men. Pharmacotherapy is the most common initial intervention, but our current understanding of medication usage trends for LUTS/BPH is incomplete and prior studies have relied on limited datasets that have predominantly focused on older men. We assessed trends in the pharmacological management of LUTS/BPH among a national sample of men with private and Medicare insurance over an 8-year period. METHODS: As part of the Urologic Diseases in America project, two insurance claims databases were analyzed over the 2006-2013 study period: the Centers for Medicare & Medicaid Services Medicare (CMS) 5% Sample for an annual average of 105,180 male Medicare beneficiaries aged ≥65 years with LUTS/BPH and the Optum© de-identified Clinformatics® Data Mart Database (CDM) for an annual average of 104,766 privately insured males aged 40-64 years with LUTS/BPH. The percentage of patients receiving LUTS/BPH-related prescriptions was assessed annually over the study period and stratified by 5-year age groups. RESULTS: Use of prescription medications for LUTS/BPH increased throughout the study period (see Figure). The increase was greater for men with private insurance as compared to Medicare (14% vs 5% increase). The proportion of patients who filled prescriptions increased with increasing age, with up to 67% of LUTS/BPH patients aged 85+ years filling prescriptions in 2013. CONCLUSIONS: Over an 8-year study period, BPH was increasingly managed with pharmacotherapy. This increase was especially pronounced among younger men with private insurance. This analysis is unique in that the utilization of administrative claims data allowed for assessment of prescribing trends across different care delivery settings and among a large national sample of men as young as 40 years of age.Source of Funding: Funded by the NIH via a contract to Social & Scientific Systems.

Trends and Patterns of Testosterone Therapy among U.S. Male Medicare Beneficiaries, 1999 to 2014.

We explored the Medicare database (1999 to 2014) to provide a comprehensive assessment of testosterone therapy patterns in the older U.S. male population. We estimated annual age-standardized incidence (new users) and prevalence (existing users) of testosterone therapy according to demographic characteristics, comorbidities and potential indications. There were 392,698 incident testosterone therapy users during 88 million person-years. Testosterone therapy users were predominantly younger, white nonHispanic, and located in South and West U.S. Census regions. On average testosterone therapy use increased dramatically during 2007 to 2014 (average annual percent change 15.5%), despite a decrease in 2014. In 2014 the most common recorded potential indications for any testosterone therapy were hypogonadism (48%), fatigue (18%), erectile dysfunction (15%), depression (4%) and psychosexual dysfunction (1%). Laboratory tests to measure circulating testosterone concentrations for testosterone therapy were infrequent with 35% having had at least 1 testosterone test in the 120 days preceding testosterone therapy, 4% the recommended 2 pre-testosterone therapy tests, and 16% at least 1 pre-testosterone therapy test and at least 1 post-testosterone therapy test. Testosterone therapy remains common in the older U.S. male population, despite a recent decrease. Although testosterone therapy prescriptions are predominantly for hypogonadism, a substantial proportion appear to be for less specific conditions. Testosterone tests among men prescribed testosterone therapy appear to be infrequent.

Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance

ObjectiveTo characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. mpMRI has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established. MethodsUsing Surveillance, Epidemiology, and End Results registry data linked to Medicare claims data, we identified men with localized prostate cancer diagnosed between 2008 and 2013 and managed with active surveillance. We classified men into 2 treatment groups: active surveillance without mpMRI and active surveillance with mpMRI. We then fit a multivariable logistic regression models to examine changing mpMRI utilization over time, and factors associated with the receipt of mpMRI. ResultsWe identified 9467 men on active surveillance. Of these, 8178 (86%) did not receive mpMRI and 1289 (14%) received mpMRI. The likelihood of receiving mpMRI over the entire study period increased by 3.7% (P = .004). On multivariable logistic regression, patients who were younger, white, had lower comorbidity burden, lived in the northeast and west, had higher incomes and lived in more urban areas had greater odds of receiving mpMRI (all P < .05). ConclusionFrom 2008 to 2013, use of mpMRI in active surveillance increased gradually but significantly. Receipt of mpMRI among men on surveillance for prostate cancer varied significantly across demographic, geographic, and socioeconomic strata. Going forward, studies should investigate causes for this variation and define ideal strategies for equitable, cost-effective dissemination of mpMRI technology.

Risk factors for postprostate biopsy infection.

103 Background: Prostate biopsy is a common procedure that many U.S. men endure during their lifetime. Evidence suggests that the risk of post-biopsy infections is increasing. We aimed to characterize risk factors for post-biopsy infections using nationally representative data. Methods: We analyzed Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify 246,299 male Medicare beneficiaries aged over 65 years who underwent prostate biopsy between 2001 and 2013. Multivariable logistic regression was used to assess risk factors for post-biopsy infection.The primary outcomes were any infection within 30 days of prostate biopsy, and infections requiring hospital admission within 30 days of biopsy. Results: In this cohort, 7.0% of men developed an infection within 30 days and 1.0% required hospital admission for infection. The vast majority of biopsies were performed transrectally (99.5%) without a rectal swab culture performed prior to biopsy to direct antimicrobial prophylaxis (99.7%). Risk factors for post-biopsy infection and hospitalization on multivariable analysis included age over 80 years, odds ratio (OR) 1.23 (95% confidence interval (CI) 1.17 to 1.29, for any infection, and OR 1.71 (95% CI 1.52 to 1.92) for infection requiring hospitalization, Black race, OR 1.29 (95% CI 1.23 to 1.35) for any infection, and OR 1.41 (95% CI 1.25 to 1.58) for hospitalization, and Hispanic ethnicity, OR 1.61 (95% CI 1.46 to 1.77) for any infection, and OR 1.92 (95% CI 1.52 to 2.42) for hospitalization. The risk of infection also increased with Charlson score of 3 or greater, OR 1.32 (95% CI 1.25 to 1.39), and OR 2.04 (95% CI 1.73 to 2.40) for any infection or hospitalization, respectively. High surgeon volume (&gt;11.6 cases) was protective, OR 0.92 (95% CI 0.88 to 0.96) for any infection, and OR 0.76 (95% CI 0.69 to 0.85) for hospitalization. Conclusions: Among other factors, we identify patient age, Charlson score, race, ethnicity, and surgeon volume as significant predictors of post-prostate biopsy infection and hospitalization. These results should aid in identifying patients who may benefit from alternative techniques, such as targeted or augmented antimicrobial prophylaxis, or transperineal biopsy, to minimize this common source of morbidity.

Trends in Testosterone Prescribing for Age-related Hypogonadism in Men With and Without Heart Disease

This cohort study examines the trend in prescription testosterone use among male Medicare beneficiaries with and without coronary artery disease aged 50 years or older.

Impact of United States Preventive Services Task Force Recommendations on Utilization of Prostate-specific Antigen Screening in Medicare Beneficiaries

Previous studies assessing the impact of United States Preventive Services Task Force (USPSTF) recommendations on utilization of prostate-specific antigen (PSA) screening have not investigated longer-term impacts of 2008 recommendations nor have they investigated the impact of 2012 recommendations in the Medicare population. This study aimed to evaluate change in utilization of PSA screening, post-2008 and 2012 USPSTF recommendations, and assessed trends and determinants of receipt of PSA screening in the Medicare population. This retrospective study of male Medicare beneficiaries utilized Medicare Current Beneficiary Survey data and linked administrative claims from 2006 to 2013. Beneficiaries aged ≥65 years, with continuous enrollment in parts A and B for each year they were surveyed were included in the study. Beneficiaries with self-reported/claims-based diagnosis of prostate cancer were excluded. The primary outcome was receipt of PSA screening. Other measures included age groups (65 to 74 and ≥75), time periods (pre-2008/post-2008 and 2012 recommendations), and sociodemographic variables. The study cohort consisted of 11,028 beneficiaries, who were predominantly white (87.56%), married (69.25%), and unemployed (84.4%); 52.21% beneficiaries were aged ≥75. Declining utilization trends for PSA screening were observed in men aged ≥75 after 2008 recommendations and in both age groups after 2012 recommendations. The odds of receiving PSA screening declined by 17% in men aged ≥75 after 2008 recommendations and by 29% in men aged ≥65 after 2012 recommendations. The 2008 and 2012 USPSTF recommendations against PSA screening were associated with declines in utilization of PSA screening during the study period. USPSTF recommendations play a significant role in affecting utilization patterns of health services.

Geographic Variation in Cystoscopy Rates for Suspected Bladder Cancer between Female and Male Medicare Beneficiaries

To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation. We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates. Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013. Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer.

Impact of USPSTF recommendations on utilization of PSA screening in Medicare beneficiaries.

166 Background: Previous studies assessing the impact of the United States Preventive Services Task Force (USPSTF) recommendations on utilization of prostate-specific antigen (PSA) screening have not investigated longer-term impacts of the 2008 recommendations nor have they investigated the impact of the 2012 recommendations in the Medicare population. The study aim was to evaluate change in utilization of PSA screening, post USPSTF recommendations of 2008 and 2012, and to assess trends and determinants of receipt of PSA screening in the Medicare population. Methods: This retrospective study of male Medicare beneficiaries utilized Medicare Current Beneficiary Survey (MCBS) data and linked administrative claims from 2006-2013. Beneficiaries aged ≥65 years, with continuous enrollment in Parts A and B for each year they were surveyed were included in the study cohort. Beneficiaries with self-reported or claims-based diagnosis of prostate cancer were excluded. Beneficiaries with Medicare eligibility due to end stage renal disease or disability were also excluded. The primary outcome was receipt of PSA screening. Other measures include age groups (65-74 and ≥75), time periods (pre- and post-2008 and 2012 recommendations), and sociodemographic variables. Results: The study cohort consisted of 11,028 beneficiaries, who were predominantly white (87.56%), married (69.25%), and unemployed (84.4%); 52.21% beneficiaries were aged ≥75. Declining utilization trends for PSA screening were observed only in men aged ≥75 after 2008 recommendations and in both age groups after 2012 recommendations. The odds of receiving PSA screening declined by 17% percent in men aged ≥75 after the 2008 recommendations and by 29% in men aged ≥65 after the 2012 recommendations. Conclusions: The USPSTF recommendations of 2008 and 2012 against PSA screening were associated with declines in utilization of PSA screening during the study period. USPSTF recommendations play a significant role in affecting utilization patterns of health services. Future studies should evaluate if the proposed 2017 update to these recommendations advocating shared decision-making for PSA screening in men aged 55-69 increase utilization in this age-group.

Decubitus ulcers in patients undergoing vascular operations do not influence mortality but affect resource utilization

While it is anticipated that decubitus ulcers are detrimental to outcomes after vascular operations, the contemporary influence of perioperative decubitus ulcers in vascular surgery remains unknown. Using the National Impatient Survey, all adult patients who underwent vascular operation were selected. Patients were stratified by the presence or absence (non-decubitus ulcers) of decubitus ulcer. Case-mix adjusted hierarchical mixed-models examined in-hospital mortality, the occurrence of any complication, and discharge disposition. A total of 538,808 cases were analyzed. Decubitus ulcers were most prevalent among Caucasian male Medicare beneficiaries (P<.001). Decubitus ulcer patients also underwent more nonelective vascular operations (P<.001). Wound, infectious, and procedural complications were more common in patients with decubitus ulcers (P<.001). Failure to rescue, defined as mortality after any complication, was more than doubled in decubitus ulcers (non-decubitus ulcers: 1.5%, decubitus ulcers: 3.2%, P<.001). Similarly, unadjusted mortality was also doubled in patients undergoing vascular operation with decubitus ulcers (non-decubitus ulcers: 3%, decubitus ulcers: 6%, P<.001). After risk adjustment among all patients, neither the presence of a decubitus ulcer nor specific ulcer staging increased the adjusted odds of death. Having a decubitus ulcer increased the adjusted odds of discharge to an intermediate care facility (odds ratio 2.9, P<.001). These patients also had 1.6 times the total charges compared to their non-decubitus ulcer cohort (non-decubitus ulcers: $49,460±$281 vs decubitus ulcers: $81,149±$5,855, P<.001). Contrary to common perception, perioperative decubitus ulcer does not adversely affect mortality after vascular operation in patients proceeding to operative intervention. Patients with decubitus ulcers are, however, at higher risk for complications and incur sizeable additional charges.

MP11-06 REGIONAL-LEVEL INAPPROPRIATE IMAGING RATES FOR PROSTATE AND BREAST CANCERS ARE CORRELATED: POTENTIAL LESSONS FOR THE CHOOSING WISELY CAMPAIGN

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II1 Apr 2014MP11-06 REGIONAL-LEVEL INAPPROPRIATE IMAGING RATES FOR PROSTATE AND BREAST CANCERS ARE CORRELATED: POTENTIAL LESSONS FOR THE CHOOSING WISELY CAMPAIGN Danil Makarov, Sounok Sen, Pamela Soulos, Heather Gold, James Yu, Joseph Ross, and Cary Gross Danil MakarovDanil Makarov More articles by this author , Sounok SenSounok Sen More articles by this author , Pamela SoulosPamela Soulos More articles by this author , Heather GoldHeather Gold More articles by this author , James YuJames Yu More articles by this author , Joseph RossJoseph Ross More articles by this author , and Cary GrossCary Gross More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.421AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Signal detection theory suggests the criterion for medical decision making varies between individuals. It is unknown whether hospital referral regions (HRRs) similarly have characteristic criteria. To answer this question, we sought to determine whether rates of inappropriate imaging among incident prostate and breast cancer patients were associated at the HRR-level. METHODS We identified low risk prostate and breast cancer patients from the SEER-Medicare database as defined in the Choosing Wisely Campaign. Our dependent variable of interest was the HRR-level rates of advanced imaging among low risk prostate cancer patients. Our independent variable of interest was the HRR-level rates of breast cancer imaging among low risk patients. We calculated the Pearson correlation between HRR-level imaging rates, weighted by the inverse variance of the breast cancer imaging rates. We also used logistic regression to model prostate cancer imaging rates as a function of breast cancer imaging rates, adjusted for patient- and environmental-level covariates. RESULTS We identified 9,219 male Medicare beneficiaries with prostate cancer, and 30,398 female beneficiaries with breast cancer. Prostate cancer imaging rates were associated with breast cancer imaging rates, with a Pearson correlation coefficient of 0.35 (p<0.01). Adjusted for age and comorbidity, a man with low risk prostate cancer had odds ratios of 1.87 (1.21-2.88), 1.17 (0.77-1.80) and 1.73 (1.12-2.69) to undergo inappropriate imaging if he were living in the fourth, third and second quartiles of inappropriate breast cancer imaging, as compared to living in the lowest quartile of breast cancer imaging. CONCLUSIONS At a regional-level, there is an association in imaging rates between prostate and breast cancers, a pair of diseases diagnosed in non-overlapping populations and cared for by non-overlapping providers. This finding confirms the predictions of signal detection theory that the criterion for medical decision making may be characteristic of a region. It also suggests that policy efforts should seek to improve quality of care and reduce healthcare spending in high-utilization areas, rather than focus on professional societies or specific-disease support groups. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e97 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Danil Makarov More articles by this author Sounok Sen More articles by this author Pamela Soulos More articles by this author Heather Gold More articles by this author James Yu More articles by this author Joseph Ross More articles by this author Cary Gross More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Treatment‐related complications of radiation therapy after radical prostatectomy: comparative effectiveness of intensity‐modulated versus conformal radiation therapy

Intensity-modulated radiation therapy (IMRT) is frequently utilized after prostatectomy without strong evidence for an improvement in outcomes compared to conformal radiation therapy (RT). We analyzed a large group of patients treated with RT after radical prostatectomy (RP) to compare complications after IMRT and CRT. The Surveillance, Epidemiology and End Results (SEER)-Medicare database was queried to identify male Medicare beneficiaries aged 66 years or older who underwent prostatectomy with 1+ adverse pathologic features and received postprostatectomy RT between 1995 and 2007. Chi-square test was used to compare baseline characteristics between the treatment groups. First complication events, based upon administrative procedure or diagnosis codes occurring >1 year after start of RT, were compared for IMRT versus CRT groups. Propensity score adjustment was performed to adjust for potential confounders. Multivariable Cox proportional hazards models of time to first complication were performed. A total of 1686 patients were identified who received RT after RP (IMRT = 634, CRT = 1052). Patients treated with IMRT were more likely to be diagnosed after 2004 (P < 0.001), have minimally invasive prostatectomy (P < 0.001) and have positive margins (P = 0.019). IMRT use increased over time. After propensity score adjustment, IMRT was associated with lower rate of gastrointestinal (GI) complications, and higher rate of genitourinary-incontinence complications, compared to CRT. The observed outcomes after IMRT must be considered when determining the optimal approach for postprostatectomy RT and warrant additional study.

The Impact of Recent Screening Recommendations on Prostate Cancer Screening in a Large Health Care System

The United States Preventive Services Task Force recently recommended against routine prostate cancer screening, stating that the risks of screening outweigh the benefits. We determined the impact of this recommendation on prostate cancer screening in a large health system. We obtained data on all screening prostate specific antigen tests performed at University Hospitals Case Medical Center and affiliated hospitals in northeastern Ohio from January 2008 to December 2012. We examined the total number of prostate specific antigen tests ordered with time and adjusted for patient volume by fitting a regression line. The overall trend was examined and stratified by location (urban, suburban or rural), patient age and provider type (primary care or urology). A total of 43,498 screening prostate specific antigen tests were performed from January 2008 to December 2012. Most tests were ordered by specialists in internal medicine (64.9%), followed by family medicine (23.7%), urology (6.1%) and hematology/oncology (1.3%). Prostate specific antigen screening increased with time until March 2009, when initial screening trials were published. Prostate specific antigen testing then decreased significantly and continued to decrease after the task force recommendations. Similar patterns were noted in almost all subgroups. The greatest decrease in screening wasobserved by urologists and in patients in the intermediate age group (50 to 59 years). United States Preventive Services Task Force recommendations appeared to have decreased prostate cancer screening. The greatest impact was seen for urologists and patients in the intermediate age group. Further study is needed to determine the long-term effects of these recommendations on the screening, diagnosis, treatment and prognosis of this prevalent malignancy.

The cost implications of prostate cancer screening in the Medicare population

Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

The cost implications of prostate cancer screening in the Medicare population.

6549 Background: Recent debate about prostate specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost associated with screening. Methods: We assembled a population-based cohort of male Medicare beneficiaries aged 66-99 years who had never been diagnosed with prostate cancer at the end of 2005 (n = 84,699) and followed them for two years to assess the cost of PSA screening and downstream procedures (biopsy, pathology, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. The relation of screening cost to stage of prostate cancer at diagnosis at the HRR level was analyzed using multivariate Poisson models. We also evaluated the initial treatment cost of Medicare fee for service beneficiaries diagnosed with prostate cancer during 2006-2007 (n = 31,653). Results: Approximately 42.8% of the 84,699 men received PSA screening tests during the two-year study period, with 2.4% undergoing biopsy. The annual expenditures by the national fee for service Medicare program were $454 million for screening and $1.79 billion for initial treatment (in 2009 US dollars). The mean annual screening cost at the regional (HRR) level ranged from $16 to $65 per beneficiary. Downstream biopsy-related procedures (biopsy, pathology, and hospitalization due to biopsy complications) accounted for 73% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage [incidence rate ratio (IRR) = 1.23, 95% confidence interval (CI): 1.07-1.42] and localized cancer (IRR = 1.31, 95% CI: 1.13-1.53). Conclusions: Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.