Male Medicare Beneficiaries Research Articles

Impact of the 2008 US Preventive Services Task Force Recommendation to Discontinue Prostate Cancer Screening Among Male Medicare Beneficiaries

For clinical evidence to have an impact on the health of populations, guideline recommendations must be rapidly and widely disseminated and physicians and other health care professionals must act responsively. Recommendations to discontinue care may be even more challenging. Recently, the US Preventive Services Task Force (USPSTF) recommended that no man receives prostate-specific antigen (PSA)-based screening for prostate cancer.1 While the impact of this recommendation will not be immediately understood in practice, the impact of the USPSTF’s August 2008 recommendation to discontinue PSA-based prostate cancer screening for men 75 years and older may inform expectations.2

Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration

We examined the association of previous transurethral manipulation with stricture complexity and disease duration among men referred for bulbar urethral reconstruction. We retrospectively reviewed the records of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010. Only men treated with initial open surgery for bulbar strictures were included in analysis, thus excluding those with hypospadias, lichen sclerosus, pelvic radiation, prior urethroplasty, incomplete data, or pure penile or posterior urethral stenosis. Cases were divided into 2 groups based on the history of transurethral treatment for urethral stricture before urethroplasty, including group 1-0 or 1 and group 2-2 or greater treatments. Of 101 patients with bulbar urethral stricture and all data available 50 and 51 underwent 0 to 1 and 2 or greater previous transurethral treatments, respectively. Repeat transurethral manipulation was strongly associated with longer strictures and the need for complex reconstruction. Repeat transurethral manipulation of bulbar urethral strictures was also associated with an eightfold increase in disease duration between stricture diagnosis and curative urethroplasty. Repeat transurethral manipulation of bulbar strictures is associated with increased stricture complexity and a marked delay to curative urethroplasty.

Linkages between utilization of prostate surgical pathology services and physician self-referral.

Federal law prohibits a physician from referring Medicare patients for procedures or services to health care entities in which the physician has a financial relationship. This law has exceptions which enable physicians to self-refer under certain conditions. This study evaluates the effects of self-referral on use rates of surgical pathology services performed in conjunction with prostate biopsies and whether such changes are linked to urologist self-referral arrangements. A targeted market area case study design was employed to identify the sample from Medicare claims data. The sample included male beneficiaries who resided in geographically dispersed counties; were continuously enrolled in Medicare fee-for-service (FFS) during 2005-2007; and who met the criteria to be a potential candidate to undergo a prostate biopsy. Prostate biopsy procedures per 1000 male Medicare beneficiaries in each county; counts of surgical pathology specimens (jars) associated with prostate biopsy procedures per 1000 male Medicare beneficiaries in each county. Regression analysis shows the self-referral share (percentage) of total utilization was associated with significant increases in the use rate of prostate surgical pathology specimens (p<.01). The use rate of prostate surgical pathology specimens (jars) would be 41.5 units higher in a county where the self-referral share of total utilization was 50% compared to a county with no self-referral (share equals 0%). The findings show that urologist self-referral of prostate surgical pathology services results in increased utilization and higher Medicare spending. The results suggest that exceptions in federal and state self-referral prohibitions need to be reevaluated.

Editorial Comment

This report adds to the ever-increasing body of evidence-based medicine that male urethral stricture disease is disproportionately treated in the United States today using temporizing and palliative measures. Furthermore, it adds to the body of data that definitive urethral reconstruction is rarely performed (0.7%) and corroborates results we previously published on the self-reported practice patterns of U.S. urologists. 1 Bullock T.L. Brandes S.B. Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States. J Urol. 2007; 177: 685-690 Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar Trends in Stricture Management Among Male Medicare Beneficiaries: Underuse of Urethroplasty?UrologyVol. 77Issue 2PreviewTo analyze the trends in male urethral stricture management using the 1992-2001 Medicare claims data and to determine whether certain racial and ethnic groups have a disproportionate burden of urethral stricture disease. Full-Text PDF

Trends in Stricture Management Among Male Medicare Beneficiaries: Underuse of Urethroplasty?

To analyze the trends in male urethral stricture management using the 1992-2001 Medicare claims data and to determine whether certain racial and ethnic groups have a disproportionate burden of urethral stricture disease. We analyzed the Medicare claims for fiscal years 1992, 1995, 1998, and 2001. The "International Classification of Disease, 9th revision," diagnosis codes were used to identify men with urethral stricture. The demographic characteristics assessed included patient age, race, and comorbidities, as measured using the Charlson index. Treatments were identified using the Physician Current Procedural Terminology Coding System, 4th edition, procedure codes and stratified into 4 treatment types: urethral dilation, direct vision internal urethrotomy, urethral stent/steroid injection, and urethroplasty. The overall rates of stricture diagnosis decreased from 10,088/100,000 population in 1992 to 6897 in 2001 (from 1.4% to 0.9%). The stricture prevalence was greatest among black and Hispanic men, although the urethroplasty rates were greatest among white men. Direct vision internal urethrotomy was the most common treatment, followed by urethral dilation, urethral stent/steroid injection, and urethroplasty. The urethroplasty rates remained stable, but quite low (0.6%-0.8%), during the study period. The overall rates of stricture diagnosis decreased from 1992 to 2001. Despite the poor overall efficacy of urethrotomy and urethral dilation relative to urethroplasty and despite the known complications of stent placement in this setting, the urethroplasty rates were the lowest of all treatments. Although we could not determine the treatment success with these data, these findings suggest an underuse of the most efficacious treatment of urethral stricture disease, urethroplasty.

How Can Rates of Prostate‐Specific Antigen Screening Be Reduced in Men Aged 80 and Older?

How Can Rates of Prostate‐Specific Antigen Screening Be Reduced in Men Aged 80 and Older?

The morbidity of urethral stricture disease among male medicare beneficiaries.

BackgroundTo date, the morbidity of urethral stricture disease among American men has not been analyzed using national datasets. We sought to analyze the morbidity of urethral stricture disease by measuring the rates of urinary tract infections and urinary incontinence among men with a diagnosis of urethral stricture.MethodsWe analyzed Medicare claims data for 1992, 1995, 1998, and 2001 to estimate the rate of dual diagnoses of urethral stricture with urinary tract infection and with urinary incontinence occurring in the same year among a 5% sample of beneficiaries. Male Medicare beneficiaries receiving co-incident ICD-9 codes indicating diagnoses of urethral stricture and either urinary tract infection or urinary incontinence within the same year were counted.ResultsThe percentage of male patients with a diagnosis of urethral stricture who also were diagnosed with a urinary tract infection was 42% in 2001, an increase from 35% in 1992. Eleven percent of male Medicare beneficiaries with urethral stricture disease in 2001 were diagnosed with urinary incontinence in the same year. This represents an increase from 8% in 1992.ConclusionsAmong male Medicare beneficiaries diagnosed with urethral stricture disease in 2001, 42% were also diagnosed with a urinary tract infection, and 11% with incontinence. Although the overall incidence of stricture disease decreased over this time period, these rates of dual diagnoses increased from 1992 to 2001. Our findings shed light into the health burden of stricture disease on American men. In order to decrease the morbidity of stricture disease, early definitive management of strictures is warranted.

Prevalent and incident use of androgen deprivation therapy among men with prostate cancer in the United States

Purpose Androgen deprivation therapy (ADT) for prostate cancer increased substantially through the 1990s, but more recent national trends regarding incident and prevalent use have been incompletely characterized. Methods Linked Surveillance, Epidemiology, and End Results (SEER)–Medicare data were used to study patterns of ADT utilization. Prevalence of ADT in the male Medicare population was estimated by examining a cohort of prostate cancer patients and a 5% noncancer control population, from 1991 to 2005. ADT use across different indications was examined for men with incident cancers from 2000 to 2002. Nested logit models were used to examine determinants of ADT use in men with lower risk prostate cancer not treated definitively by surgery or radiation. Results Prevalent ADT use increased through the 1990s, peaked in 2000 at 3.17% of all male Medicare beneficiaries, subsequently stabilized, then dropped in 2005 to 2.92%. Between 2000 and 2002, use in incident prostate cancer was stable, with 44.8% use in all cases, 15% of cases as an adjuvant with radiation, and 14% as a primary therapy. In the nested logit model, predictors of ADT use in a lower risk setting were older age, higher stage and grade, and elevated prostate-specific antigen levels. Conclusions Following a period of rapid expansion during the 1990s, incident and prevalent use of ADT has leveled, and may be starting to decline. Further research is needed to monitor how reductions in reimbursement for GnRH agonists will affect appropriate use of ADT as well as use in settings where its benefits may be marginal.

Racial disparities in abdominal aortic aneurysm repair among male Medicare beneficiaries.

Although investigators have reported that abdominal aortic aneurysm (AAA) repair is performed less frequently in black subjects than in white subjects, these findings may be explained by a lower prevalence of AAA disease among black subjects. We examine this assumption by determining the relative rate (RR) of elective AAA repair in black men vs white men after accounting for differences in disease prevalence. We used Medicare data from January 2001 to December 2003 to identify men 65 years and older undergoing elective or urgent AAA repair. We calculated the age-adjusted RR of repair in black men vs white men. We then used findings from the Aneurysm Detection and Management Veterans Affairs Cooperative Study to determine the ratio of screen-detected AAA prevalence among black men vs white men. Finally, we calculated prevalence-adjusted RRs of repair. Medicare data study. Men 65 years and older undergoing elective or urgent AAA repair. Prevalence-adjusted RR of AAA repair in black men vs white men. The annual rate of elective AAA repair in black men was less than one-third that in white men (42.5 vs 147.8 per 100,000; RR, 0.29; 95% confidence interval [CI], 0.27-0.31). The disparity in urgent AAA repair was smaller, with black men undergoing repair at roughly half the rate of white men (26.1 vs 50.5 per 100,000; RR, 0.52; 95% CI, 0.48-0.56). The screen-detected disease prevalence of AAA among black men was less than half that among white men. Adjusting for this difference in prevalence diminished but did not erase the disparity in elective AAA repair (RR, 0.73; 95% CI, 0.68-0.77) and suggested that black men face a higher rate of urgent AAA repair (RR, 1.30; 95% CI, 1.21-1.41). Black men undergo elective AAA repair at a lower rate than white men even after accounting for their decreased disease burden. However, the prevalence-adjusted rate of urgent repair is higher among black men. Whether the lower frequency of elective procedures is responsible for the higher frequency of urgent procedures warrants further investigation.

Racial Disparities in Abdominal Aortic Aneurysm Repair Among Male Medicare Beneficiaries—Invited Critique

Racial Disparities in Abdominal Aortic Aneurysm Repair Among Male Medicare Beneficiaries—Invited Critique

Prostate cancer screening, treatment, and outcomes— A population-based study

10017 Background: It remains unknown whether more intense prostate cancer screening and treatment reduces prostate cancer mortality. We describe the experiences of two population-based cohorts with 15-years follow-up (1987–2001) to address the following questions: 1) does more intense screening and treatment for prostate cancer lead to lower mortality in community settings, and 2) do older men (age ≥75–79) benefit from more intense prostate cancer screening and treatment. Methods: Population-based cohort study consisting of white male Medicare beneficiaries who resided in the regions covered by the Seattle (N=88,863) and Connecticut (N=114,785) cancer registries. Inclusion criteria are age 65–79 and free of prostate cancer on January 1, 1987. All study subjects were followed through death or the end of 2001. The main outcomes are rates of screening for prostate cancer, treatment with radical prostatectomy, external beam radiotherapy, and prostate cancer specific mortality. Results: Between 1987 and 1990, compared to men in Connecticut, men in the Seattle region were 5.4 times (95% C.I. 4.8 - 6.1) more likely to undergo PSA testing, 2.2 times (95% C.I. 1.8 - 2.7) more likely to under go prostate biopsy, 5.9 times (95% C.I. 5.5 - 6.9) more likely to have radial prostatectomy, and 2.3 times (95% C.I. 2.2 - 2.5) more likely to have external beam radiation. The cumulative risk of radical prostatectomy or external beam radiation reached 9.1% in the Seattle cohort and 5.0% in the Connecticut cohort in 2001. After 15 years of follow-up, prostate cancer mortality rates were similar for subjects in the two study regions (hazard ratio of Seattle to CT: 1.01, 95% C.I. 0.93 - 1.09). For older men (aged 75–79 in 1987), however, the prostate cancer mortality rate was slightly higher in the Seattle than the Connecticut cohort (hazard ratio: 1.16, 95% C.I. 1.02 - 1.32). Conclusion: More intense screening for prostate cancer, surgery or radiation among a cohort of Medicare beneficiaries in the Seattle area compared with their counterparts in Connecticut has not lead to significantly lower mortality from prostate cancer over 15 years of follow-up. No significant financial relationships to disclose.

UROLOGIC DISEASES IN AMERICA PROJECT: URINARY INCONTINENCE IN MALES—DEMOGRAPHICS AND ECONOMIC BURDEN

We quantified and describe the demographics and economic burden of male urinary incontinence in the United States of America. The analytic methods used to generate these results have been described previously. Urinary incontinence (UI) affects men of all ages, including 17% of males older than 60 years in the United States, which is an estimated 3.4 million men. There is a strong trend toward an increasing prevalence of UI with increasing age as well as an increase in the prevalence of UI in males with time. Ethnicity has less of a role in prevalence estimates in men than in women. The largest impact of UI in elderly men is in physician office visits, followed by outpatient services and surgeries. Resource use is greatest in the nursing home setting, where more than half of men have UI and require assistance with toileting. The overall economic burden for male UI is estimated at 18.8 billion dollars in direct medical costs in 1998/1999 dollars. Medical expenditures for UI for male Medicare beneficiaries 65 years and older have doubled since 1992. Compared to persons without UI the presence of UI increases the annual expenditures per person yearly from 3,204 dollars to 7,702 dollars. The direct and indirect costs of male UI increased throughout the 1990s with annual expenditures per person yearly in men with UI more than double that in men without UI. Given the aging population and staggering impact of UI in nursing home settings, there is a compelling need for further research into effective prevention, treatment and management strategies.

Care following Acute Myocardial Infarction in the Veterans Administration Medical Centers: A Comparison with Medicare

To compare patients treated for acute myocardial infarction (AMI) in a Veterans Health Administration (VHA) facility to similar patients treated under Medicare. Administrative data on 13,129 elderly male veterans hospitalized for AMI in a VHA facility between October 1, 1996, and September 30, 1999, and a matched set of male Medicare beneficiaries with AMI treated in a non-VHA facility during the same time period. We conducted a retrospective cohort study using propensity score methods to identify a matched set of male elderly AMI patients treated either in a VHA facility or in a non-VHA facility under Medicare. We compared the two groups of patients according to characteristics of the admitting hospital, distances traveled for care, the use of invasive procedures, and mortality. We assessed the robustness of our conclusions to biases arising from unmeasured confounders using sensitivity analyses. VHA patients were significantly less likely than Medicare beneficiaries to be admitted to high-volume facilities (for example, 25 percent versus 46 percent in 1999, p<0.001) or facilities with the capability to perform invasive cardiac procedures. Compared to Medicare patients, VHA patients traveled almost twice as far to their admitting hospital. The VHA patients were significantly less likely to undergo coronary angiography or revascularization in the 30 days following their AMI (p<0.001 for all comparisons). Veterans treated in the VHA had significantly higher mortality at one-year in all years studied (for example, 35.2 percent versus 30.6 percent in 1999). The proportion of elderly VHA patients admitted to high-volume facilities increased and 30-day mortality rates decreased between 1997 and 1999. Using sensitivity analyses to assess possible effects of unmeasured confounders, we could explain some but not all of the observed mortality differences. We observed differences in the way care for AMI patients was structured, in the use of invasive therapies, and in long term mortality between patients treated in VHA hospitals and those treated in non-VHA facilities under Medicare. Future research should focus on explanations for the differences between the two systems and for the reduction in short-term mortality among VHA patients. Further study of these differences both between and within the systems of care may help identify cost-effective strategies to improve care in both sectors.

Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut

Objective:To determine whether the more intensive screening and treatment for prostate cancer in the Seattle-Puget Sound area in 1987-90 led to lower mortality from prostate cancer than in Connecticut.Design: Natural...

Trends in radical prostatectomy in New York State.

The purpose of this study was to examine trends in radical prostatectomy in New York State for the period 1991-1993. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries in New York State for the period 1991-1993. Basic trend data were also analyzed for 1990. Pattern analysis was conducted on the 4,154 procedures performed between 1990-1993. In depth hospital chart review was conducted of the 220 cases of radical prostatectomy performed in patients 75 years of age and over between 1991 and 1993 and of a random sample of 263 of 1,266 patients 70-74 years of age. A total of 452 hospital charts were examined for a broad range of information, including family history and therapeutic preferences, preoperative work-up, staging, intraoperative and postoperative transfusions, postoperative complications, and mortality. The rate of radical prostatectomy dramatically rose among New York State male Medicare beneficiaries between 1990 and 1992 and remained at a high plateau in 1993. Pattern analysis revealed a tripling of the procedure rate among those 70-74 years of age and a doubling of the rate in those 75 years of age and older. It was also found that a high proportion of radical prostatectomies in men 70 years of age and older were performed by relatively few hospitals. Although rates of radical prostatectomy rose in New York State during the period under study, these rates were lower than those reported several years earlier in other parts of the country. This may reflect an overall conservative approach to the management of prostate cancer, especially among older men, on the part of New York's urologic community. The overall postoperative complication rate was 18.5% and the mortality rate 1.3%. These rates are similar to those found in other series. Prostate cancer in older men usually has a protracted course. Radical prostatectomy in such men is associated with operative risks, and significant immediate and long-term complications. In addition, the procedure provides only marginal benefit of 10 years because of competing mortality in older men. The results of this study show a need for provider and patient focused educational efforts to reduce the numbers of radical prostatectomies in older men where the benefits are marginal compared to operative risks and significant immediate and long term complications.

An Assessment of Radical Prostatectomy

Objectives. —To examine temporal trends and geographic variation in radical prostatectomy rates and short-term outcomes. Design. —Population-based study of radical prostatectomy for the years 1984 through 1990. Poisson regression was used to estimate temporal and regional effects. Setting. —The 50 states and the District of Columbia. Participants. —A 20% national sample of male Medicare beneficiaries aged 65 years or older. Main Outcome Measures. —Rate of radical prostatectomy; 30-day mortality; and major cardiopulmonary complications, vascular complications, or surgical repairs within 30 days of radical prostatectomy. Results. —A total of 10598 radical prostatectomies were identified. The adjusted rate of radical prostatectomy in 1990 was 5.75 times that in 1984. The relative increase was similar in all age groups. Substantial geographic variation existed in rates from 1988 through 1990: all states in the New England and Mid-Atlantic regions had rates equal to or below 60 per 100 000 male Medicare beneficiaries, while all states in the Pacific and Mountain regions had rates equal to or above 130 per 100 000. The mortality and morbidity after radical prostatectomy are not trivial for older men (aged 75 years and older)—almost 2% died and nearly 8% suffered major cardiopulmonary complications within 30 days of the operation. Conclusion. —The sharp increase and wide geographic variation in radical prostatectomy rates make the evaluation of this surgical procedure a pressing issue. The rising rate of radical prostatectomy among men aged 75 years and older merits special attention. ( JAMA . 1993;269:2633-2636)

An assessment of radical prostatectomy. Time trends, geographic variation, and outcomes. The Prostate Patient Outcomes Research Team.

To examine temporal trends and geographic variation in radical prostatectomy rates and short-term outcomes. Population-based study of radical prostatectomy for the years 1984 through 1990. Poisson regression was used to estimate temporal and regional effects. The 50 states and the District of Columbia. A 20% national sample of male Medicare beneficiaries aged 65 years or older. Rate of radical prostatectomy; 30-day mortality; and major cardiopulmonary complications, vascular complications, or surgical repairs within 30 days of radical prostatectomy. A total of 10,598 radical prostatectomies were identified. The adjusted rate of radical prostatectomy in 1990 was 5.75 times that in 1984. The relative increase was similar in all age groups. Substantial geographic variation existed in rates from 1988 through 1990: all states in the New England and Mid-Atlantic regions had rates equal to or below 60 per 100,000 male Medicare beneficiaries, while all states in the Pacific and Mountain regions had rates equal to or above 130 per 100,000. The mortality and morbidity after radical prostatectomy are not trivial for older men (aged 75 years and older)--almost 2% died and nearly 8% suffered major cardiopulmonary complications within 30 days of the operation. The sharp increase and wide geographic variation in radical prostatectomy rates make the evaluation of this surgical procedure a pressing issue. The rising rate of radical prostatectomy among men aged 75 years and older merits special attention.