Anna Krasnova

Morbidity and Mortality of Locally Advanced Prostate Cancer: A Population Based Analysis Comparing Radical Prostatectomy versus External Beam Radiation

Purpose: The management of locally advanced prostate cancer remains controversial. We compared the effect of primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer. Materials and Methods: We retrospectively analyzed the records of 2,935 elderly men 65 years old or older in the SEER (Surveillance, Epidemiology and End Results)‐Medicare linked database who underwent external beam radiation therapy or radical prostatectomy for locally advanced prostate cancer. Propensity adjusted Cox proportional hazard and regression models were fit to examine urinary and gastrointestinal toxicities, the use of androgen deprivation therapy, and overall and prostate cancer specific mortality. Results: A total of 1,429 men (48.69%) underwent radical prostatectomy and had a median followup of 11.47 years (IQR 6.17–17.17) years. A total of 1,506 men (51.31%) received external beam radiation therapy and had a median followup of 7.04 years (IQR 4.11–10.51, p <0.001). Patients treated with radical prostatectomy were at significantly higher risk for urinary and sexual toxicities (HR 1.93, 95% CI 1.66–2.24 and HR 5.50, 95% CI 3.59–8.42, respectively). However, they were at lower risk for gastrointestinal toxicities (HR 0.75, 95% CI 0.65–0.86) than those treated with external beam radiation therapy. Radical prostatectomy was associated with lower odds of androgen deprivation therapy 5 years after primary treatment (OR 0.53, 95% CI 0.41–0.69, p <0.001). External beam radiation therapy was associated with higher overall and prostate specific mortality (HR 1.41, 95% CI 1.09–1.82 and HR 2.35, 95% CI 1.85–2.98, respectively). Conclusions: We found significant toxicity and survival differences in elderly men who underwent primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer. While our findings must be interpreted within the limitations of studies that rely on administrative claims, they may yet help tailor individual therapies for elderly men who present with locally advanced prostate cancer.

Accountable care organizations and the use of cancer screening

Cancer preventive services, when used appropriately, result in improved health, better quality of life and decreased costs. For these reasons, cancer preventive services represent important priorities within the Affordable Care Act (ACA). Among the many provisions to improve access to preventive services the ACA introduced Accountable Care Organizations (ACOs) as trajectory to deliver coordinated, high-quality care. In order to evaluate this benchmark, we analyzed (in 2016/Boston) screening prevalence of breast cancer, a recommended screening test according to the United States Preventive Services Task Force (USPSTF), and prostate cancer, for which screening is no longer recommended by the USPSTF, among traditional Medicare beneficiaries and those enrolled in ACOs. We used propensity-score weighting to adjust for baseline confounders. We found that the prevalence of breast cancer screening (35.0% vs. 25.2%, p<0.001) and prostate cancer screening (54.6% vs. 41.7%, p<0.001) is higher among ACO enrollees. Our results suggest increased utilization of cancer preventive care within ACOs, regardless of whether the test is recommended or not. Better efforts may be needed within the ACO infrastructure to encourage recommended preventive care, but also penalize unnecessary use of low value services.

Racial Disparity in Delivering Definitive Therapy for Intermediate/High-risk Localized Prostate Cancer: The Impact of Facility Features and Socioeconomic Characteristics

BACKGROUND The gap in prostate cancer (PCa) survival between Blacks and Whites has widened over the past decade. Investigators hypothesize that this disparity may be partially attributable to differences in rates of definitive therapy between races. OBJECTIVE To examine facility level variation in the use of definitive therapy among Black and White men for localized PCa. DESIGN, SETTING, AND PARTICIPANTS Using data from the National Cancer Data Base, we identified 223 873 White and 59 262 Black men ≥40 yr of age receiving care within the USA with biopsy confirmed localized intermediate/high-risk PCa diagnosed between January 2004 and December 2013. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multilevel logistic regression was fitted to predict the odds of receiving definitive therapy for PCa. Sensitivity and subgroup analyses were performed to adjust for inherent patient and facility-level differences when appropriate. RESULTS AND LIMITATIONS Eighty-three percent (n=185 647) of White men received definitive therapy compared with 74% (n=43 662) of Black men between 2004 and 2013. Overall rates of definitive therapy during that time increased for both White (81% vs 83%, p<0.001) and Black (73% vs 75%, p=0.001) men. However, 39% of treating facilities demonstrated significantly higher rates of definitive therapy in White men, compared with just 1% favoring Black men. Our study is limited by potential selection bias and effect modification. CONCLUSIONS After adjusting for sociodemographic and clinical factors, we found that most facilities favored definitive therapy in Whites. Health care providers should be aware of these inherit biases when counseling patients on treatment options for localized PCa. Our study is limited by the retrospective nature of the cohort. PATIENT SUMMARY We found significant differences in rates of radiation and surgical treatment for prostate cancer among White and Black men, with most facilities favoring Whites. Nonclinical factors such as treatment facility type and location influenced rates of therapy.

End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals

Importance More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.

Liver Disease in Men Undergoing Androgen Deprivation Therapy for Prostate Cancer

Purpose: Androgen deprivation therapy is associated with the development of diabetes and metabolic syndrome. To our knowledge its effect on the development of nonalcoholic fatty liver disease, a condition which frequently co‐occurs with metabolic syndrome and other subsequent liver conditions such as liver cirrhosis, hepatic necrosis or any liver disease, has not been investigated. Materials and Methods: We identified 82,938 men 66 years old or older who were diagnosed with localized prostate cancer in the SEER (Surveillance, Epidemiology and End Results)‐Medicare database from 1992 to 2009. Men with preexisting nonalcoholic fatty liver disease, liver disease, diabetes or metabolic syndrome were excluded from study. Propensity score adjusted, competing risk regression models were created to compare the risk of nonalcoholic fatty liver disease in men who were vs were not treated with androgen deprivation. We also explored the influence of cumulative exposure to androgen deprivation therapy, calculated as monthly equivalent doses of gonadotropin‐releasing hormone agonists/antagonists (fewer than 7, 7 to 11 or more than 11 doses). Results: Overall 37.5% of men underwent androgen deprivation therapy. They were more likely to be diagnosed with nonalcoholic fatty liver disease (HR 1.54, 95% CI 1.40–1.68), liver cirrhosis (HR 1.35, 95% CI 1.12–1.60), liver necrosis (HR 1.41, 95% CI 1.15–1.72) and any liver disease (HR 1.47, 95% CI 1.35–1.60). A dose‐response relationship was observed between the number of androgen deprivation therapy doses, and nonalcoholic fatty liver disease and any liver disease. Conclusions: Androgen deprivation therapy in men with prostate cancer is associated with the diagnosis of nonalcoholic fatty liver disease. The usual limitations of an observational study design apply, including possible inaccuracy in defining outcomes in a population based registry.

Impact of Accountable Care Organizations on Prostate Cancer Screening & Biopsies in the United States

Introduction: Accountable care organizations are designed to financially incentivize efficiency and reduce low value care. To determine if accountable care organizations have impacted prostate cancer screening patterns, we analyzed trends in prostate specific antigen screening and prostate biopsies by accountable care organization and nonaccountable care organization providers. Methods: Using a random 20% sample of Medicare claims, we selected men 66 years old or older. In 2014 beneficiaries were attributed to accountable care organization and nonaccountable care organization providers using a modified Medicare Shared Savings Program algorithm. Beneficiaries treated by these same providers in 2010 served as the control population. Inverse probability weighting and difference in differences analyses were used to compare trends in prostate specific antigen screening and prostate biopsies in 2010 and 2014. Analyses were stratified by the age groups 66 to 69 years old and 70 years old or older. Results: Among the beneficiaries treated by accountable care organization and nonaccountable care organization providers, prostate specific antigen screening rates were 62.4% and 60.5% in 2010 vs 55.9% and 54.4% in 2014 in men 66 to 69 years old, respectively (p=0.3). Prostate biopsy rates were 2.5% and 2.3% in 2010 vs 1.7% and 1.6% in 2014, respectively (p=0.6). In men 70 years old or older, prostate specific antigen screening rates were 54.3% and 54.2% in 2010 vs 46.0% and 46.4% in 2014, respectively (p=0.2). Similarly, prostate biopsy rates were 1.8% and 1.7% in 2010 vs 1.1% and 1.1% in 2014, respectively (p=0.7). Conclusions: Although decreasing the use of low value services is a fundamental goal of accountable care organizations, prostate specific antigen screening and prostate biopsy trends were similar for accountable care organization and nonaccountable care organization providers across all age groups in the study years. This finding suggests that accountable care organization implementation did not have an impact on prostate specific antigen screening or prostate biopsy use.

MP32-08 ACCOUNTABLE CARE ORGANIZATIONS AND THE USE OF PROSTATE CANCER SCREENING

impact of ACO participation on readmission after major surgery, procedure specific readmissions and mortality rates. We compared outcomes in the pre-implementation and post-implementation periods. RESULTS: We identified 388,003 patients of whom 61,938 (16%) underwent surgery in an ACO hospital. Overall, 60% were treated in the pre-implementation period. We noted significant secular trends in the non-ACO group from preto post-implementation in overall readmission rate (11.0% relative decrease, p<0.001) and mortality (11.1% relative decrease, p<0.001). ACO participation had a significant effect on readmission rate, accounting for an added 7.4% relative decrease, but no effect on mortality rate (Figure A, C; difference-indifferences estimator p1⁄40.024, p1⁄40.25, respectively). Trends for cystectomy were not significant for readmission (Figure B) or mortality in either group. CONCLUSIONS: The overall readmission and mortality rates after major surgery decreased significantly between 2010 and 2014. ACOs accounted for an additional 7.4% reduction in overall readmission rates. Our findings demonstrate a synergistic effect of ACO participation and national readmission policy on readmissions after major surgery.

Intraoperative cholangiography during cholecystectomy among hospitalized medicare beneficiaries with non-neoplastic biliary disease

BACKGROUND Prior studies of Medicare beneficiaries with both neoplastic and non-neoplastic indications for cholecystectomy demonstrated a reduced risk of common bile duct (CBD) injury when intraoperative cholangiography (IOC) was used. We sought to determine the association between IOC and CBD injury during inpatient cholecystectomy for non-neoplastic biliary disease and compare survival among those with or without CBD injury. METHODS Retrospective study of patients ≥66 who underwent inpatient cholecystectomy (2005-2010) for gallstones, cholecystitis, cholangitis, or gallbladder obstruction. The association between IOC and CBD injury was analyzed using multivariable logistic regression and survival after cholecystectomy was analyzed using multivariable Cox regression. RESULTS Among 472,367 patients who underwent cholecystectomy, 0.3% had a CBD injury. IOC was associated with increased CBD injury (adjusted OR 1.41[1.27-1.57]). CBD injury was associated with increased hazards of death (adjusted HR 1.37[1.25-1.51]). CONCLUSIONS IOC in patients with non-neoplastic biliary disease was associated with increased odds of CBD injury. This likely reflects its selective use in patients at higher risk of CBD injury or as a confirmatory test when an injury is suspected.