Phyllis Yan

Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis.

Objective To investigate the efficacy and safety of alpha blockers in the treatment of patients with ureteric stones. Design Systematic review and meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Web of Science, Embase, LILACS, and Medline databases and scientific meeting abstracts to July 2016. Review methods Randomized controlled trials of alpha blockers compared with placebo or control for treatment of ureteric stones were eligible.Two team members independently extracted data from each included study. The primary outcome was the proportion of patients who passed their stone. Secondary outcomes were the time to passage; the number of pain episodes; and the proportions of patients who underwent surgery, required admission to hospital, and experienced an adverse event. Pooled risk ratios and 95% confidence intervals were calculated for the primary outcome with profile likelihood random effects models. Cochrane Collaboration’s tool for assessing risk of bias and the GRADE approach were used to evaluate the quality of evidence and summarize conclusions. Results 55 randomized controlled trials were included. There was moderate quality evidence that alpha blockers facilitate passage of ureteric stones (risk ratio 1.49, 95% confidence interval 1.39 to 1.61). Based on a priori subgroup analysis, there seemed to be no benefit to treatment with alpha blocker among patients with smaller ureteric stones (1.19, 1.00 to 1.48). Patients with larger stones treated with an alpha blocker, however, had a 57% higher risk of stone passage compared with controls (1.57, 1.17 to 2.27). The effect of alpha blockers was independent of stone location (1.48 (1.05 to 2.10) for upper or middle stones; 1.49 (1.38 to 1.63) for lower stones). Compared with controls, patients who received alpha blockers had significantly shorter times to stone passage (mean difference −3.79 days, −4.45 to −3.14; moderate quality evidence), fewer episodes of pain (−0.74 episodes, −1.28 to −0.21; low quality evidence), lower risks of surgical intervention (risk ratio 0.44, 0.37 to 0.52; moderate quality evidence), and lower risks of admission to hospital (0.37, 0.22 to 0.64; moderate quality evidence). The risk of a serious adverse event was similar between treatment and control groups (1.49, 0.24 to 9.35; low quality evidence). Conclusions Alpha blockers seem efficacious in the treatment of patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger stones. These results support current guideline recommendations advocating a role for alpha blockers in patients with ureteric stones. Systematic review registration PROSPERO registration No CRD42015024169.

Health Care Integration and Quality among Men with Prostate Cancer

Purpose: The delivery of high quality prostate cancer care is increasingly important for health systems, physicians and patients. Integrated delivery systems may have the greatest ability to deliver high quality, efficient care. We sought to understand the association between health care integration and quality of prostate cancer care. Materials and Methods: We used SEER‐Medicare data to perform a retrospective cohort study of men older than age 65 with prostate cancer diagnosed between 2007 and 2011. We defined integration within a health care market based on the number of discharges from a top 100 integrated delivery system, and compared rates of adherence to well accepted prostate cancer quality measures in markets with no integration vs full integration (greater than 90% of discharges from an integrated system). Results: The average man treated in a fully integrated market was more likely to receive pretreatment counseling by a urologist and radiation oncologist (62.6% vs 60.3%, p=0.03), avoid inappropriate imaging (72.2% avoided vs 60.6%, p <0.001), avoid treatment when life expectancy was less than 10 years (23.7% vs 17.3%, p <0.001) and avoid multiple hospitalizations in the last 30 days of life (50.2% vs 43.6%, p=0.001) than when treated in markets with no integration. Additionally, patients treated in fully integrated markets were more likely to have complete adherence to all eligible quality measures (OR 1.38, 95% CI 1.27–1.50). Conclusions: Integrated systems are associated with improved adherence to several prostate cancer quality measures. Expansion of the integrated health care model may facilitate greater delivery of high quality prostate cancer care.

Factors Associated with Preventive Pharmacological Therapy Adherence among Patients with Kidney Stones

OBJECTIVE To determine adherence patterns for thiazide diuretics, alkali citrate therapy, and allopurinol, collectively referred to as preventive pharmacological therapy (PPT), among patients with kidney stones. METHODS Using medical claims data, we identified adults diagnosed with kidney stones between 2002 and 2006. Through National Drug Codes, we determined those with one or more prescription fills for a PPT agent. We measured adherence to PPT (as determined by the proportion of days covered formula) within the first 6 months of starting therapy and performed multivariate analysis to evaluate patient factors associated with PPT adherence. RESULTS Among 7980 adults with kidney stones who were prescribed PPT, less than one third (30.2%) were adherent to their regimen (indicated by proportion of days covered  ≥ 80%). Among those on monotherapy, rates of adherence differed by the type of PPT agent prescribed: 42.5% for thiazides, 40.0% for allopurinol, and 13.4% for citrate therapy. Factors that were independently associated with lower odds of PPT adherence included combination therapy receipt, female gender, less generous health insurance, and residence in the South or Northeast. In contrast, older patients and those with salaried employment had a higher probability of PPT adherence. CONCLUSION Adherence to PPT is low. These findings help providers identify patients where PPT adherence will be problematic. Moreover, they suggest possible targets for quality improvement efforts in the secondary prevention of kidney stones.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care

Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low‐value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care.

Urologist Practice Affiliation and Intensity-modulated Radiation Therapy for Prostate Cancer in the Elderly

BACKGROUND Prostate cancer treatment is a significant source of morbidity and spending. Some men with prostate cancer, particularly those with significant health problems, are unlikely to benefit from treatment. OBJECTIVE To assess relationships between financial incentives associated with urologist ownership of radiation facilities and treatment for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort of Medicare beneficiaries with prostate cancer diagnosed between 2010 and 2012. Patients were further classified by their risk of dying from noncancer causes in the 10 yr following their cancer diagnosis by using a mortality model derived from comparable patients known to be cancer-free. INTERVENTION Urologists were categorized by their practice affiliation (single-specialty groups by size, multispecialty group) and ownership of a radiation facility. OUTCOME MEASUREMENTS AND ANALYSIS Use of intensity-modulated radiation therapy (IMRT) and use of any treatment within 1 yr of diagnosis. Generalized estimating equations were used to adjust for patient differences. RESULTS Among men with newly diagnosed prostate cancer, use of IMRT ranged from 24% in multispecialty groups to 37% in large urology groups (p<0.001). Patients managed in groups with IMRT ownership (n=5133) were more likely to receive IMRT than those managed by single-specialty groups without ownership (43% vs 30%, p<0.001), regardless of group size. Among patients with a very high risk (> 75%) of noncancer mortality within 10 yr of diagnosis, both IMRT use (42% vs 26%, p<0.001) and overall treatment (53% vs 44%, p<0.001) were more likely in groups with ownership than in those without, respectively. CONCLUSIONS Urologists practicing in single-specialty groups with an ownership interest in radiation therapy are more likely to treat men with prostate cancer, including those with a high risk of noncancer mortality. PATIENT SUMMARY We assessed treatment for prostate cancer among urologists with varying levels of financial incentives favoring intervention. Those with stronger incentives, as determined by ownership interest in a radiation facility, were more likely to treat prostate cancer, even when treatment was unlikely to provide a survival benefit to the patient.

Medicare Accountable Care Organizations Are Not Associated With Reductions in the Use of Low-Value Coronary Revascularization

Background: Because specialty care accounts for half of Medicare expenditures, improving its value is critical to the success of Medicare accountable care organizations (ACOs) in curbing spending growth. However, whether ACOs have reduced low-value specialty care without compromising use of high-value services remains unknown. Methods and Results: Using national Medicare data, we identified 2 cohorts: beneficiaries for whom the value of coronary revascularization is lower (those with ischemic heart disease without angina, congestive heart failure, or recent admission for acute myocardial infarction) and beneficiaries for whom its value is higher (those with recent acute myocardial infarction admission). We then determined the provider groups who cared for the cohorts, distinguishing between those participating (n=298) and those not participating in a Medicare ACO (1329). After measuring the provider groups’ use of coronary artery bypass grafting and percutaneous coronary intervention among the 2 cohorts, we fit multivariable models to test the statistical significance of rates of change in low- and high-value revascularization after ACO participation. During the pre-ACO period, participating and nonparticipating provider groups had similar rates of low- and high-value revascularization. Our multivariable model results show that rates of change for low- and high-value coronary revascularization were not altered by a provider group’s participation in a Medicare ACO (lower value: difference, −0.04 per year; 95% confidence interval, −0.11 to 0.03; higher value: difference, 0.96 per year; 95% confidence interval, −0.46 to 2.4). Conclusions: We found no association between provider group participation in a Medicare ACO and use of low- or high-value coronary revascularization.

Accountable care organizations and prostate cancer care

Introduction: Accountable care organizations have the potential to increase the value of health care by improving population health and enhancing financial stewardship. How practice context modifies effects on a specialty focused disease, such as prostate cancer care, has implications for their success. Methods: We performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single specialty, large single specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12‐month period after diagnosis according to accountable care organization alignment and practice affiliation. Results: Of 15,640 patients with newly diagnosed prostate cancer 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had use of curative treatment similar to that of those not in accountable care organizations (71.4% vs 70.0%, respectively, p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations (

Reimbursement and use of intensity-modulated radiation therapy for prostate cancer

20,916 vs

Follow-Up Care after ED Visits for Kidney Stones—A Missed Opportunity

19,773, p=0.03). However, this relationship was independent of practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p <0.05) but not with treatment (p=0.87). Conclusions: Patients with prostate cancer aligned with accountable care organizations had similar rates of treatment but increased spending in the year after diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Emergency Department Switching and Duplicate Computed Tomography Scans in Patients With Kidney Stones

Abstract The use of intensity-modulated radiation therapy (IMRT) for prostate cancer increased through the mid-2000s, in association with acquisition of the devices by large urology groups. More recently, reimbursement for IMRT in the office setting (generally representing freestanding facilities owned by physicians) has been declining. The aim of the study was to examine trends in IMRT use and related payments in the office versus hospital outpatient setting over time. In this retrospective cohort study, a total of 66,967 men aged 66 years or older, with newly diagnosed prostate cancer from 2007 through 2012 were identified in a 20% national sample of Medicare claims. IMRT use in the office versus hospital outpatient setting was examined over time, adjusted for patient characteristics using multivariable logistic regression models. Mean reimbursement for IMRT treatments and total IMRT-related payments were plotted by year. IMRT use increased from 28.6% to 38.0% of newly diagnosed men with prostate cancer over the study period, exclusively related to growth in the office setting. In particular, use in the office setting increased from 13.2% in 2007 to 22.1%, whereas use in the hospital outpatient setting remained essentially steady throughout the period around 15%. During the same period mean reimbursement for IMRT in the office setting declined from