Medicare breast surgery fees and treatment received by older women with localized breast cancer

Dissemination and Implementation-A Primer for Accelerating "Time to Translation" in Radiation Oncology

The field of radiation oncology has achieved significant technological and scientific advancements in the 21st century. Yet uptake of new evidence-based practices has been heterogeneous, even in the presence of national and international guidelines. Addressing barriers to practice change requires a deliberate focus on developing and testing strategies tailored to improving care delivery and quality, especially for vulnerable patient populations. Implementation science provides a systematic approach to developing and testing strategies, though applications in radiation oncology remain limited. In this critical review, we aim to (1) assess the time from first evidence to widespread adoption, or "time to translation," across multiple evidence-based practices involving radiation therapy, and (2) provide a primer on the application of implementation science to radiation oncology. Specifically, we discuss potential targets for implementation research in radiation oncology, including both evidence-based practices and quality metrics, and highlight examples of studies evaluating implementation strategies. We also define key concepts and frameworks in the field of implementation science, review common study designs, including hybrid trials and cluster randomization, and discuss the interaction with related disciplines such as quality improvement and behavioral economics. Ultimately, this review aims to illustrate how a comprehensive understanding of implementation science could be used to promote equity and quality in cancer care through the development of effective, scalable, and sustainable care delivery solutions.

TP53 Mutations and Outcomes in Breast Cancer: Reading beyond the Headlines

TP53 is the most frequently mutated gene in breast cancer, but its role in survival is confounded by different studies concluding that TP53 mutations are associated with negative, neutral, or positive outcomes. Closer examination showed that many studies were limited by factors such as imprecise methods to detect TP53 mutations and small cohorts that combined patients treated with drugs having very different mechanisms of action. When only studies of patients receiving the same treatment(s) were compared, they tended to agree. These analyses reveal a role for TP53 in response to different treatments as complex as its different biological activities. We discuss studies that have assessed the role of TP53 mutations in breast cancer treatment and limitations in interpreting reported results.

The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis

BACKGROUND

Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.

METHODS

Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.

RESULTS

A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of $960.

CONCLUSIONS

There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments

OBJECTIVE

To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.

DATA SOURCES/STUDY SETTING

Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD).

STUDY DESIGN

We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities.

DATA COLLECTION

We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims.

PRINCIPAL FINDINGS

MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts.

CONCLUSIONS

Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.

Decision to Adopt Medical Technology

Objective. To understand decision making concerning adoption and nonadoption of accelerated partial breast radiotherapy (RT) prior to long-term randomized trial evidence. Methods. A total of 36 radiation oncologists and surgeons were recruited through purposive and snowball sampling strategies from September 2010 through January 2013. Semistructured phone interviews were conducted and audio-recorded and lasted 20–45 minutes. Qualitative analysis was conducted using a framework approach, iteratively exploring key concepts and emerging issues raised by subjects. Interviews were transcribed and imported into Atlas.ti v6. Transcripts were independently coded by 3 researchers shortly after each interview, followed by consensus development on each coded transcript. Barriers and facilitators of adoption, practice patterns, and informational/educational sources concerning accelerated partial breast RT were all assessed to determine major themes. Results. Nearly half of physicians were surgeons (47%), and half were radiation oncologists (53%), with 61% overall in urban settings. Twenty-nine of the 36 physicians interviewed used brachytherapy-based partial breast RT. Five major factors were involved in physicians’ decisions to adopt accelerated partial breast RT: facilitators encouraging adoption (e.g., enthusiastic colleagues and patient convenience), financial and prestige incentives, pressures to adopt (e.g., potential declines in referrals), judgment concerning acceptable level of scientific evidence, and barriers (e.g., not having appropriate machinery or referral mechanism in place). If technology was adopted, clinical guideline adherence varied. Conclusions. Technology adoption is based on financial and social pressures, along with often-limited scientific evidence and what seems “best” for patients. For technology adoption and diffusion to be rational and evidence-based, we must encourage appropriate financial payment models to curb use outside of research studies and promote development of additional treatment registries until sufficient evidence is gathered.

Factors associated with geographic variation in cost per episode of care for three medical conditions

OBJECTIVE

To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options.

METHODS

We use 2004-2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry's Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes).

RESULTS

Higher Medicare reimbursement for surgical episodes and greater availability of the relevant specialists are significantly associated with more surgery and higher cost per episode for all three conditions, while greater availability of primary care physicians is significantly associated with less frequent surgery and lower cost per episode.

CONCLUSION

Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.

Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons

BACKGROUND

The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes.

METHODS

We collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided.

RESULTS

Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (P(diff) < .001 for each of the differences). Similarly, each of the differences at 10 years was statistically significant (P < .001).

CONCLUSIONS

Our work demonstrates the contributions of treatments and margin status to long-term ipsilateral disease-free survival and the link between surgeons and these key measures of care. Although variation by surgeon could be generated by patients' preferences, the extent of variation and its contribution to long-term health outcomes are troubling. Further work is required to determine why women with positive margins receive no additional treatment and why margin status and receipt of radiation therapy vary by surgeon.

Medicare Part B reimbursement and the perceived quality of physician care

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor's care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians' ability to balance bill significantly reduce the perceived quality of care under Part B.

The pen and the scalpel: effect of diffusion of information on nonclinical variations in surgical treatment

BACKGROUND

As information is disseminated about best practices, variations in patterns of care should diminish over time.

OBJECTIVE

To test the hypotheses that differences in rates of a surgical procedure are associated with type of insurance in an era of evolving practice guidelines and that insurance and site differences diminish with time as consensus guidelines disseminate among the medical community.

METHODS

We use lymph node dissection among women with ductal carcinoma in situ (DCIS) as an example of a procedure with uncertain benefit. Using a sample of 1051 women diagnosed from 1985 through 2000 at 2 geographic sites, we collected detailed demographic, clinical, pathologic, and treatment information through abstraction of multiple medical records. We specified multivariate logistic models with flexible functions of time and time interactions with insurance and treatment site to test hypotheses.

RESULTS

Lymph node dissection rates varied significantly according to site of treatment and insurance status after controlling for clinical, pathologic, treatment, and demographic characteristics. Rates of lymph node dissection decreased over time, and differences in lymph node dissection rates according to site and generosity of insurance were no longer significant by the end of the study period.

CONCLUSIONS

We have demonstrated that rates of a discretionary surgical procedure differ according to nonclinical factors, such as treatment site and type of insurance, and that such unwarranted variation decreases over time with diminishing uncertainty and in an era of diffusion of clinical guidelines.

Primary physicians' response to changes in fees

The study examines how the service production of primary physicians in Norway is influenced by changes in fees. The data represent about 2,650 fee-for-service physicians for the years 1995--2000. We constructed a variable that made it possible to estimate income effects of fee changes on service levels. Service production was measured by the number of consultations per physician, the number of laboratory tests per consultation and the proportion of consultations lasting more than 20 min. Our main finding is that fee changes have no income effect on service production. Our results imply that fee regulation can be an effective means of controlling physicians' income, and therefore government expenditure, on primary physician services.

Medicare fees and physicians' medicare service volume: beneficiaries treated and services per beneficiary

Using merged physician survey and Medicare claims data, this study analyzes how fee levels, market factors, and financial incentives affect physicians' fee-for-service Medicare service volume. We find that Medicare fees are positively related to both the number of beneficiaries treated (eta = 0.12 to 0.61) and service intensity (eta = 1.04-1.71). Physicians with apparent incentives to induce demand appear to manipulate the mix of services provided in order to increase the effective Medicare fee. Finally, several market factors appear to influence the quantity of Medicare services physicians provide. Results highlight limitations of the present system for compensating physicians in Medicare's fee-for-service program.

Do age and ethnicity predict breast cancer treatment received? A cross-sectional urban population based study. Breast cancer treatment: age and ethnicity

PURPOSE

To evaluate the treatment patterns of women aged 55 years or older with newly diagnosed breast cancer and to examine the association between age and ethnicity/race on treatment selection.

METHODS

A cross-sectional survey between January 1 and June 30, 2001 of 401 women was performed of Hispanic, black and non-Hispanic white women in Los Angeles County, aged 55 years or older with newly diagnosed breast cancer. Regression analysis examined the association between: (a) age and treatment selection and (b) ethnicity/race and treatment selection, adjusting for the effect of possible confounders.

RESULTS

In this study of urban breast cancer patients (64.1% response rate), blacks were less likely to receive hormone (OR=0.36) or chemotherapy therapy (OR=0.50) while older patients were less likely to receive lymph node dissection after lumpectomy (OR=0.48) and chemotherapy (OR=0.22).

CONCLUSION

Although there are racial and age disparities in breast cancer treatment, other factors such as education, income status, insurance plan, functional status, and comorbidity also play an important role.

Psychosocial determinants and outcomes of chemotherapy in older women with breast cancer: what do we know? What do we need to know?

With the aging of the U.S. population and rising breast cancer incidence with advancing age, the absolute number of women aged 65 years and older diagnosed with and surviving breast cancer will dramatically increase over the coming decades. Despite this demographic imperative, we know little about the impact of adjuvant therapies in this age group. We synthesized data to describe key findings and gaps in knowledge about the outcomes of adjuvant breast cancer treatment in women aged 65 years and and older ("older women"). We reviewed research published between 1995 and June 2005 on breast cancer outcomes among older women treated with adjuvant therapy for breast cancer. Outcomes included communication, emotional distress, satisfaction, and multiple quality-of-life domains. Only 16 articles focused exclusively on older women and chemotherapy; and only one included a large sample of older women (N = 1755). Most common domains included comorbidities, symptoms, and survival. Of the 13 clinical trials and three observational studies we reviewed, only one clinical trial measured quality of life and psychological factors such as coping. None of the studies examined patient preferences or patient-physician communication (processes of care) in older women. Few studies have been designed to specifically evaluate adjuvant therapy processes and outcomes among older women, especially interactions between treatment and comorbidity, and the impact of the processes of care on outcomes. In addition, only narrow segments of the older population with breast cancer (e.g., well-educated, nonminority women) have been included in trials to date. Thus, at present we do not have sufficient data to assist physicians and their older patients in developing adjuvant treatment decisions and plans tailored to older women's needs, preferences, and concerns.

Versorgungsforschung in der operativen Medizin am Beispiel der Mammakarzinomchirurgie

The epidemiological relevance of breast cancer in Germany has led to a number of initiatives actually changing the processes and structures of care. The ultimate aim of health services research in surgery is to evaluate the impact of these initiatives on the effectiveness and efficiency of the respective health care services. Results of international studies show for instance breast-conserving therapy to be related to the patients' socioeconomic status. In addition, breast specialists tend to operate more in adherence to practice guidelines and to implement new procedures like sentinel lymph node biopsies earlier. Preliminary results from Germany also demonstrate a considerable practice variation in breast cancer surgery. Causes and effects of such variation still have to be explored. For that purpose, newly available data sources on health care services in relation to breast cancer surgery in Germany could be used. The inherent challenge is to combine data from tumour registries, statutory comparative quality assurance activities and inpatient remuneration via DRGs for health services research in surgery.

The effect of physician characteristics and their practice environment on surgical referral patterns for early-stage breast cancer in Iowa

The objective of this article was to examine whether characteristics of referring physicians and their practice environment were associated with surgical referral behavior for early-stage breast cancer patients. A total of 2801 women diagnosed with early-stage breast cancer and their referring physicians were identified from the Iowa Surveillance, Epidemiology, and End Results (SEER) database during 1989-1996. The Iowa Physician Inventory was used to collect information on characteristics of referring physicians. Multiple logistic regression analyses were conducted to evaluate characteristics of the referring physicians and their practice environment to explain surgical referral behavior. Affiliation with physicians' networks and professional diversity among area specialists were associated with increased referrals to surgeons more likely to perform breast-conserving surgery. Promoting interaction among physicians, particularly among those with different specialties, may increase the diffusion of new behaviors into clinical practice.

A participatory action research approach for identifying health service needs of Hispanic immigrants: implications for occupational therapy

SUMMARY Recently, the field of Community Occupational Therapy has started to enter into new research areas, one being participatory research. This paper illustrates a participatory research methodology adapted by community residents and a research team to identify the service needs of an underserved Hispanic population as well as set action agendas to meet their needs. In order to plan and implement health programs, community residents participated actively in the needs assessment, action agenda development and brainstorming of solutions to address health and community needs and concerns. Concerns identified included the lack of affordable bilingual dentists and youth involvement in gangs, drugs, and alcohol. The results of the needs assessment were shared and discussed during five public forums in which 180 Hispanics from the community discussed the dimensions of the issues and alternative solutions. This process resulted in an agenda of health issues and ideas for improvement from the perspective of Hispanics. We emphasized the advantages of using participatory methodologies when developing health and community services within Hispanic communities. Additionally, the implications for advancing a Scholarship of Practice agenda for Community Occupational Therapy are discussed.

Assessment of the Current Medicare Reimbursement System for Breast Cancer Operations

BACKGROUND

Medicare determines procedural reimbursement by means of formulas considering physician work, practice, and liability expenses. Since no mechanism exists to consider outcomes in calculating reimbursements, we hypothesized that Medicare reimbursements do not correlate with outcomes for different breast cancer operations.

METHODS

We prospectively studied 240 patients with T1, 2N0M0 breast cancer in three surgical treatment arms: segmental mastectomy with axillary node dissection (SM&ALND ; n = 42); SM with sentinel node dissection (SM&SLND ; n = 96); and mastectomy without reconstruction (MRM; n = 102). Outcome parameters of complications, hospital stay, analgesic usage, and days to return to work were correlated with procedure reimbursements.

RESULTS

Median follow-up was 26 months. SM&SLND patients rarely required hospital stays (14%) in comparison with either SM&ALND (96%) or MRM patients (99%) (P < 0.001). SM&ALND and MRM patients required 9 and 10 median days of narcotics, respectively, versus 1 day in the SLND group (P < 0.001). SM&SLND patients returned to work at a median of 3 days, in comparison with 19 for SM&ALND and 26 for MRM patients (P < 0.001). Complications were more common in the MRM group (67% numbness/10% pain) and the SM&ALND group (56%/9%) than in the SM&SLND group (0%/1%). Reimbursements were inversely correlated with outcomes. MRM was reimbursed the highest, at an average of 1,075.03 dollars, with SM&ALND at 882.72 dollars. SM&SLND was reimbursed at 642.00 dollars.

CONCLUSIONS

Medicare reimbursements for breast cancer operations do not correlate with outcomes. Less-invasive procedures are paid for at lower rates despite better outcomes and fewer complications. The data from this study raise the question of the impact of reimbursement on breast procedure selection.

Outcomes and quality of life following breast cancer treatment in older women: when, why, how much, and what do women want?

BACKGROUND

There are few comprehensive reviews of breast cancer outcomes in older women. We synthesize data to describe key findings and gaps in knowledge about the outcomes of breast cancer in this population.

METHODS

We reviewed research published between 1995 and June 2003 on breast cancer quality of life and outcomes among women aged 65 and older treated for breast cancer. Outcomes included communication, satisfaction, and multiple quality of life domains.

RESULTS

Few randomized trials or cohort studies that measured quality of life after treatment focused exclusively on older women. Studies from older women generally noted that, with the exception of axillary dissection, type of surgical treatment generally had no effect on long-term outcomes. In contrast, the processes of care, such as choosing therapy, good patient-physician communication, receiving treatment concordant with preferences about body image, and low perceptions of bias, were associated with better quality of life and satisfaction.

CONCLUSIONS

With the exception of axillary dissection, the processes of care, and not the therapy itself, seem to be the most important determinants of long-term quality of life in older women.