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A study of the records of more than 50,000 men with newly diagnosed prostate cancer found that androgen-deprivation treatment, either as gonadotropin-releasing hormone agonists or orchiectomy, increases the risk of fracture and of hospitalization due to fracture. Androgen-deprivation treatment, either as gonadotropin-releasing hormone agonists or orchiectomy, increases the risk of fracture and of hospitalization due to fracture. Androgen-deprivation therapy for prostate cancer can reduce morbidity, palliate metastases, and improve survival in locally advanced disease when combined with radiation. 1 – 3 However, androgen-deprivation therapy alone, in the form of gonadotropin-releasing hormone agonists, is increasingly being used in men with localized prostate cancer (cancer confined to the prostate) and in men in whom the level of prostate-specific antigen (PSA) rises after prostatectomy 4 – 6 — both situations in which most patients are minimally symptomatic and no survival benefit has been demonstrated. 1 , 7 For these reasons, it is important to have accurate data on the toxic effects of androgen deprivation. 8 , 9 Bone . . .

Background Same‐day discharge following radical prostatectomy has become increasingly common, with single‐institution series suggesting it reduces healthcare costs without increasing adverse events. However, this practice has not been studied nationally, outside of specialized centers. This study assesses 30‐day readmissions, observation stays, and emergency department visits among men with prostate cancer undergoing prostatectomy. Study Design We used national Medicare data to identify men undergoing prostatectomy for prostate cancer between 2016 and 2021. We focused on patients discharged either the same day or the day after surgery to include only those with an uneventful postoperative course presumably eligible for same‐day discharge. We used multivariable logistic regression to measure relationships between discharge day (same‐day vs. next‐day) and 30‐day readmissions, adjusted for patient factors. We also assessed the association between the day of discharge and a secondary outcome, a composite of readmission, observation stay, or emergency department visits within 30 days. Results Our cohort included 528 men discharged the same day and 11,513 discharged the next day. By 2021, same‐day discharges rose to 9.2%. Same‐day discharge was associated with an almost two‐fold increase in the odds of a readmission within 30 days (adjusted OR: 1.93; 95% CI 1.35–2.76; p < 0.01). However, the odds of an acute care event, measured by a composite of any readmission, observation stay, or emergency department visit, were similar in both groups (adjusted OR: 1.16; 95% CI 0.90–1.50; p = 0.27). Conclusions Same‐day discharges after prostatectomy have increased substantially but were associated with a two‐fold increase in odds of a readmission within 30 days. However, global adverse events, as measured by our composite outcome, were similar.

Studies assessing the impact of advanced practice providers (APPs), including nurse practitioners and physician assistants, have demonstrated a similar quality of care for patients admitted to the hospital for medical diagnoses. However, no studies have examined the relationship between APP integration and morbidity after cancer surgery. This study assesses the relationship between APP staffing intensity and patient outcomes following major abdominal cancer surgery. We used 100% national Medicare data (2010-2019) to assess the link between APP staffing intensity and surgical outcomes for patients undergoing major abdominal cancer surgery, including cystectomy, colectomy, hepatectomy, esophagectomy, gastrectomy, and pancreatectomy. The primary exposure was the ratio of APPs per 100 hospital beds, and patients were empirically divided into tertiles. Outcomes included readmission rates and length of stay, adjusted for patient and hospital level factors. As a secondary outcome, we measured 30-day perioperative mortality. We analyzed 326,547 colectomy patients, 50,400 cystectomy patients, 14,112 esophagectomy patients, 27,152 gastrectomy patients, 15,225 hepatectomy patients, and 46,287 pancreatectomy patients. Surgery at centers with the most advanced practice providers per beds (i.e., the highest tertile) was associated with shorter length of stays for most surgery types analyzed. Unadjusted 30-day readmissions tended to be lower in patients undergoing more complex procedures, such as esophagectomy (21.5% vs. 24.3%; p = 0.006) but not for the less complex operations studied, such as colectomy (13.6% vs. 13.5%; p = 0.22). However, clinical differences in outcomes were lost on analyses controlling for patient and hospital factors (IRR length of stay: 0.98-1.01; p = 0.002-087) (OR readmissions: 0.86-1.01; p = 0.003-0.80). The relationship between hospital APP staffing intensity and surgical outcomes was varied and heterogenous. However, differences in outcomes were primarily explained by hospital factors. More work is needed to determine process measures associated with the deployment of inpatient APPs.

Introduction Dual eligible beneficiaries are a vulnerable population who often experience inferior access to care and outcomes compared to non‐dual eligible beneficiaries. The Oncology Care Model (OCM) is an alternative payment model that aims to improve coordination and quality of care in beneficiaries receiving chemotherapy and thus may improve care for dual eligible beneficiaries with cancer. Methods We used 100% Medicare claims data from 2014 through 2019 and included beneficiaries with bladder, breast, esophageal, colorectal, kidney, lung, pancreatic, or prostate cancer receiving chemotherapy. We constructed multivariable difference‐in‐differences regression models to evaluate the effect of OCM participation on healthcare utilization and quality of care at the end‐of‐life among dual eligible beneficiaries. We also compared healthcare utilization and quality of care outcomes to non‐dual eligible beneficiaries. Results We identified 3,043,944 episodes of care among 1,260,892 unique Medicare beneficiaries. Ten percent of all beneficiaries (n = 126,758) were dual eligible and 64,087 (22%) of episodes among dual eligible patients were in an OCM participating practice. We noted no effect of OCM participation on healthcare utilization or end‐of‐life quality of care for dual eligible beneficiaries. However, we observed higher rates of hospitalization, emergency department visits, intensive care unit stays, and a lower number of office visits among dual eligible beneficiaries compared to non‐dual eligible beneficiaries. Conclusions Participation in OCM was not associated with improvements in quality of care or healthcare utilization for dual eligible beneficiaries. Dual eligible beneficiaries experience lower quality of care across several measures compared to non‐dual eligible beneficiaries. Focused policies and incentives may be necessary to address disparities within emerging health reforms. Participation in the Oncology Care Model was not associated with improvements in quality or utilization for dual eligible beneficiaries. Dual eligible beneficiaries continue to experience lower quality across several utilization measures compared to non‐dual eligible beneficiaries.

Introduction and Objectives Prior work has demonstrated racial disparities in surgical outcomes for solid organ cancers. We sought to assess the relationship between hospital quality and racial disparities in achievement of textbook outcomes among patients undergoing surgery for prostate, kidney, and bladder cancer. Methods We used 100% national Medicare Provider Analysis and Review files from 2017 to 2020 to assess textbook outcomes in Patients undergoing bladder (i.e., radical cystectomy), kidney (i.e., radical or partial nephrectomy), and prostate (i.e., radical prostatectomy) surgery for genitourinary malignancies. Our exposure was hospital‐level quality, assessed by the predicted to expected ratio of achievement of textbook outcomes, agnostic to social and economic determinants of health. Our main outcome was achievement of textbook outcomes in White and Black patients. We defined the textbook outcome as the absence of in‐hospital mortality, mortality within 30 days of surgery, readmission within 30 days of discharge, a postoperative complication, and prolonged length of stay. The secondary outcome was percentage of Black and White patients treated at the highest quality hospitals. Results As hospital quality increased, disparities in the receipt of textbook outcome for White and Black patients narrowed. For every 0.1 increment increase in the predicted to expected ratio of hospital quality, Black‐White disparities in the odds of achieving textbook outcomes decreased by 5.7% (interaction OR: 1.06; 95% CI 1.01–1.11 p = 0.026). Black patients were less likely to be treated at the highest quality hospitals compared to White patients (45.2% vs. 49.5% p = < 0.001%). Conclusions Compared to White patients, Black patients had lower odds of textbook outcomes after surgery for prostate, kidney, and bladder cancer. The racial differences in achieving textbook outcomes were narrowed as hospital quality increased. Black patients were less likely than White patients to be treated at the highest‐quality hospitals. Our findings underscore the importance of improved access to high quality care among Black patients. Patients undergoing bladder, kidney, or prostate cancer surgery at major teaching hospitals have higher rates of textbook outcomes when compared to patients at nonteaching hospitals. While the volume‐outcome relationship explains differences in kidney cancer, it does not fully account for disparities in outcomes seen in bladder and prostate cancer surgeries.

Introduction In the past decade, the management of advanced prostate cancer has shifted to novel hormonal therapies. As a result, urologists have increased their involvement in the management of advanced prostate cancer. These therapies require close monitoring due to the possibility of adverse cardiometabolic events. We assessed outcomes among men diagnosed with advanced prostate cancer started on novel hormonal therapy by a urologist compared to those by a medical oncologist. Methods We performed a retrospective cohort study of Medicare beneficiaries with advanced prostate cancer treated with a novel hormonal therapy between 2012 and 2019. The primary outcome was an adverse event comprised of a hospital visit for a cardiometabolic event within 6 months of starting a novel hormonal therapy. Secondary outcomes included monthly out‐of‐pocket costs and treatment adherence. Results There were 1212 (23%) and 4124 (77%) patients who were prescribed a novel hormonal therapy for the first time by a urologist and medical oncologist, respectively. No difference in the composite adverse event measure was observed in those managed by urologists or medical oncologists (4.2% vs. 4.7%, respectively, p = 0.49). Out‐of‐pocket costs, in men without low‐income subsidies, did not vary by specialty ( $772 vs. $ 790, p = 0.58). Adherence to treatment did not vary in men managed by urologists or medical oncologists (75% vs. 74%, respectively, p = 0.64). Conclusions The specialty of the physician prescribing a novel hormonal therapy was not associated with the risk of a cardiometabolic adverse event. Further, management by a urologist did not adversely affect costs to patients or adherence.

Introduction A paradigm shift in advanced prostate cancer toward the use of oral specialty drugs has been accompanied by increased involvement of urologists. In fact, some urology groups can deliver these medications in the office, providing them directly to their patients. Methods A retrospective cohort study was performed using a 20% national sample of men with advanced prostate cancer enrolled in Traditional Medicare and managed by independent urology groups between 2011 and 2019. Urology groups with and without in‐office dispensing were identified. Multivariable logistic regression was used to assess relationships between urology group characteristics and in‐office dispensing. A difference‐in‐differences design was used to measure the effect of in‐office dispensing on the use of oral specialty drugs within urology group markets compared to markets without dispensing. Results Urology group characteristics associated with adoption of in‐office dispensing included large practice size (OR 2.9, 95% CI 1.2–6.5), increasing volume of men with advanced prostate cancer (OR 1.1 per 10‐patient increase, 95% CI 1.0–1.2), decreasing social vulnerability of the group's patient population (OR 0.81 per 0.1 unit increase, 95% CI 0.69–0.95), lower competition (OR 1.02 per 100 unit increase in the Herfindahl–Hirschman Index, 95% CI 1.0–1.1), and radiation vault ownership (OR 3.1, 95% CI 1.1–8.4). Compared with markets of urology groups that did not adopt in‐office dispensing, adopting markets experienced a significant increase in oral specialty drug prescriptions (adjusted difference‐in‐differences estimate, 46 prescriptions per 1000 men, p < 0.001). Conclusions Adoption of in‐office dispensing by independent urology groups increased oral specialty drug prescriptions for advanced prostate cancer within a group's market.

Introduction Men with newly diagnosed prostate cancer often appropriately elect for either immediate treatment or conservative management. The out‐of‐pocket costs they face vary by management strategy, with immediate treatment often superseding those of conservative management, potentially influencing patient decisions. We estimated the anticipated out‐of‐pocket costs that commercially insured men with newly diagnosed prostate cancer face and measured their association with immediate treatment. Methods From MarketScan, we identified men with newly diagnosed prostate cancer from 2010–2020. Separately, using actual out‐of‐pocket costs (summing deductible, copay, coinsurance) among patients undergoing arthroscopic meniscal repair (n = 383,187), we derived regression coefficients for patient‐level variables (e.g., health plan type) that inform their financial liability. We applied these coefficients to men with prostate cancer and estimated their predicted out‐of‐pocket costs, our main exposure. We sorted patients into quartiles and used logistic regression to calculate adjusted probabilities of immediate treatment (versus conservative management). Results We identified 58,206 men with prostate cancer and rank ordered them by predicted out‐of‐pocket cost. Approximately 12% of men had a predicted out‐of‐pocket cost of zero, and among those with non‐zero cost sharing, the median out‐of‐pocket cost was$350 (IQR: $ 275, $486). Across quartiles of predicted out‐of‐pocket costs, adjusted percentages of immediate treatment were in a narrow range between 77.8% (95% CI: 76.8%, 78.8%) for Quartile 1% and 78.6% (95% CI: 77.7%, 79.5%) for Quartile 4. Conclusion Among commercially insured men with prostate cancer, predicted out‐of‐pocket costs varied substantially. However, the choice of management, immediate treatment or conservative management, appears insensitive (i.e., inelastic) to patient anticipated financial liability.

Background Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear. Methods Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups. Results Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high‐risk of noncancer mortality (range of practice‐level rates of treatment for high: 57%–71% and very high: 41%–61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high‐risk of noncancer mortality (26% and 40%, respectively). Conclusions Variation among urology practices in use of treatment was highest for men with high and very high‐risk noncancer mortality. Practice characteristics explained a large share of this variation. Despite increasing use of conservative management for men with prostate cancer, there is tremendous variation in its uptake. This variation may be amplified by features of the delivery system, particularly among men with competing health risks, for whom treatment decisions are challenging. In this study, we find that variation in use of treatment was highest for men with high and very high‐risk noncancer mortality. Characteristics of the delivery system, measured at the level of the practice explained a large share of this variation.

Introduction Medicare Advantage (MA) managed care plans, now chosen by 51% of Medicare beneficiaries, are incentivized to constrain healthcare spending and utilization, a shift in financial incentives compared to Traditional Medicare's fee‐for‐service payment model. Beyond its primary beneficiaries, MA's mechanisms to constrain utilization may impact Traditional Medicare beneficiaries with prostate cancer through “spillover” effects on physician behavior. Methods From a 20% sample of Medicare claims, we identified patients diagnosed with prostate cancer from 2016 to 2019. We calculated MA penetration [MA beneficiaries/(Traditional Medicare and MA beneficiaries)] at the practice‐level. We assessed the relationship between practice‐level MA penetration and two measures of quality—potential overtreatment (i.e., treatment among those with > 75% noncancer mortality within 10 years of diagnosis) and confirmatory testing (repeat prostate biopsy, MRI, or genomic test)—using a multilevel logistic regression. We also assessed two measures of utilization, price standardized spending (i.e., global utilization) and overall treatment. Results We identified 41,092 patients. Median practice‐level MA penetration was 33% (IQR 23%–43%). Increasing practice‐level MA penetration was associated with increased odds of overall treatment among all Traditional Medicare beneficiaries (adjusted OR 1.03 (95% CI 1.01–1.05), p = 0.01, per 10% increase in MA penetration). However, MA penetration was not associated with our quality measures, potential overtreatment and confirmatory testing, or price‐standardized spending. Conclusions MA penetration at the urology practice‐level varies considerably. In men with prostate cancer, greater practice‐level MA penetration was associated with increased odds of treatment, but not overall utilization—even where it might influence quality. MA penetration at the urology practice‐level varies considerably. Higher MA penetration was associated with increased treatment, namely surgery, among patients with Traditional Medicare without changes in quality. Our work suggests that, in the context of prostate cancer, increasing MA penetration may not always be associated with constrained utilization among Traditional Medicare beneficiaries.