Journal of the National Cancer Institute Advance Access originally published online on April 7, 2009
JNCI Journal of the National Cancer Institute 2009 101(8):571-580; doi:10.1093/jnci/djp039
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© The Author 2009. Published by Oxford University Press.
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Provider Treatment Intensity and Outcomes for Patients With Early-Stage Bladder Cancer
Affiliations of authors: Division of Oncology, Department of Urology (BKH, JEM), Division of Health Services Research, Department of Urology (BKH, ZY, RLD, JEM), Department of Surgery (JDB), and Michigan Surgical Collaborative for Outcomes Research and Evaluation (BKH, JDB), University of Michigan Health System, Ann Arbor, MI
Correspondence to: Brent K. Hollenbeck, MD, MS, Division of Oncology, Department of Urology, University of Michigan Health System, 1500 East Medical Center Dr, TC 3875, Ann Arbor, MI 48109 (e-mail: bhollen{at}umich.edu).
Background: Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes.
Methods: We used the Surveillance, Epidemiology, and End Results–Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided.
Results: The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High–treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low–treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low– vs high–treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high–treatment intensity providers than by low–treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02).
Conclusions: Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high–treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.
| CONTEXT AND CAVEATS Prior knowledge Little is known about how urologists vary in the aggressiveness with which they treat patients during the first 2 years after a diagnosis of early-stage bladder cancer. Study design Linked Surveillance, Epidemiology, and End Results (SEER)–Medicare data were used to identify patients who were diagnosed with early-stage bladder cancer and the physician primarily responsible for each patient's care and to examine associations between initial treatment intensity and subsequent outcomes, including survival. Contribution Urologists who provided the most aggressive treatment had, on average, more than double the Medicare expenditures per patient compared with those who provided the least aggressive treatment, but their patients did not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions. Implications It may be possible to eliminate unnecessary procedures and thus reduce the costs of caring for patients with early-stage bladder cancer. Limitations The use of observational data did not allow the authors to account for unmeasured differences between patients in different treatment intensity groups. The use of SEER–Medicare data limits the generalizabity of the finding to patients older than 65 years. From the Editors
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Manuscript received November 5, 2008; revised January 9, 2009; accepted February 2, 2009.
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J Natl Cancer Inst 2009 101: 539.
J Natl Cancer Inst 2009 101: 539.
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