了解早期膀胱癌患者治疗强度的差异。

Understanding the variation in treatment intensity among patients with early stage bladder cancer.

机构信息

Robert Wood Johnson Foundation Clinical Scholar Program, University of Michigan, Ann Arbor, Michigan 48105-2967, USA.

出版信息

Cancer. 2010 Aug 1;116(15):3587-94. doi: 10.1002/cncr.25221.

DOI:10.1002/cncr.25221

PMID:20564128

Abstract

BACKGROUND

Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care.

METHODS

By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n=18,276). The primary outcome was the intensity of initial treatment that patients received, as measured by all Medicare payments for bladder cancer incurred in the 2 years after diagnosis. Multilevel models were fitted to partition the variation in treatment intensity attributable to patient versus provider factors, and the potential savings to Medicare from reducing the physician contribution were estimated.

RESULTS

Provider factors accounted for 9.2% of the variation in treatment intensity. Increasing provider treatment intensity did not correlate with improved cancer-specific survival (P=.07), but it was associated with the subsequent receipt of major interventions, including radical cystectomy (P<.001). If provider-level variation was reduced and clinical practice was aligned with that of physicians who performed in the 25th percentile of treatment intensity, then total payments made for the average patient could be lowered by 18.6%, saving Medicare $18.7 million annually.

CONCLUSIONS

The current results indicated that a substantial amount of the variation in initial treatment intensity for early stage bladder cancer is driven by the physician. Furthermore, a more intensive practice style was not associated with improved cancer-specific survival or the avoidance of major interventions. Therefore, interventions aimed at reducing between-provider differences may improve the value of cancer care.

摘要

背景

鉴于早期膀胱癌的最佳治疗方法存在不确定性，医生在处理这种疾病时的方法存在差异。本文作者将癌症登记数据与医疗索赔数据相关联，以确定变异的来源和提高癌症治疗价值的机会。

方法

利用 Surveillance, Epidemiology, and End Results-Medicare 数据库（1992-2005 年）中的数据，提取了早期膀胱癌患者（n=18276）。主要结果是患者接受的初始治疗强度，通过诊断后 2 年内所有 Medicare 支付的膀胱癌费用来衡量。采用多水平模型将治疗强度的变异性归因于患者和提供者因素，并估计从减少医生贡献中为 Medicare 节省的潜在费用。

结果

提供者因素占治疗强度变异性的 9.2%。增加提供者的治疗强度与癌症特异性生存的改善没有相关性（P=.07），但与随后的主要干预措施的接受有关，包括根治性膀胱切除术（P<.001）。如果降低提供者层面的变异并使临床实践与治疗强度排在第 25 百分位的医生一致，那么平均每位患者的总支付费用可降低 18.6%，每年为 Medicare 节省 1870 万美元。