Department of Urologic Surgery, University of Minnesota, 420 Delaware St SE, MMC 394, Minneapolis, MN 55455, USA.
J Natl Cancer Inst. 2010 Dec 15;102(24):1826-34. doi: 10.1093/jnci/djq417. Epub 2010 Dec 3.
Use of androgen suppression therapy (AST) in prostate cancer increased more than threefold from 1991 to 1999. The 2003 Medicare Modernization Act reduced reimbursements for AST by 64% between 2004 and 2005, but the effect of this large reduction on use of AST is unknown.
A cohort of 72,818 men diagnosed with prostate cancer in 1992-2005 was identified from the Surveillance, Epidemiology, and End Results database. From Medicare claims data, indicated AST was defined as 3 months or more of AST in the first year in men with metastatic disease (n = 8030). Non-indicated AST was defined as AST given without other therapies such as radical prostatectomy or radiation in men with low-risk disease (n = 64,788). The unadjusted annual proportion of men receiving AST was plotted against the median Medicare AST reimbursement. A multivariable model was used to estimate the odds of AST use in men with low-risk and metastatic disease, with the predictor of interest being the calendar year of the payment change. Covariates in the model included age in 5-year categories, clinical tumor stage (T1-T4), World Health Organization grade (1-3, unknown), Charlson comorbidity (0, 1, 2, ≥ 3), race, education, income, and tumor registry site, all as categorical variables. The models included variations in the definition of AST use (≥ 1, ≥ 3, and ≥ 6 months of AST). All statistical tests were two-sided.
AST use in the low-risk group peaked at 10.2% in 2003, then declined to 7.1% in 2004 and 6.1% in 2005. After adjusting for tumor and demographic covariates, the odds of receiving non-indicated primary AST decreased statistically significantly in 2004 (odds ratio [OR] = 0.70, 95% confidence interval = 0.61 to 0.80) and 2005 (OR = 0.61, 95% confidence interval = 0.53 to 0.71) compared with 2003. AST use in the metastatic disease group was stable at 60% during the payment change, and the adjusted odds ratio of receiving AST in this group was unchanged in 2004-2005.
In this example of hormone therapy for prostate cancer, decreased physician reimbursement was associated with a reduction in overtreatment without a reduction in needed services.
从 1991 年到 1999 年，雄激素抑制治疗（AST）在前列腺癌中的使用增加了两倍多。2003 年《医疗保险现代化法案》在 2004 年至 2005 年期间将 AST 的报销减少了 64%，但这种大幅减少对 AST 使用的影响尚不清楚。
从监测、流行病学和最终结果数据库中确定了 1992-2005 年期间被诊断患有前列腺癌的 72818 名男性组成的队列。从医疗保险索赔数据中，转移性疾病（n=8030）男性中 AST 持续 3 个月或以上被定义为指示性 AST。无指示性 AST 定义为在低危疾病（n=64788）男性中没有接受其他治疗（如根治性前列腺切除术或放疗）的 AST。根据 Medicare AST 报销中位数绘制接受 AST 的男性比例的年度图。使用多变量模型来估计低危和转移性疾病男性使用 AST 的几率，感兴趣的预测因素是支付变化的日历年。模型中的协变量包括年龄的 5 年分类、临床肿瘤分期（T1-T4）、世界卫生组织分级（1-3，未知）、Charlson 合并症（0、1、2、≥3）、种族、教育程度、收入和肿瘤登记处地点，均为分类变量。该模型还包括 AST 使用定义的变化（≥1、≥3 和≥6 个月的 AST）。所有统计检验均为双侧。
低危组的 AST 使用比例在 2003 年达到 10.2%的峰值，然后在 2004 年下降至 7.1%，在 2005 年下降至 6.1%。在调整肿瘤和人口统计学协变量后，与 2003 年相比，2004 年（比值比[OR] = 0.70，95%置信区间= 0.61-0.80）和 2005 年（OR = 0.61，95%置信区间= 0.53-0.71）接受非指示性原发性 AST 的几率统计学显著降低。在支付变更期间，转移性疾病组的 AST 使用率稳定在 60%，该组接受 AST 的调整后比值比在 2004-2005 年没有变化。
在这种前列腺癌激素治疗的例子中，医生报销减少与过度治疗减少而必要服务未减少相关。
