Keating Nancy L, Huskamp Haiden A, Schrag Deborah, McWilliams John M, McNeil Barbara J, Landon Bruce E, Chernew Michael E, Normand Sharon-Lise T
Department of Health Care Policy, Harvard Medical School.
Division of General Internal Medicine.
Med Care. 2018 Jan;56(1):69-77. doi: 10.1097/MLR.0000000000000840.
Technological advances can improve care and outcomes but are a primary driver of health care spending growth. Understanding diffusion and use of new oncology therapies is important, given substantial increases in prices and spending on such treatments.
Examine diffusion of bevacizumab, a novel (in 2004) and high-priced biologic cancer therapy, among US oncology practices during 2005-2012 and assess variation in use across practices.
Population-based observational study.
A total of 2329 US practices providing cancer chemotherapy.
Random 20% sample of 236,304 Medicare fee-for-service beneficiaries aged above 65 years in 2004-2012 undergoing infused chemotherapy for cancer.
Diffusion of bevacizumab (cumulative time to first use and 10% use) in practices, variation in use across practices overall and by higher versus lower-value use. We used hierarchical models with practice random effects to estimate the between-practice variation in the probability of receiving bevacizumab and to identify factors associated with use.
We observed relatively rapid diffusion of bevacizumab, particularly in independent practices and larger versus smaller practices. We observed substantial variation in use; the adjusted odds ratio (95% confidence interval) of bevacizumab use was 2.90 higher (2.73-3.08) for practices 1 SD above versus one standard deviation below the mean. Variation was less for higher-value [odds ratio=2.72 (2.56-2.89)] than lower-value uses [odds ratio=3.61 (3.21-4.06)].
Use of bevacizumab varied widely across oncology practices, particularly for lower-value indications. These findings suggest that interventions targeted to practices have potential for decreasing low-value use of high-cost cancer therapies.
技术进步可改善医疗服务及结果，但也是医疗支出增长的主要推动因素。鉴于此类治疗的价格和支出大幅增加，了解新型肿瘤治疗方法的传播和使用情况很重要。
研究2005 - 2012年期间贝伐单抗（一种2004年上市的新型高价生物癌症治疗药物）在美国肿瘤医疗实践中的传播情况，并评估各医疗实践中使用情况的差异。
基于人群的观察性研究。
美国2329家提供癌症化疗的医疗实践机构。
2004 - 2012年期间年龄在65岁以上、接受癌症静脉化疗的236304名医疗保险按服务收费受益人的20%随机样本。
贝伐单抗在各医疗实践中的传播情况（首次使用和10%使用率的累积时间），各医疗实践总体及高价值与低价值使用情况的使用差异。我们使用具有医疗实践随机效应的分层模型来估计接受贝伐单抗概率的医疗实践间差异，并确定与使用相关的因素。
我们观察到贝伐单抗的传播相对较快，尤其是在独立医疗实践机构以及规模较大与较小的医疗实践机构中。我们观察到使用情况存在显著差异；与平均水平相差一个标准差以上的医疗实践机构使用贝伐单抗的调整优势比（95%置信区间）比低于平均水平一个标准差的机构高2.90倍（2.73 - 3.08）。高价值使用情况的差异[优势比 = 2.72（2.56 - 2.89）]小于低价值使用情况[优势比 = 3.61（3.21 - 4.06）]。
贝伐单抗在肿瘤医疗实践中的使用差异很大，尤其是在低价值适应症方面。这些发现表明，针对医疗实践机构的干预措施有可能减少高成本癌症治疗的低价值使用情况。
