Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
J Clin Oncol. 2020 Dec 1;38(34):4055-4063. doi: 10.1200/JCO.20.00890. Epub 2020 Oct 6.
Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending.
We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period.
The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; = .07) over the 6-month episode period.
P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.
肿瘤医生开具的癌症药物处方存在最大的实践差异，也是癌症治疗费用最大的部分。我们评估了一家全国性商业保险公司持续进行的肿瘤学支付绩效（P4P）计划与循证癌症药物处方和支出变化之间的关联。
我们使用涵盖 6.7%美国成年人的行政索赔数据进行了一项观察性差异差异研究。我们利用 P4P 计划的地理交错、随时间变化的推出，模拟了一个阶梯式楔形研究设计。我们纳入了 2013 年至 2017 年间由 1867 名参与肿瘤医生为患有乳腺癌、结肠癌或肺癌的年龄在 18 岁或以上的患者开具的癌症药物治疗方案的患者。暴露是一个随时间变化的二分变量，对于接受 P4P 计划后开具癌症药物治疗方案的患者为 1。主要结局是患者的药物治疗方案是否为方案认可的循证治疗方案。我们还评估了 6 个月发病期内的支出。
P4P 计划与证据为基础的治疗方案的处方率从干预前的 57.1%增加到干预期间的 62.2%，差异为+5.1 个百分点（95%置信区间，3.0 个百分点至 7.2 个百分点；<.001）。P4P 计划还与癌症药物支出增加 3339 美元（95%置信区间，1121 美元至 5557 美元；=.003）和患者自付费用增加 253 美元（95%置信区间，100 美元至 406 美元；=.001）相关，但在 6 个月发病期内总医疗保健支出没有显著变化（2772 美元；95%置信区间，-181 美元至 5725 美元；=.07）。
P4P 计划可能在增加循证癌症药物处方方面有效，但不一定能节省成本。
