Geisel School of Medicine, Hanover, New Hampshire.
Geisel School of Medicine, Hanover, New Hampshire.
Int J Radiat Oncol Biol Phys. 2022 Sep 1;114(1):39-46. doi: 10.1016/j.ijrobp.2022.01.044. Epub 2022 Feb 9.
Radiation utilization for breast cancer and metastatic bone disease varies in modality, fractionation, and cost, despite evidence demonstrating equal effectiveness and consensus recommendations such as Choosing Wisely that advocate for higher value care. We assessed whether the Oncology Care Model (OCM), an alternative payment model for practices providing chemotherapy to patients with cancer, affected the overall use and value of radiation therapy in terms of Choosing Wisely recommendations.
We used Centers for Medicare & Medicaid Services administrative data to identify beneficiaries enrolled in traditional fee-for-service Medicare who initiated chemotherapy episodes at OCM and propensity-matched comparison practices. Difference-in-difference (DID) analyses evaluated the effect of OCM on overall use of postoperative radiation for breast cancer, use of intensity modulated radiation therapy and hypofractionation for breast cancer, and fractionation patterns for treatment of metastatic bone disease from breast or prostate cancer. We performed additional analyses stratified by the presence or absence of a radiation oncologist in the practice.
Among 27,859 postoperative breast cancer episodes, OCM had no effect on overall use of radiation therapy after breast surgery (DID percentage point difference = 0.4%; 90% confidence interval [CI], -1.7%, 2.4%) or on use of intensity modulated radiation therapy in this setting (DID = -0.6; 90% CI, -3.1, 2.0). Among 19,366 metastatic bone disease episodes, OCM had no effect on fractionation patterns for palliation of bone metastases (DID for ≤10 fractions = -1.1%; 90% CI, -2.6%, 0.4% and DID for single fraction = -0.2%; 90% CI, -1.9%, 1.6%). Results were similar for practices with and without a radiation oncologist. We did not evaluate the effect of OCM on hypofractionated radiation after breast-conserving surgery owing to evidence of differential baseline trends.
OCM had no effect on use of radiation therapy after breast-conserving surgery for breast cancer or on fractionation patterns for metastatic bone disease. Future payment models directly focused on radiation oncology providers may be better poised to improve the value of radiation oncology care.
尽管有证据表明同等疗效和诸如“明智选择”等共识建议主张提供更高价值的护理，但乳腺癌和转移性骨病的放射治疗在方式、分割和费用上存在差异。我们评估了肿瘤治疗模式（Oncology Care Model，OCM）——一种为接受化疗的癌症患者提供服务的实践的替代支付模式，是否会根据“明智选择”建议，影响放射治疗的整体使用和价值。
我们使用医疗保险和医疗补助服务中心（Centers for Medicare & Medicaid Services）的行政数据，确定参加传统按服务收费医疗保险并在 OCM 和倾向匹配比较实践中开始化疗的受益人的数据。差异（Difference-in-difference，DID）分析评估了 OCM 对乳腺癌术后放射治疗的整体使用、乳腺癌调强放疗和适形分割的使用，以及乳腺癌或前列腺癌转移性骨病治疗的分割模式的影响。我们对实践中是否存在放射肿瘤学家进行了分层分析。
在 27859 例乳腺癌术后病例中，OCM 对乳房手术后整体放射治疗的使用没有影响（DID 百分点差异=0.4%；90%置信区间[CI]，-1.7%，2.4%），也没有影响这种情况下的调强放疗的使用（DID=-0.6；90%CI，-3.1，2.0）。在 19366 例转移性骨病病例中，OCM 对姑息性骨转移的分割模式没有影响（DID≤10 个分数=-1.1%；90%CI，-2.6%，0.4%和 DID 为单剂量=-0.2%；90%CI，-1.9%，1.6%）。对于有或没有放射肿瘤学家的实践，结果是相似的。由于基线趋势存在差异，我们没有评估 OCM 对保乳手术后短程放疗的影响。
OCM 对乳腺癌保乳手术后的放射治疗使用或转移性骨病的分割模式没有影响。未来直接针对放射肿瘤学提供者的支付模式可能更有能力提高放射肿瘤学护理的价值。
