NEJM Article Weighs in on IMRT Usage by Urologists

[Mr RADical]

Very interesting article being published tomorrow:

http://www.nejm.org/doi/pdf/10.1056/NEJMsa1201141

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[Gfunk6]

CONCLUSIONS
Urologists who acquired ownership of IMRT services increased their use of IMRT substantially more than urologists who did not own such services. Allowing urologists to self-refer for IMRT may contribute to increased use of this expensive therapy.

This surprises precisely no one.

The question is, what do you plan to do about it?

 

[medgator]

Nice follow up study to this one. Glad to see nejm keeping the gu community honest

http://www.nejm.org/doi/full/10.1056/NEJMsa0910784

Seriously though, this is really a grass is green and sky is blue kind of study. This is likely going to be ignored by the gu community, who will likely cry foul when they see the funding source at the end of the abstract

 

[Gfunk6]

Supported by an unrestricted educational research contract between the American Society for Radiation Oncology and Georgetown University.

No potential conflict of interest relevant to this article was reported.

Lol wut?

ASTRO needs to be careful. If they push this self-referral issue too hard, Legislators may conclude that physicians should not own Rad Onc hardware under any circumstances due to the possibility that doctors may actually be reimbursed fairly and not slaves to faceless bureaucrats. Don't throw the baby out with the bathwater.

 

[math]

Nice follow up study to this one. Glad to see nejm keeping the gu community honest

http://www.nejm.org/doi/full/10.1056/NEJMsa0910784

Seriously though, this is really a grass is green and sky is blue kind of study. This is likely going to be ignored by the gu community, who will likely cry foul when they see the funding source at the end of the abstract

AUA Responds to NEJM Article on IMRT Use:

The following statement has been released by the AUA:

"The American Urological Association (AUA) is committed to ensuring the delivery of appropriate, high-quality healthcare to men with prostate cancer and welcomes the opportunity to discuss these issues in a constructive manner. Unfortunately, given its inherent biases and flawed methodologies, Dr. Mitchell's article does not contribute to the discourse. Specifically, there are serious concerns about the author's selection of control groups that may not be representative of general practice trends. Prior studies using the SEER database (the data source considered most reflective of the United States as it includes roughly 25 percent of the U.S. population affected with cancer) have shown significant declines in the use of brachytherapy in the United States during the same time period, yet Dr. Mitchell's control groups fail to show any decline in brachytherapy use. As the methods used to select the control groups are poorly described, one cannot help but wonder whether Dr. Mitchell chose the control groups to arrive at results that were acceptable to the study's sponsors.

Limitations of the current study aside, the AUA supports initiatives that benefit patients by providing coordinated, continuous care and management of urologic disease, including IMRT. Earlier this year, the AUA Board of Directors adopted a set of guiding principles for in-office ancillary services to help guide its members. We believe that provision of ancillary services, such as IMRT, should be transparent and in the patient's best interest, with all treatment advice or referrals based on objective, medically acceptable and supported recommendations. Patients should be reassured that their urologic care will not be disrupted or penalized if they seek an alternate physician supplier or provider of IMRT.

In its June 2011 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended against limiting the Stark law exception for ancillary services, citing potential "unintended consequences, such as inhibiting the development of organizations that integrate and coordinate care within a physician practice." The General Accountability Office (GAO) recently issued a series of reports on self-referral and flatly rejected the recommendation to limit the Stark exception.

As a leading advocate for the specialty of urology, the AUA is committed to advancing research that will improve quality of care for patients with urologic disease. The AUA is developing a quality registry, AQUA, that is designed to provide data to help identify trends in the diagnosis and treatment of prostate cancer and eventual outcomes related to treatment options. The registry will be launched in 2014."

 

[medgator]

AUA Responds to NEJM Article on IMRT

Limitations of the current study aside, the AUA supports initiatives that benefit patients by providing coordinated, continuous care and management of urologic disease, including IMRT. Earlier this year, the AUA Board of Directors adopted a set of guiding principles for in-office ancillary services to help guide its members. We believe that provision of ancillary services, such as IMRT, should be transparent and in the patient's best interest, with all treatment advice or referrals based on objective, medically acceptable and supported recommendations. Patients should be reassured that their urologic care will not be disrupted or penalized if they seek an alternate physician supplier or provider of IMRT.

In its June 2011 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended against limiting the Stark law exception for ancillary services, citing potential "unintended consequences, such as inhibiting the development of organizations that integrate and coordinate care within a physician practice." The General Accountability Office (GAO) recently issued a series of reports on self-referral and flatly rejected the recommendation to limit the Stark exception.

As a leading advocate for the specialty of urology, the AUA is committed to advancing research that will improve quality of care for patients with urologic disease. The AUA is developing a quality registry, AQUA, that is designed to provide data to help identify trends in the diagnosis and treatment of prostate cancer and eventual outcomes related to treatment options. The registry will be launched in 2014."

Was just about to post that. Right on schedule. And of course they ripped the study apart. Honestly, I think the aua is right. There should be a disclosure in the waiting room of every urorads practice

The cat is out of the bag and I don't see astro getting rid of urorads at this point

 

[Reaganite]

Nice follow up study to this one. Glad to see nejm keeping the gu community honest

http://www.nejm.org/doi/full/10.1056/NEJMsa0910784

Seriously though, this is really a grass is green and sky is blue kind of study. This is likely going to be ignored by the gu community, who will likely cry foul when they see the funding source at the end of the abstract

In my opinion, the biggest problem with urorads is not that more patients get RT, but rather, we as rad oncs haven't taken a stronger initiative to control these set ups. Right now, we just allow ourselves to be someone else's bitc* and let the uros command how much we should make. I'd much rather see rad oncs striking these deals...bringing together uros, med oncs, surgeons etc. in a model that delivers good patient care but also makes us rich.

Also, regarding closure of the in-office ancillary exemption, don't think that's gonna mean more patients for your private practice. These uros will rediscover RP or their practice is gonna be bought out by the hospital who can still legally incentivize them.

I would also argue that having uros sending more patients for RT and doing fewer RPs isn't necessarily a bad thing. I think RT is a better option than surgery. Granted, uros have a profit motive, but an indirect consequence of this is that patients who would have been pushed to surgery are now getting RT. We are probably also treating a lot more positive margins/ECE after RP (this used to be anethema to urologists), and I bet a lot fewer high risk patients are getting RPs. I actually locum for a urorads deal occasionally, and we treat tons of positive margins after surgery. For those who deal with urologists who aren't incentivized you know how hard it is to get them to send the positive margins. In the end, it would be interesting to know how much of that increased volume of referrals to RT are patients who should have received RT in the first place.

 

[radiaterMike]

How many of those patients with positive margins should have never had surgery in the first place ?

 

[ramsesthenice]

How many of those patients with positive margins should have never had surgery in the first place ?

Probably a lot. Above several people have gotten on urologists for using reimbursment to guide treatment. That sucks but every field, including radiation oncologists (cough, post IMRT brachy boost, cough) does that. Doesn't make it right, but makes it harder to throw stones.

However, what really burns me that several of our uro guys do is they really believe optimal treatment for high risk PC is trimodality therapy. I have personally heard them tell patients "if we start with surgery then we can still do radiation and drugs for a real good chance to cure this, but if we start with radiation you can't get the surgery and we will have less options for cure." That is absolute horse crap and they are setting people up for the morbidity of surgery and radiation with not a shred of evidence for increased control. It also puts me in an akward situation because then I have to find a PC way of contradicting the surgeons. I hate it.

 

[ramsesthenice]

I don't see how post-pelvis (IMRT or 3DCRT) brachytherapy is in the same light of reimbursement driven. It might pay a bit more but the time that goes into it is significantly more. Furthere, there is a fair amount of quality data supporting EBRT + Brachytherapy to the point that its included on the standard arms of RTOG Trials with LDR or HDR boost. I don't see that in the same light as urologists who stopped giving hormones when reimbursement went down and passed the buck or the guys who build uroroads centers for the IMRT charge.

I can agree with you that it has its place, especially in select patients. We certainly use it in some patients where there are technical advantages from time to time. I also don't put it in the same ball park as stopping hormones etc.

But I do think reimbursements helped drive that movement. It is substantially more than a standard course of IMRT. And there are centers that almost exclusively treat with brachy boost and did before the data matured. I have a hard time believing reimbursment had nothing to do with their decision to treat this way. It worked out, and Im not saying they are wrong and agree that now we have a feesable alternative for cases that need it.

 

[oncology2020]

Lol wut?

ASTRO needs to be careful. If they push this self-referral issue too hard, Legislators may conclude that physicians should not own Rad Onc hardware under any circumstances due to the possibility that doctors may actually be reimbursed fairly and not slaves to faceless bureaucrats. Don't throw the baby out with the bathwater.

exactly..someone needs to tell ASTRO leadership that they're actually going to end up doing more harm for the field of rad onc if they keep fighting this the way they currently are..ASTRO clearly setting the field up for more government regulation..what ASTRO is ignoring is that if they get their wish the government isnt going to selectively regulate just urology's use of rad therapy but also rad oncs..such a change would proportionally hurt the field of rad onc much more than urology

rad oncs need to stop being technicians and actually be more aggressive in offering these services themselves instead of letting urologists take the lead..thats what ASTRO should be promoting to its members instead of trying to take this to the media or government

how the authors can state that there is "no conflict of interest" when being funded by ASTRO is boggling to the mind

 

[Reaganite]

exactly..someone needs to tell ASTRO leadership that they're actually going to end up doing more harm for the field of rad onc if they keep fighting this the way they currently are..ASTRO clearly setting the field up for more government regulation..what ASTRO is ignoring is that if they get their wish the government isnt going to selectively regulate just urology's use of rad therapy but also rad oncs..such a change would proportionally hurt the field of rad onc much more than urology

rad oncs need to stop being technicians and actually be more aggressive in offering these services themselves instead of letting urologists take the lead..thats what ASTRO should be promoting to its members instead of trying to take this to the media or government

how the authors can state that there is "no conflict of interest" when being funded by ASTRO is boggling to the mind

Totally agree. Here's the other thing: closing the in office ancillary exemption won't necessarily stop urology self-referral. There are other stark exemptions that can be exploited to self-refer. For example, some urology groups are now buying radiation centers and leasing the center to a rad onc. As long as the lease is fair market value and the physician owners are not reimbursed on a per patient basis, they can refer to the center and make a profit on the lease. That profit can actually be quite good. Not necessarily urorad good, but in certain circumstances can still bring 6 figures per doc. It's totally stark kosher and would not be blocked if they close the in office exemption.

 

[medgator]

What options does ASTRO have realistically that doesn't specifically target urorads? It will be tough legislatively to target just urorads and so ASTRO is plotting a course that though not perfect is at least bringing the issue to light which is a big step.

The train has left the station imo. I think disclosure laws should be created/strengthened just like when a practice owns an imaging center. Urorads practices should Disclose it to the patient and let them know there are alternative places. If nothing else, the disclosure will certainly make an educated patient examine the recommendation for imrt more closely

We own diagnostic imaging in my practice and I never attempt to force/steer a patient to our center for imaging. Should be no different with rt

 

[ramsesthenice]

I don't put this discussion in the same realm as what urorads is doing, we are talking treatment options that are validated versus offering patients only 1 option.

We are in 100% agreement here. They are not in the same relm. I was referring to something much more specific that really is not that important. For once, I was trying to be be somewhat fair to the uro side by implying we were not 100% innocent ourselves in all situations.