Brachytherapy After Breast-Conserving Surgery More Common at For-Profit Hospitals
NEW YORK (Reuters Health) – For-profit hospitals are more likely to over-treat older women with breast cancer, a new study suggests.
Using data from Medicare beneficiaries, researchers found brachytherapy after breast-conserving surgery – more expensive than the standard whole breast irradiation – is more commonly performed at for-profit hospitals than at other hospitals.
“Economic incentives can have a profound impact on cancer care,” Dr. Cary P. Gross from Yale Cancer Center and Yale University School of Medicine in New Haven, Connecticut told Reuters Health by email. “It is critical to put patients in the driver’s seat – provide them with the best available information on the risks and benefits of treatment, the financial incentives of their providers, and let them make informed decisions.”
Breast brachytherapy for older women is a newer therapy with scant comparative effectiveness data and higher reimbursements compared with standard whole breast irradiation, and some data suggest that the harms of brachytherapy may actually outweigh the benefits, the researchers note.
Dr. Gross and colleagues used national Medicare data to assess the relation between for-profit hospital ownership and the adoption of brachytherapy among 35,118 Medicare beneficiaries (ages 66-94 years) with breast cancer receiving breast-conserving surgery (BCS).
Nearly three-quarters of the women (72%) received adjuvant radiotherapy, including 22,496 who underwent BCS at not-for-profit hospitals and 2816 who underwent BCS at a for-profit hospital.
Overall, 15.7% of women who received radiotherapy received brachytherapy. Women at for-profit hospitals were 50% more likely than women at not-for-profit hospitals to receive brachytherapy, and women who received BCS at higher surgical volume hospitals were twice as likely to receive brachytherapy as women treated at lower volume hospitals.
Among the oldest women (those for whom a benefit of radiotherapy is least likely), the likelihood of receiving any radiotherapy was 22% higher at for-profit hospitals than at not-for-profit hospitals (58.9% vs. 53.9%, respectively; p=0.03), and the likelihood of receiving brachytherapy was 66% higher at for-profit hospitals (12.4% vs. 8.0%; p=0.003).
In contrast, there was no association between hospital ownership and the overall use of radiotherapy.
“Thus, older women received more aggressive care at for-profit hospitals, despite being less likely to benefit from radiotherapy,” the researchers conclude.
“We need to move away from a payment scheme that favors the use of new and unproven interventions,” Dr. Gross said. “It’s critical to support innovation, but the way to do that is not to haphazardly reimburse at high levels just because an intervention is ‘new.'”
“First you build a better mousetrap,” Dr. Gross said. “Then you prove it’s better. Then you might charge more for it. We seem to be forgetting that middle step. Investment in comparative effectiveness research now can yield tremendous rewards later, in terms of knowledge about which treatments work best, and savings by not overpaying for ineffective therapies.”
Dr. Gross clarified, “I’m not saying that brachytherapy is necessarily ineffective – but we just need to determine what is effective and what isn’t.”
Dr. Benjamin D. Smith from The University of Texas MD Anderson Cancer Center in Houston told Reuters Health by email, “Health services research studies such as this are critically important to help illuminate our understanding of cancer care as it is actually delivered in the US.”
“The insights generated can be used by policymakers to develop ideas to improve care,” he added.
“Reimbursement structures based more on results and quality than procedures accomplished would likely help to bend the cost curve and discourage use of costly treatments,” Dr. Smith said.
“It is important to consider and understand how the health care milieu impacts patient treatments,” Dr. Smith concluded. “It is likely that many factors extrinsic to the patient and her cancer influence the type of treatment she receives. Being cognizant of these factors can help make us better physicians and also help to promote a more patient-centered, rather than physician- or hospital-centered, approach to patient care.”
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