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A review of medical claims for 11,674 elderly patients treated for localized prostate cancer showed that only about one-third met a quality-of-care guideline calling for a visit to a radiation oncologist twice during the year following external beam radiotherapy.
Most patients did receive follow-up care, however. About 68% returned for one visit with a radiation oncologist. When the investigators looked at visits to a radiation oncologist or a urologist, they found 80% of men had two follow-up visits and 91% had one visit.
"This suggests that patients aren't simply being lost to follow-up when they've had radiation therapy, but rather that radiation oncologists are likely to see their patients at least once. But then there is some kind of shared-care-model follow-up, in which the patient is also seen by perhaps the referring urologist after radiotherapy," Dr. Justin E. Bekelman said in presenting the findings.
Why physicians are not adhering to the guideline and how this variation may affect clinical outcomes merits study, said Dr. Bekelman, a radiation oncology resident at Memorial Sloan-Kettering Cancer Center in New York. "Coordination of care between urologists and radiation oncologists is important," he said, noting that radiation oncologists who see their patients only once after treatment "may miss opportunities to assess and manage the toxicity of radiotherapy."
Similarly, Dr. Badrinath R. Konety said in a discussion of the study that lower-than-recommended follow-up by radiation oncologists "could lead to overuse of radiation therapy."
Radiation oncologists tend to underestimate treatment effects, said Dr. Konety, a urologist at the University of California, San Francisco. "It is important that the patients who get whole pelvic radiation or any kind of radiation follow up with the radiation oncologists so they are aware of the outcomes."
Dr. Bekelman and his coinvestigators at Memorial Sloan-Kettering analyzed linked data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database and Medicare claims for patients aged 65 and older who were diagnosed with clinically localized prostate cancer and treated with primary external beam radiotherapy. Patients who had brachytherapy or a combination of EBRT and brachytherapy were excluded.
The study included 23,018 patients diagnosed from 1994 to 2002, but Dr. Bekelman presented data on only 11,674 men diagnosed during 2000-2002. The median age was 73 years. Three-quarters of the men lived in urban areas.
Just 14% were black or Hispanic. Treatment was provided at teaching facilities for 45% of the patients, at community facilities for 25%, and at stand-alone centers for 30%.
The study assessed how well delivery of care corresponded to five EBRT-applicable quality-of-care indicators among those endorsed by a panel of experts convened by the RAND Health Science Program (J. Clin. Oncol. 2003;21:1928-36).
Adherence was generally high for the technical measures: seeing a board-certified radiation oncologist (85% of patients), use of conformal treatment planning (85%), use of high-energy photons greater than 10 millivolts (75%), and use of custom immobilization (97%). But only 34% of patients completed two follow-up visits with the treating physician.
The investigators also devised a composite measure comprising conformal radiotherapy, high-energy photons, and custom immobilization.
Overall, adherence to this sixth indicator was 64%. The Detroit-area SEER registry had the highest adherence with the composite measure (89%); Connecticut had the lowest (44%). Adherence was highest in teaching hospitals (75%), followed by community hospitals (61%) and stand-alone facilities (51%).
Analysis by census tract income of the patients' counties of residence showed that the adherence rate was 62% for the bottom two quartiles, 64% for the third quartile, and 70% for the fourth quartile (incomes above $65,000).
Study limitations included possible variation in care or coding quality, lack of information on radiotherapy doses, and inability to link variations in care to patient outcomes, Dr. Bekelman noted.
Also, failure to bill for and document follow-up visits could have contributed to observed variation in adherence, he noted.
He and his colleagues recommended establishment of a population-based program to track quality measures including radiotherapy doses, posttreatment prostate-specific antigen levels, and common radiotherapy toxicities).
The investigators also called on the American Urological Association and the American Society for Therapeutic Radiology and Oncology to develop a consensus statement that would establish "explicit recommendations for coordinated follow-up of radiotherapy patients."
Bekelman J.E. Trends in the quality of external beam radiotherapy for elderly men with localized prostate cancer. Abstract 6507.
Commentary |
Health care quality has been the focus of a great deal of scholarly effort in the past decade. In 2007, the quality movement will arrive at the front door of nearly all clinicians, as the Centers for Medicare and Medicaid rolls out its Physician Quality Reporting Initiative. In the future, quality cannot be claimed—it must be demonstrated (or so the thinking goes). This SEER database survey finds that only one-third of patients treated with external beam radiotherapy completed two follow-up visits with the treating radiation oncologist. The authors point out that this "falls short" of the guideline enumerated by a panel of experts. The implication is that this is a bad thing. Is it? Our practice includes a large percentage of men who live several hours from the treatment center. We typically see them once a year, sharing follow-up care with the local urologist who made the initial diagnosis. According to the RAND criteria, that is "falling short." Should we be concerned? We should point out that in the small percentage of men with significant morbidity, we may choose to see them more frequently. A closer look at the data reveals that 80% of men are seen twice when visits to a urologist or a radiation oncologist are counted. In our view, this shared-care model is an efficient use of resources. It allows patients to be seen by the two professionals most intimately involved in the diagnosis and treatment of their cancer. It is an opportunity for the disciplines to collaborate by sharing information and knowledge. The authors are to be congratulated for pointing out a weakness of the study design: the inability to link follow-up variations with outcomes. Unless there are outcomes (patient satisfaction, etc.) that indicate the shared care model is inferior, however, we will continue our current practice. — W. Robert Lee, M.D., and Judd W. Moul, M.D.
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