Brent K. Hollenbeck

Background: Biochemical recurrence (BCR) after radical prostatectomy for localized prostate cancer affects nearly one in four patients. Although androgen deprivation therapy (ADT) is used in this setting, its impact on metastatic disease outcomes remains unclear in contemporary population-based cohorts. Methods: We performed a retrospective cohort study using national Veterans Health Administration electronic health record and Central Cancer Registry data. Men undergoing radical prostatectomy between 2005 and 2015 were followed through 2019. We defined BCR as prostate-specific antigen (PSA) ≥0.20 ng/mL. We examined biochemically recurrent prostate cancer management and disease progression to castration resistance and metastatic disease. Results: Of 28,452 men with prostate cancer treated surgically, 7,912 (28%) developed BCR, with 10.5% developing metastatic disease (median follow-up, 110 months). Salvage ADT with or without radiotherapy was administered to 24% of patients. In adjusted models, salvage ADT use was associated with worse metastasis-free survival [adjusted hazard ratio (aHR), 1.96; 95% confidence interval (CI), 1.71–2.25] and increased castration-resistant therapy (aHR, 20.51; 95% CI, 14.48–29.04). Higher pathologic T stage, Gleason grade group, PSA, nodal involvement, and faster PSA doubling times were predictive of metastasis. Conclusions: In this large national cohort of men with BCR after surgery, most did not develop metastatic disease during nearly 10 years of follow-up, and one in four patients was treated with ADT. The association between ADT and adjusted outcomes likely reflects more aggressive disease among men selected for hormonal therapy. Impact: These findings underscore the importance of continued risk stratification refinement and management optimization for recurrent prostate cancer.

Introduction: Physician assistants (PAs) and nurse practitioners (NPs) are increasingly integrated into surgical teams. Although their training varies, existing literature often considers PAs and NPs interchangeable when assessing their impact. The aim of this study was to measure the effects of PA vs NP team composition on surgical outcomes in men with prostate cancer. Methods: We performed a retrospective cohort study using a 20% national sample of traditional Medicare beneficiaries undergoing radical prostatectomy between January 2010 and December 2020. The cohort included patients treated by independent urology groups with at least 1 PA or NP. Groups were stratified into 3 mutually exclusive categories: PA only, NP only, and both PA and NP. Generalized estimating equations measured the association between provider composition and surgical outcomes (ie, postoperative complications, prolonged length of hospitalization, and readmission within 90 days), adjusting for patient-level and group-level variables. Results: Over the study period, 424 independent urology groups with at least 1 PA or NP managed 8975 men undergoing radical prostatectomy. Patient age, race, and comorbidity were similar across team compositions. After adjustment, there was no association between team composition and complications, prolonged length of hospitalization, or readmission ( P > .05 for all outcomes). For example, complications occurred in 9.8%, 11.4% and 11.5% of men managed by the PA-only, NP-only, and both PA and NP groups, respectively. Conclusion: Among independent urology practices performing radical prostatectomy, outcomes did not differ between practices employing only PAs, only NPs, or both PAs and NPs. These findings suggest that employing PAs, NPs, or a combination is not associated with differences in postoperative outcomes.

Background: Independent physician groups may develop novel revenue streams through ownership of services (eg, radiology equipment, ambulatory surgery centers), supplementing fee-for-service income. This form of entrepreneurial activity and its implied incentives for utilization may influence physician behavior and patient management. We developed an index measuring entrepreneurial activity of independent urology groups and assessed its association with diagnostic testing in men with benign prostatic hyperplasia (BPH). Methods: We identified Traditional Medicare beneficiaries with BPH presenting to an independent urology group between 2017 and 2019. Using factor analysis of 9 unique ownership characteristics, we developed an index measuring entrepreneurial activity of independent urology groups (0–100-point scale). We assessed the relationship between the entrepreneurial index and 3 types of testing within 90 days of the initial new patient visit. At the patient level, we measured completion of a urinalysis (guideline-recommended), optional BPH testing (eg, ultrasound, cystoscopy), and testing unrelated to a BPH workup (ie, prostate-specific antigen, testosterone). Results: The urology group entrepreneurial index ranged from 0 to 97.2, with 20.6% (n=706/3430) of groups owning at least 1 ancillary service (ie, index >0). Among 49,285 men, an increasing entrepreneurial index (per 10-point increase) was associated with greater odds of undergoing a urinalysis (OR=1.13; 95% CI: 1.09–1.18; P P =0.002), and testing unrelated to BPH (OR=1.21; 95% CI: 1.15–1.27; P <0.001). Conclusions: Entrepreneurial activity in urology, through ownership of ancillary services, is concentrated in a subset of groups. Among men presenting with BPH, the index was associated with increased guideline-recommended, optional, and unrelated testing.

Background: Enrollment in Medicare Advantage (MA) has expanded rapidly and MA plans may rely on selective provider networks to manage utilization. While selective contracting has been described for primary care physicians, less is known about how MA networks are constructed for surgical specialists such as urologists, who manage common and costly conditions including prostate cancer. Methods: We conducted a national observational study using a 20% sample of Medicare fee-for-service claims (2016 to 2021) linked to 2021 MA network data. We identified 9,124 urologists practicing in hospital referral regions (HRR) with at least one MA network. Urologists were classified as in-network or out-of-network within each network-HRR and further categorized by network breadth, defined as narrow (<30% of local urologists) or broad. Outcomes were weighted by network enrollment and included urologist characteristics, prostate cancer-related and benign procedure volume, and two claims-based quality measures: use of MRI prior to prostate biopsy and consultation with radiation oncology after new prostate cancer diagnosis. Results: Among 9,124 urologists, 98% participated in at least one MA network. Across 7,516 network-HRR combinations, networks included a mean of 42 urologists (SD 47), with inclusion ranging from 9% to 100% of local urologists. Compared with the average urologist excluded from a network in the HRR, the average in-network urologist had a higher annual patient volume (107 vs 95, p<0.01), performed more prostate biopsies (3.18 vs. 2.89 per year, p<0.01), and performed more prostatectomies (0.48 vs. 0.35 per year, p<0.01), without differences in quality measures. The average urologist in narrow networks had a lower overall procedure volume but were more likely to perform prostatectomy among newly diagnosed patients (21% vs. 14%, p<0.01). Quality patterns were mixed, with higher MRI use prior to biopsy (15% vs. 12%, p<0.01) but lower radiation oncology consultation (50% vs. 54%, p<0.01). Among 12,735 network-county combinations, 1.8% failed to meet Medicare’s urologist adequacy standards. Conclusions: MA urology networks vary widely in breadth and composition. Narrow networks are associated with distinct prostate cancer management patterns that may have implications for access and quality, underscoring the need to assess specialty network adequacy standards.

The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating Accountable Care Organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a 2-sided risk model (ie, bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019, the Centers for Medicare and Medicaid Services launched the Pathways to Success program, which required shifting to a 2-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to reassess their potential shared savings vs losses, particularly in light of benchmarking methodology changes; reconsider perceived nonrevenue benefits; and reassess participation in the MSSP vs other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared savings and deliver accountable care.

Objective:To examine changes in the volume of patients with advanced prostate cancer and prescriptions for abiraterone and enzalutamide among urology practices with and without in-office di...

Financial incentives embedded in the US health care delivery system have the potential to influence physician behavior. Changes to the Medicare Physician Fee Sc

New biological agents, imaging tests, and devices are among the many sectors of technology that have an important role in health care delivery. These technologi

E17055 Background: Many men with prostate cancer will be exposed to ADT at some point during cancer survivorship. Unfortunately, ADT overuse in low-value scenarios is not uncommon (e.g., monotherapy in localized prostate cancer, biochemically-recurrent non-metastatic disease) resulting in more harms than benefits. We conducted an innovative survey study to unpack ADT overuse to inform behavior change and de-implementation strategies. Methods: Our survey used the Theoretical Domains Framework (TDF), and the Capability, Opportunity, Motivation – Behavior (COM-B) Model. The survey was fielded to the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on their likelihood of stopping ADT monotherapy in the case of a localized prostate cancer patient presenting to their office (yes/probably yes, probably no/no), and characterized Likert scale responses to 7 COM-B statements. We used multivariable logistic regression to identify associations between stopping ADT and COM-B responses across a dichotomized Likert scale of “strongly disagree/disagree/neutral” and “agree/strongly agree.”. Results: Our survey was completed by 84 respondents (13% response rate), with 27% indicating ‘probably no’/‘no’ to stopping low-value ADT monotherapy in the case of a localized prostate cancer patient presenting to their office. Our multivariable model identified 2 COM-B statements significantly associated with lower likelihood of stopping low-value ADT. Conclusions: Using an innovative, behavioral theory-informed survey, we identified that providers less likely to stop low-value ADT had greater concern about patient worry and were more interested in providing ADT recommendations consistent with peers, informing de-implementation strategy selection. Clinical trial information: MCT03579680.