Chicago, IL—For-profit hospitals are more likely than their nonprofit counterparts to treat elderly patients with breast cancer with an expensive form of radiotherapy—despite lacking evidence of its benefit, researchers from the Yale Cancer Outcomes, Public Policy and Effectiveness Research Center reported at ASCO 2013.
“We wanted to evaluate how hospital ownership affects the adoption of technology,” said Sounok Sen, BSE, MD, Yale School of Medicine, New Haven, CT. “We found that Medicare beneficiaries receiving breast-conserving surgery at for-profit hospitals disproportionately received brachytherapy….While brachytherapy has been rapidly adopted, it costs twice as much as external beam radiotherapy and is reimbursed more substantially,” Dr Sen pointed out.
“While the long-term risks and benefits of brachytherapy are still being defined,” he added, “payers may want to reconsider the wisdom of reimbursement policies that promote the rapid adoption of newer and unproven cancer therapies without incorporating rigorous assessments.”
Although for-profit and nonprofit hospitals may have financial incentives, “for-profit providers may have additional incentives to fulfill their fiduciary responsibilities and their mission to shareholders,” Dr Sen suggested. “This may affect the pattern of care as it relates to the adoption of new or higher-margin technology.”
“The literature has suggested that financial gain exerts a powerful influence on the individual and the institution,” he added.
Radiotherapy a “Salient Example”
Dr Sen and colleagues evaluated the use of brachytherapy, a new radiotherapy modality in breast cancer, against recent evidence indicating that radiotherapy of any form is not always necessary in some patient subsets.
Specifically, the Cancer and Leukemia Group B (CALGB) 9343 trial showed that in women aged ≥70 years with low-risk breast cancer, external beam radiotherapy did not improve overall survival or disease-free survival at 10 years, although it did reduce local or regional recurrences. The guidelines now therefore state that radiotherapy can safely be eliminated in this population.
New radiotherapy modalities— specifically brachytherapy—have some advantages over older approaches, including shorter length of treatment and reduced toxicity. Brachytherapy’s efficacy in breast cancer, however, has not been well established, and some studies suggest that the risks are increased with this therapy compared with conventional radiotherapy.
The researchers used the Medicare database of women aged 66 years to 94 years who underwent breast-conserving surgery in 2008 and 2009, and determined hospital ownership status by the Medicare Hospital General Information data set.
A total of 35,118 women were included (mean age, 74 years; 27% aged ≥80 years) who were treated at 2255 nonprofit hospitals and 420 for-profit hospitals. Adjuvant radiotherapy was administered to 72% of the patients, including brachytherapy in 15.7%.
Radiotherapy of any type was more common at for-profit hospitals among women aged ≥80 years. This 22% relative increase in radiotherapy was largely driven by brachytherapy. Brachytherapy was most common in all women who were treated at for-profit hospitals compared with nonprofit hospitals (20.2% vs 15.2%, respectively; P <.001), with the greatest difference observed among the elderly (Table).
Financial Incentives Influence Use
Treatment at a for-profit hospital was associated with an odds ratio of 1.29 for receiving brachytherapy in women aged 66 years to 79 years (P = .04) and of 1.66 in women aged ≥80 years (P = .003).
“Women whose surgery was performed at for-profit hospitals were significantly more likely to receive any radiation, driven by the differential use of newer, less proven brachytherapy,” Dr Sen said.
He suggested that for-profit hospitals may have had “financial incentives and fiduciary responsibilities, or a desire to be at the vanguard of care or build market share,…but it is also possible that brachytherapy was chosen to enhance convenience and tolerability for the patient. It’s challenging to delineate the incentives.”