Abstract
PURPOSE
Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiotherapy (RT) regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC.
METHODS AND MATERIALS
We performed a retrospective cohort analysis of all external beam episodes RT (EBRT) for BC and PC from 2015–2019 to assess predictors of short-course RT (SCRT) utilization and calculate spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, as well as the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the covariables above.
RESULTS
Of 143,729 BC episodes and 114,214 PC episodes, 80,106 (55.73%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9,418 (IQR, $7,966-$10,982) vs. $13,601 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6,924 (IQR, $4,509-$12,905) for SBRT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes, as well as treatment at hospital-affiliated over freestanding sites (p<0.001 for all).
CONCLUSIONS
In this evaluation of BC and PC RT episodes from 2015–2019, we found that shorter-course RT resulted in lower costs vs. longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate and applicable in the two most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.
Keywords: Breast Cancer, Prostate Cancer, Medicare Spending, Short-Course Radiation Therapy, Radiation Oncology Model
INTRODUCTION
Breast cancer (BC) and prostate cancer (PC) are the most common indications for radiotherapy (RT) in the United States, comprising approximately 31% of all diagnosed cancer in women and 27% of all diagnosed cancer in men, respectively.1 Standard treatment options for patients typically involve long radiotherapy courses of over 40 fractions for patients with PC and over 20 fractions in the adjuvant setting for patients with BC. Although RT is an integral part of care for patients with PC and BC, longer RT courses may pose challenges for patients including the financial toxicity associated with travel and missed work, the risk of treatment non-completion, and the greater direct costs of care associated with multiple fractions.2,3 In the last decade, practice-changing studies have demonstrated the safety and efficacy of shorter courses of radiation for PC and BC. Hypofractionated radiation has been associated with similar clinical outcomes as standard fractionation regimens for early stage PC and BC, with acceptable adverse effect profiles. Additionally, shorter courses are associated with increased treatment completion, acceptable patient satisfaction, and decreased financial burden for the patient and broader healthcare system.4–6 Despite these advances and the recent endorsement from national guidelines, uptake of short-course radiotherapy (SCRT) has been variable; it has been hypothesized that a variety of factors may influence treatment recommendations, including delayed adoption of newer techniques, concerns about late long-term toxicity, and different reimbursements associated with fewer fractions.7
Recent efforts on behalf of Centers for Medicare and Medicaid Services (CMS) to restructure radiation oncology (RO) payment systems have reinvigorated the conversation about SCRT in light of proposed bundled payments for each disease episode.8 However, practice patterns of hospital-affiliated and standalone facilities may have varied considerably prior to the proposed model. We use recent and updated CMS data from 2015–2019 to assess trends in SCRT utilization and spending for PC and BC.
METHODS AND MATERIALS
Patient Population and Study Design
The episode-based data for this study were provided by the Centers for Medicare and Medicaid Services (CMS) and covers 84% of all Medicare beneficiaries.9 This data is sourced from the CMS RO Model episode file and contains data on episodes of radiation treatment for Medicare fee-for-service beneficiaries during 2015–2019 who would qualify for the RO Model by treatment setting. Specifically, beneficiaries were treated in hospital-outpatient departments or freestanding centers to be eligible. We performed a retrospective cohort analysis of all RT episodes for breast (ICD-10: C50-D05) and prostate (ICD-10: C61) cancer from 2015–2019. Medicare beneficiaries who died within 90 days of the episode were excluded; this criterion served as a surrogate for aggressive disease or poor functional status. Additionally, we excluded beneficiaries who were younger than 65 years and PC beneficiaries who received major surgical procedures during the episode or within the previous 90 days (Figure 1). Due to its use of publicly available, de-identified data, this study was deemed exempt by the Institutional Review Board.
Figure 1:
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Diagram depicting cohort selection. Episode-based data for this study were provided by the Centers for Medicare and Medicaid Services (CMS).
Definition of Treatments and Outcomes
All beneficiaries in the study received external beam radiation therapy (EBRT), including conventional external-beam and intensity-modulated radiation therapy (IMRT), during the episode. For patients with breast cancer, receipt of short-course radiotherapy (SCRT) was defined as receiving 11–20 fractions (in accordance with the UK START and Canadian hypofractionation trials) and receipt of longer-course RT (LCRT) as >20 fractions. For patients with PC, receipt of stereotactic body radiotherapy (SBRT) was defined as receipt of <10 fractions of stereotactic body radiation, moderate hypofractionation (mEBRT) as 10–30 fractions of EBRT/IMRT, and LCRT as >30 fractions of EBRT/IMRT based on the HYPO-RT-PC trial.10 These ranges were designed as such because the data source categorized number of fractions into bins of ten fractions (i.e., 1–10, 11–20, 21–30, etc.). Type of radiation modality was discerned from the data element labels provided in the RO Model file. For the primary analysis, receipt of SCRT among PC patients was defined as receipt of SBRT or mEBRT. Episodes of radiotherapy delivered with protons or brachytherapy were excluded to limit comparisons to photon-based EBRT. Total Medicare spending was defined as the sum of winsorized payment for professional and technical services furnished during the episode in 2019 dollars. Spending amounts were provided for all episodes, with winsorization based on the 1st and 99th percentiles of the proposed episodes in the outpatient setting. Episodes with incomplete payment information were excluded from the analysis.
Statistical Analysis
Baseline characteristics among beneficiaries who received SCRT vs. LCRT were compared using Pearson’s chi-squared test for categorical variables and Kruskal-Wallis test for continuous variables. Trends in utilization of SCRT regimens were evaluated using multivariable logistic regression, adjusting for age group (65–74, 75–84, 85+), treatment year (2015–2019), treatment setting (freestanding vs. hospital-affiliated center), RT delivery technique (EBRT vs. IMRT), and the interaction between time and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs. LCRT) in addition to the covariables listed above. Each analysis was conducted separately in BC and PC episodes, and sensitivity models were created for the PC cohort with receipt of SBRT over LCRT and mEBRT over LCRT as separate dependent variables. Sensitivity models stratified by spending type (professional vs. technical services) were created for the spending analysis, while further sensitivity models excluding BC and PC patients who received systemic therapy were created for the overall analysis. All statistical testing was 2-sided, with results deemed statistically significant at P < .05. Analyses were performed with Stata/SE, version 17.0 (StataCorp LLC).
RESULTS
Of 143,729 BC episodes, 80,106 (55.73%) were SCRT regimens and 63,623 (44.27%) were LCRT. Median total spending for SCRT regimens among BC episodes was $9,418 (IQR, $7,966-$10,982) vs. $13,601 (IQR, $11,814-$15,499) for LCRT. The BC patients who received SCRT were older (>75 years: [SCRT] 33.93% vs. [LCRT] 31.72%), more likely to be diagnosed in later years (diagnosis in 2019: 26.90% vs 16.24%), and more likely to get treated at a hospital affiliated center (71.89% vs. 63.77%).
Of 114,214 PC episodes, 25,955 (22.72%) were SCRT regimens while 88,239 (77.28%) were LCRT. Median total spending was $6,924 (IQR, $4,509-$12,905) for SBRT, $18,768 (IQR, $15,421-$20,740) for mEBRT, and $27,319 (IQR, $25,446-$29,421) for LCRT. Similar to the BC patients, the PC patients who received SCRT were older (>75 years: 44.89% vs. 36.69%), more likely to be diagnosed in later years (diagnosis in 2019: 35.94% vs 19.49%), and more likely to get treated at a hospital affiliated center (71.89% vs. 63.77%, Table 1).
Table 1:
Baseline characteristics of patients with breast and prostate cancer receiving short-course (SCRT) or long-course radiotherapy (LCRT). P values were obtained using Pearson’s chi-squared test for categorical variables and Kruskal-Wallis test for continuous variables. a
| Breast Cancer | Prostate Cancer | |||||
|---|---|---|---|---|---|---|
|
| ||||||
| Characteristic | SCRT | LCRT | P Value | SCRT | LCRT | P Value |
|
| ||||||
| Total Cohort No. (%) | 63,623 (44.27) | 80,106 (55.73) | N/A | 25,955 (22.72) | 88,259 (77.28) | N/A |
| Median Total Spending, $ (IQR) | 9,418 (7,966–10,983) | 13,602 (11,814–15,499) | <.001 | 15,331 (7,806–19,920) | 27,319 (25,446–29,421) | <.001 |
| Median Professional Spending, $ (IQR) | 1,736 (1,430–2,040) | 2,414 (2,066–2,826) | <.001 | 2,278 (1,441–3,211) | 4,373 (3,789–4,851) | <.001 |
| Median Technical Spending, $ (IQR) | 7,655 (6,513–8,947) | 11,168 (9,691–12,680) | 12,927 (6,227–16,974) | 22,878 (21,424–24,982) | ||
| Treatment Modality (%) | <.001 | <.001 | ||||
| EBRT | 61,011 (44.90) | 74,874 (55.10) | – | 14,365 (14.05) | 87,904 (85.95) | – |
| IMRT | 2,612 (33.30) | 5,232 (66.70) | – | 7,465 (95.79) | 328 (4.21) | – |
| SBRT | – | – | 4,125 (99.35) | 27 (0.65) | ||
| Age (%) | <.001 | <.001 | ||||
| 65–74 | 42,033 (43.45) | 54,695 (56.55) | – | 14,302 (20.38) | 55,870 (79.62) | – |
| 75–84 | 18,624 (45.84) | 22,003 (54.16) | – | 9,635 (24.13) | 30,294 (75.87) | – |
| 85+ | 2,966 (46.53) | 3,408 (53.47) | – | 2,018 (49.06) | 2,095 (50.94) | – |
| Year (%) | <.001 | <.001 | ||||
| 2015 | 8,889 (33.03) | 18,021 (66.97) | – | 3,021 (14.79) | 17,403 (85.21) | – |
| 2016 | 10,693 (37.06) | 18,164 (62.94) | – | 3,167 (15.13) | 17,771 (84.87) | – |
| 2017 | 12,171 (42.51) | 16,463 (57.49) | – | 3,917 (17.85) | 18,025 (82.15) | – |
| 2018 | 14,758 (50.53) | 14,450 (49.47) | – | 6,522 (26.75) | 17,856 (73.25) | – |
| 2019 | 17,112 (56.81) | 13,008 (43.19) | – | 9,328 (35.16) | 17,204 (64.84) | – |
| Treatment Setting (%) | <.001 | <.001 | ||||
| Freestanding | 17,882 (38.12) | 29,025 (61.88) | – | 7,628 (13.89) | 47,273 (86.11) | – |
| Hospital-Affiliated | 45,741 (47.24) | 51,081 (52.76) | – | 18,327 (30.90) | 40,986 (69.10) | – |
For each row characteristic, the percentage of episodes that are classified as either LCRT or SCRT are depicted. Descriptive characteristics between LCRT and SCRT groups are presented in the results section of the manuscript.
In adjusted analysis, receipt of SCRT was associated with older age and later year of diagnosis among both BC and PC episodes (p<0.001), as well as treatment at hospital-affiliated over freestanding sites [(BC OR [95% CI], 1.35 [1.27–1.42], p<0.001), (PC OR, 1.63 [1.47–1.80], p<0.001)]. The interaction between treatment site and year of diagnosis was significant (p<0.05) when controlling for patient age and RT technique for both disease sites. Use of SCRT for BC episodes modestly increased over time in both hospital-affiliated and freestanding centers; for PC episodes, hospital-affiliated centers had the largest increase in SCRT relative to freestanding centers (Supplementary Figures 1 and 2). Aggregated across respective cancer sites, SCRT utilization increased significantly over time (Figure 2).
Figure 2:
Proportion of breast cancer and prostate cancer radiation episodes delivered with short-course (SCRT) or long-course radiotherapy (LCRT) from 2015–2019, stratified by cancer site.
Both BC and PC episode spending were reduced with SCRT utilization ([BC adjusted β, −$4,334 [−$4,360 to −$4,310], [PC adjusted β, −$9,180 [−$9,241 to −$9,119]), older age (age ≥85 years, [BC adjusted β: −$308.75 [−$368.31 to −$249.19], [PC adjusted β: −$172.27 [−$282.09 to −$62.45]), and conventional EBRT modality (p<0.001 for all). BC episode spending was increased among patients with later years of diagnosis (adjusted β: $196.82 [$128.43 to $265.21], p<0.001), but decreased among those treated at hospital-affiliated versus freestanding sites (adjusted β: −$416.63 [−$476.39 to −$356.86], p<0.001). In contrast, PC episode spending was decreased among patients with later years of diagnosis (adjusted β: −$1,515 [−$1,605 to −$1,425], p<0.001), yet increased among those that were treated at hospital-affiliated versus freestanding sites (adjusted β: $644.51 [$549.90 to $739.12], p<0.001). These results persisted in sensitivity analysis stratified by professional and technical costs, as well as in analyses excluding patients that received systemic therapy (Supplementary Tables 2 and 3).
DISCUSSION
In this analysis of episode-based CMS data from 2015–2019, we found that utilization of SCRT regimens resulted in decreased Medicare spending for both BC and PC episodes, and that receipt of SCRT was associated with older age and treatment at a hospital-affiliated center. Moreover, while SCRT receipt for BC episodes increased roughly equally in both treatment settings, uptake of SCRT for PC episodes in freestanding sites was more modest than in hospital-affiliated centers. Indeed, national guidelines endorsed shorter RT regimens for BC in 2011 and for PC in 2018, which potentially explains the difference in SCRT uptake between disease sites and underscores the challenge of implementing more cost-effective practices in standard cancer care.11 The overall increase in SCRT utilization over time is encouraging, however, and may be amplified in the context of previously proposed bundle payments as well as research advances that support further adoption of shorter RT regimens.12 For instance, the FAST-Forward and APBI-IMRT-Florence trials have supported non-inferiority of hypofractionated RT schedules and accelerated partial breast irradiation, respectively, compared to more common regimens, in many common clinical BC settings.13,14 The recently reported results of the PACE-B trial found that at five years, SBRT was non-inferior to conventional or moderately hypofractionated radiation in terms of biochemical and/or clinical failure for patients with intermediate-risk PC.15 In addition to acceptable disease control, there is evidence suggesting that shorter regimens are associated with improved treatment completion, less frequent treatment interruptions due to shorter treatment duration, and reduced long-term cost.16 It is likely that shorter regimens are also associated with less financial toxicity associated with multiple trips to treatment resulting in lost wages and transportation expenses.
Moreover, contrasting radiation from immunotherapy, which account for nearly 84% of the observed overall increase in Medicare outpatient cancer care spending, hypofractionated regimens have consistently demonstrated cost-effectiveness in numerous clinical settings.17 Further technological advances in hypofractionation, through refinements in radiation delivery or image guidance, for example, will only continue to yield important benefits for clinicians who are increasingly engaged in value-based contracts as well as patients who benefit from improved health outcomes and greater convenience. The new Radiation Oncology Case Rate Payment Program (ROCR) that the American Society for Radiation Oncology has been devising would further align financial incentives with appropriate evidence-based practices and effectively bolster the utilization of SCRT regimens nationwide.18 Indeed, integrated across all beneficiaries, the ROCR bundled payment program is estimated to save more than $200 million over the next five years and provide less costly, more equitable care to all beneficiaries that qualify.18 As the number of patients with cancer continues to rise, efforts to implement ROCR may support more appropriate valuation for improved per-treatment efficiency.
Furthermore, freestanding practices were less likely to deliver SCRT than hospital-affiliated practices over the study period in this analysis. The nature of the available data limits the ability to speculate about underlying reasons for this difference; data regarding ownership structure of the facility/practice, compensation structure of the prescribing physicians, beneficiary travel distance to treatment, and/or other pertinent variables are unavailable.11 However, payment under the Medicare Physician Fee Schedule declined by 5% during this period, which may have impacted the ability of freestanding practices to deliver hypofractionated courses of care. In the study period from 2015 to 2019, anticipation of the proposed RO model may have also influenced practice patterns and encouraged utilization of shorter, more cost-effective regimens; we note that at the time of writing, the CMS has placed an indefinite hold on the implementation of the RO model through its final rule notice.19 Moving forward, payers may devise payment incentives that encourage SCRT when clinically appropriate. More generally, policymakers should be aware of the heterogeneity in practice settings as they design payment models that encourage value-based care; patient-centric and evidence-based care should remain top-of-mind.20 Conducting more prospective research that explores the clinical and technical contexts of SCRT is a logical next step, as is studying the drivers of treatment utilization in various settings.11
Limitations of this study include its retrospective nature, the lack of available clinical variables, inability to discern the treatment intent and exact dosage of radiation received, and the limited number of years included in the analysis. There was also no distinction made between metastatic or localized episodes in the dataset, which may have skewed the sample towards shorter courses of radiation. Moreover, we were unable to remove all palliative episodes from the analysis because certain radiation modalities were not included as data elements in the file, such as three-dimensional conformal radiation. Nonetheless, by excluding patients with 90-day mortality as surrogates for aggressive disease, we were able to assume similar rates of palliative radiation across both analytic cohorts and mitigate misattribution. Ultimately, more research is warranted to better understand the usage, cost-effectiveness, and structural challenges of implementing SCRT in other disease sites.
CONCLUSION
In this evaluation of BC and PC RT episodes from 2015–2019, we found that shorter-course RT resulted in lower costs vs. longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate and applicable in the two most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.
Supplementary Material
Supplementary Figure 1: Proportion of breast cancer radiation episodes delivered with short-course (SCRT) or long-course radiotherapy (LCRT) from 2015-2019, stratified by site of care. SCRT was defined as receiving 11-20 fractions of external-beam radiation therapy or intensity-modulated radiation therapy.
Supplementary Figure 2: Proportion of prostate cancer radiation episodes delivered with short-course (SCRT) or long-course radiotherapy (LCRT) from 2015-2019, stratified by site of care. SCRT was defined as receiving 1-30 fractions of external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT).
Supplementary Table 1: Results from multivariable logistic regression assessing use of short-course radiotherapy (SCRT) and from multivariable linear regression modeling of Medicare spending for patients with breast cancer. Patients who received systemic therapy were excluded from the analytic cohort. a, b, c
aCohort consisted of all radiotherapy episodes from 2015–2019 for women diagnosed with breast cancer (ICD-10: C50-D05). All patients survived and received no systemic therapy for more than 90 days. Additionally, all patients were over 65 years old and received external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT) for their BC.
bUse of SCRT was defined as receiving 11–20 fractions of either EBRT or IMRT. Use of LCRT was defined as receiving >20 fractions of either EBRT or IMRT. Multivariable regression defined adjusted odds ratios for use of SCRT over LCRT, controlling for the listed covariates in addition to an interaction term between year and treatment setting.
cTotal Spending was defined as Medicare-reimbursed professional and technical service fees per 90-day RT episode, adjusted to 2019 dollars. Adjusted β coefficients can be interpreted as the difference in mean spending between the groups (or per year when assessing change over time) while holding other covariates constant.
Supplementary Table 2: Results from multivariable logistic regression assessing use of short-course radiotherapy (SCRT) and from multivariable linear regression modeling of Medicare spending for patients with prostate cancer. Patients who received systemic therapy were excluded from the analytic cohort. a, b, c
aCohort consisted of all radiotherapy episodes from 2015–2019 for women diagnosed with prostate cancer (ICD-10: C61). All patients survived, received no systemic therapy, and received no major procedures for more than 90 days. Additionally, all patients were over 65 years old and received external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT) for their BC.
bUse of SCRT was defined as receiving 1–30 fractions of either EBRT or IMRT. Use of LCRT was defined as receiving >30 fractions of either EBRT or IMRT. Multivariable regression defined adjusted odds ratios for use of SCRT over LCRT, controlling for the listed covariates in addition to an interaction term between year and treatment setting.
cTotal Spending was defined as Medicare-reimbursed professional and technical service fees per 90-day RT episode, adjusted to 2019 dollars. Adjusted β coefficients can be interpreted as the difference in mean spending between the groups (or per year when assessing change over time) while holding other covariates constant.
FUNDING:
MBL is supported by a grant from the National Cancer Institute of the National Institutes of Health (1K08CA273549). PLN is supported by grants from the National Cancer Institute of the National Institutes of Health (1R01CA240582). FC, KRT, SNM and ECD are funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748).
AUTHOR DISCLOSURES:
B.A.M. receives funding from the Prostate Cancer Foundation and (PCF), the American Society for Radiation Oncology (ASTRO), the Department of Defense, and the Sylvester Comprehensive Cancer Center outside the submitted work. K.Y is on the advisory committee on health equity for Janssen Research & Development LLC, and MyCareGorithm, LLC. P.L.N. reported receiving grants and personal fees from Bayer, Janssen, and Astellas and personal fees from Boston Scientific, Dendreon, Ferring, COTA, Blue Earth Diagnostics, and Augmenix outside the submitted work. All other authors reported no conflicts of interest.
Footnotes
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DATA SHARING STATEMENT:
Research data for this study is available upon request from the Centers for Medicare and Medicaid Services (CMS) (https://innovation.cms.gov/innovation-models/radiation-oncology-model).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Figure 1: Proportion of breast cancer radiation episodes delivered with short-course (SCRT) or long-course radiotherapy (LCRT) from 2015-2019, stratified by site of care. SCRT was defined as receiving 11-20 fractions of external-beam radiation therapy or intensity-modulated radiation therapy.
Supplementary Figure 2: Proportion of prostate cancer radiation episodes delivered with short-course (SCRT) or long-course radiotherapy (LCRT) from 2015-2019, stratified by site of care. SCRT was defined as receiving 1-30 fractions of external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT).
Supplementary Table 1: Results from multivariable logistic regression assessing use of short-course radiotherapy (SCRT) and from multivariable linear regression modeling of Medicare spending for patients with breast cancer. Patients who received systemic therapy were excluded from the analytic cohort. a, b, c
aCohort consisted of all radiotherapy episodes from 2015–2019 for women diagnosed with breast cancer (ICD-10: C50-D05). All patients survived and received no systemic therapy for more than 90 days. Additionally, all patients were over 65 years old and received external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT) for their BC.
bUse of SCRT was defined as receiving 11–20 fractions of either EBRT or IMRT. Use of LCRT was defined as receiving >20 fractions of either EBRT or IMRT. Multivariable regression defined adjusted odds ratios for use of SCRT over LCRT, controlling for the listed covariates in addition to an interaction term between year and treatment setting.
cTotal Spending was defined as Medicare-reimbursed professional and technical service fees per 90-day RT episode, adjusted to 2019 dollars. Adjusted β coefficients can be interpreted as the difference in mean spending between the groups (or per year when assessing change over time) while holding other covariates constant.
Supplementary Table 2: Results from multivariable logistic regression assessing use of short-course radiotherapy (SCRT) and from multivariable linear regression modeling of Medicare spending for patients with prostate cancer. Patients who received systemic therapy were excluded from the analytic cohort. a, b, c
aCohort consisted of all radiotherapy episodes from 2015–2019 for women diagnosed with prostate cancer (ICD-10: C61). All patients survived, received no systemic therapy, and received no major procedures for more than 90 days. Additionally, all patients were over 65 years old and received external-beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT) for their BC.
bUse of SCRT was defined as receiving 1–30 fractions of either EBRT or IMRT. Use of LCRT was defined as receiving >30 fractions of either EBRT or IMRT. Multivariable regression defined adjusted odds ratios for use of SCRT over LCRT, controlling for the listed covariates in addition to an interaction term between year and treatment setting.
cTotal Spending was defined as Medicare-reimbursed professional and technical service fees per 90-day RT episode, adjusted to 2019 dollars. Adjusted β coefficients can be interpreted as the difference in mean spending between the groups (or per year when assessing change over time) while holding other covariates constant.
Data Availability Statement
Research data for this study is available upon request from the Centers for Medicare and Medicaid Services (CMS) (https://innovation.cms.gov/innovation-models/radiation-oncology-model).