Does Practice Setting Affect Care Provided to Patients with Advanced Cancer?

Why This Study Is Important

The ongoing shift in oncology outpatient care from independent physicians’ offices to hospital outpatient departments (HOPDs) raises the question of how practice setting affects oncologists’ treatment patterns and the quality of cancer care. This study examines site-of-care differences in the use of low-value therapies and supportive care drugs, use of hospital and emergency departments (EDs) for unmanaged symptoms of chemotherapy, and use of hospice care for patients with advanced cancer.

What This Study Found

• Patients receiving chemotherapy in independent physicians’ offices were more likely to be given low-value supportive care drugs. Compared to patients treated in HOPDs, patients treated in offices were 72 percent more likely to receive ESAs and 28 percent more likely to receive G-CSF.
• Patients with advanced breast cancer were also somewhat more likely to receive low-value chemotherapy when treated in physicians’ offices, but these differences were not statistically significant after controlling for patient characteristics.
• Bevacizumab was rarely used for patients with advanced squamous NSCLC in either physicians’ offices or HOPDs, indicating appropriate care in both settings for this population.
• Use of hospitals and EDs for chemotherapy-related complications and use of hospice care did not differ according to whether the patient was treated in a physician’s office or an HOPD.

What These Findings Mean

The finding that oncologists in independent offices prescribed certain low-value cancer drugs more often than their colleagues in HOPDs points to a need to better understand the mechanisms through which practice setting could influence physicians’ behavior. Financial incentives are one possible driver of behavior and would be likely to affect physicians in private offices more directly than HOPD physicians. Payment reforms that better align incentives with best practices in clinical care may help to improve the value of office-based care. Physicians in HOPDs may also have the benefit of supportive organizational cultures, including ongoing education and peer-to-peer learning. Similar educational efforts could be helpful for office-based physicians.

More About This Study

This study used Medicare claims linked with SEER cancer registry data to identify Medicare beneficiaries newly diagnosed at Stage IV with any of six types of cancer between 2004 and 2011. Use of two low-value supportive care drugs – erythropoiesis-stimulating agents (ESAs) and white cell stimulating factors (G-CSF) – was identified for all patients, along with any chemotherapy-related inpatient admissions or ED visits and hospice services. For patients with breast cancer, use of two types of low-value chemotherapy regimens was examined: a combination of any two cytotoxic chemotherapies within 30 days and first or only use of nab-paclitaxel among patients receiving a taxane chemotherapy agent. For patients with squamous non-small cell lung cancer (NSCLC), use of bevacizumab was also assessed; this drug is not approved for this subpopulation. Patients were assigned to a practice setting based on the site of their first chemotherapy administration. Logistic regression with hierarchical modeling was used to examine site differences in the probability of receiving each study service.