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Clinical Research

Gonadotropin-releasing hormone agonist overuse: urologists’ response to reimbursement and characteristics associated with persistent overuse

Prostate Cancer and Prostatic Diseases volume 18, pages 173–181 (2015)Cite this article

Subjects

Abstract

Background:

Medicare reimbursement cuts have been associated with declining gonadotropin-releasing hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse.

Methods:

We matched American Medical Association physician data for 2138 urologists to Surveillance, Epidemiology and End Result-Medicare data for 12 943 men diagnosed with early-stage and lower-grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multilevel modeling to control for patient and provider characteristics.

Results:

Three distinct patterns of GnRH agonist overuse were observed. Urologists’ time in practice was not associated with GnRH agonist overuse (odds ratio (OR) 0.89; 95% confidence interval (CI): 0.75–1.05). However, solo practice type (OR 1.65; 95% CI: 1.34–2.02), medical school affiliation (OR 0.65; 95% CI: 0.55–0.77) and patient race were. Compared with non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI: 1.37–2.27), Hispanics (OR 1.41; 95% CI: 1.12–1.79) and men of ‘other’ race (OR 1.44; 95% CI: 1.04–1.99) had greater odds of receiving unnecessary GnRH agonists.

Conclusions:

GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.

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Acknowledgements

This study was peer-reviewed and presented at the American Society of Clinical Oncology in June 2014. Work on this study was supported by the Integrated Cancer Information and Surveillance System (ICISS), UNC Lineberger Comprehensive Cancer Center with funding provided by the University Cancer Research Fund (UCRF) via the State of North Carolina. The American Medical Association is the source for the raw physician data. The National Cancer Institute provided the SEER-Medicare linked data and reviewed the manuscript for potential privacy violations. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute's Surveillance, Epidemiology and End Results Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Souther0n California and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention's National Program of Cancer Registries, under agreement no. U55/CCR921930-02 awarded to the Public Health Institute. The statistics, tables, ideas and opinions expressed herein are those of the author(s) and endorsement by the American Medical Association, State of California, Department of Public Health the National Cancer Institute and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. We acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS) Inc.; and the Surveillance, Epidemiology and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. Dr Ellis was supported by a National Cancer Institute training grant (R25CA116339) and a University of North Carolina Lineberger Comprehensive Cancer Center Dissertation Completion Award. Dr Nielsen was supported in part by The American Cancer Society (grant number MRSG-13-154-01-CPPB) and The Urology Care Foundation/Astellas (Rising Stars in Urology Research Award). Dr Weinberger was supported by a Senior Research Career Scientist Award (91–408) from the US Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service.

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Authors and Affiliations

  1. Department of Health Policy and Management, University of Kansas School of Medicine, Kansas City, KS, USA

    S D Ellis

  2. Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    S D Ellis, M E Nielsen, W R Carpenter, S B Wheeler & M Weinberger

  3. Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    M E Nielsen

  4. Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    W R Carpenter & H Liu

  5. Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA

    G L Jackson & M Weinberger

  6. Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA

    G L Jackson

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Correspondence to S D Ellis.

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Ellis, S., Nielsen, M., Carpenter, W. et al. Gonadotropin-releasing hormone agonist overuse: urologists’ response to reimbursement and characteristics associated with persistent overuse. Prostate Cancer Prostatic Dis 18, 173–181 (2015). https://doi.org/10.1038/pcan.2015.10

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