Facility Level Variation in Rates of Definitive Therapy for Low Risk Prostate Cancer in Men with Limited Life Expectancy: An Opportunity for Value Based Care Redesign.

Purpose: We sought to identify facility level variation in the use of definitive therapy among men diagnosed with clinically localized, low risk prostate cancer who were more than 65 years old and had a limited life expectancy of less than 10 years.

Materials And Methods: Using data from the National Cancer Database we identified 18,178 men older than 65 years with less than a 10-year life expectancy receiving definitive therapy at a total of 1,172 facilities for biopsy confirmed localized, low risk prostate cancer diagnosed between January 2004 and December 2013. A multilevel, hierarchical, mixed effects logistic regression model was fitted to predict the odds of receiving definitive therapy.

Results: Overall 18,178 men (76%) older than 65 years with limited life expectancy and a diagnosis of low risk prostate cancer received definitive therapy, although the rate of therapy decreased significantly with time (p <0.001). Patients receiving definitive therapy were more often younger (80 years or older vs 66 to 69 years OR 0.12, 95% CI 0.09-0.15, p <0.001) and white rather than black (OR 0.86, 95% CI 0.75-0.98, p = 0.03). Conversely, being uninsured (OR 0.37, 95% CI 0.21-0.63, p <0.001) and receiving care at an academic medical center (OR 0.36, 95% CI 0.28-0.46, p <0.001) conferred decreased odds of undergoing definitive therapy. The proportion of men undergoing definitive therapy ranged from 0.12% to 100% across facilities.

Conclusions: We found significant facility level variation in rates of definitive therapy in men with localized prostate cancer and limited life expectancy. Health care providers and policy makers alike should be aware of the varying frequency with which this potentially low value service is performed.