Letter: IMRT ownership study methodology unsound

Editor's note: The below letter was written in response to the Urology Times article "IMRT ownership appears to influence PCa treatment."

To the editor:

The issue of financial incentives in fee-for-service medicine impacting clinical decision-making is an important one; regrettably, the conclusions of Borza et al (“IMRT ownership appears to influence PCa treatment,” October 2018, page 6) rely on antiquated data using flawed methodology that does little to contribute to this discussion-this analysis has been previously refuted in detail when it was initially published (Eur Urol 2018; 73:491-8; Eur Urol 2018; 73:499-501 [comment]).

At its core, the study’s methodology for assigning intensity-modulated radiation therapy ownership to a urologic group is unsound. The authors determined ownership of IMRT based simply on the mention of radiation services on practice websites at a single point in 2012-furthermore, they made no effort to determine the nature of the financial relationship between the group and radiation facility, or whether the groups ceased or commenced radiation services after that time. As such, groups with partial ownership or even no ownership at all (but with co-marketing agreements) would be considered identical to groups with full ownership. Conflating what may be complex business relationships and then assigning uniform financial motives to clinical decision-making based on a mere website mention lacks academic rigor.

The authors’ definition of single- or multispecialty group practice (MSG) further compounds these errors. The authors’ definition of an MSG is overly narrow as it based on inclusion of a primary care physician; however, many MSGs are comprised of different medical or surgical specialists without a PCP. Consequently, the authors did not identify a single MSG in the U.S. with ownership of radiation services.

Furthermore, the authors did not consider patient preference or appropriateness of treatment. The proportion of patients without identified curative intent was 23.7% and 28.1% in ownership and non-ownership groups, respectively. It would have been important to ascertain the effect that case mix could have had on this small differential.

In addition, the authors did not consider that the mechanics of patient decision-making in integrated urology practices differs substantially from groups where multidisciplinary services are not offered. Integrated urology practices typically include a radiation oncologist in the decision-making process, which has been documented to influence the decision of whether to have surgery or radiation as the initial modality of care for localized prostate cancer (Arch Intern Med 2010; 170:440-50; J Urol 2012; 187:103-8).

Utilization analysis of health care resources must be free of bias, methodologically sound, and relevant to current practice; regrettably, this manuscript meets none of these criteria. Given the relatively small number of urologists nationally and the increasing need for urologic services as our population ages, we have a unique opportunity to work together as a specialty to create novel care paradigms that utilize real data to optimize resource use and enhance outcomes by providing services where they are most effectively and efficiently delivered. The future health and well-being of our specialty, and more importantly our patients, demands it.

Deepak Kapoor, MD/New York