To do so, the authors utilized the Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare) database, a US national cancer registry that captures ~28% of all cancer diagnoses. By linking it to Medicare data, a greater amount of granularity can be obtained regarding individual patient management – but it is limited to patients aged 65 and older. They identified eligible 66+ men diagnosed with localized or advanced prostate cancer from 1995- 2013, linked with AMA and AHA data. The Hirschman-Herfindahl index (HHI) was computed for all serving hospitals – the HHI is a commonly accepted measure of market concentration calculated by squaring the market share of each firm competing in a market and then summing the resulting numbers; it can range from close to zero to 10,000. For each hospital, they calculated the number of competitors (number of hospitals situated within the predicted radius) and HHI. Outcomes were overall and prostate cancer-specific survival and ER admissions.
Using the SEER-Medicare database, they identified 210,602 patients with localized PCa and 43,065 patients with advanced stage PCa. Full demographics were not provided.
For both localized and advanced stage PCa cohorts, age, race, ethnicity, geographic region, comorbidity, socio-economic status, and first treatment differed by hospital competition (high competition vs. low competition). So, the level of competition impacted the patient population treated and treatment offered.
With regards to treatment recommendations, hospitals within high competition area were more likely to perform surgery, whereas hospitals within low competition area were more likely to perform radiation therapy.
Looking at mortality outcomes, among men with localized PCa, low hospital competition was associated with higher overall mortality (HR=1.08, 95% CI=1.07 - 1.10) and prostate cancer-specific mortality (HR=1.13, 95% CI=1.09 - 1.17) and higher odds of ER visits (OR=1.13, 95% CI=1.11 - 1.15). For advanced stage PCa patients, low hospital competition was associated with higher overall mortality (HR=1.11, 95% CI=1.08 - 1.15), prostate cancer-specific death (HR=1.15, 95% CI=1.09 - 1.18) and higher odds of ER visits (OR=1.16, 95% CI=1.11 - 1.22).
This novel study demonstrates that higher hospital competition is associated with reduced mortality and lower ER admission among patients with localized or advanced stage prostate cancer. Especially for advanced prostate cancer, switching patients from low to high competition hospitals may reduce overall mortality and ER visits.
However, it should be noted that these analyses did not account for hospital volume – which may be a confounder. Hospitals in high competition areas may be more urban or be tertiary referral centers – and may be sent to these centers specifically for certain treatments or because they are high volume. Until this can be accounted for, we cannot attribute competition as the reason there are better outcomes. Additional research is needed to identify the mechanism through which hospital competition affects prostate cancer care outcomes.
Limitations / Discussion Points:
- They don’t account specifically for hospital volume – which has been demonstrated in multiple studies as impacting outcomes.
Co-authors: S. Bruce Malkowicz, Bingnan Li, Thomas Guzzo, Alan Wein, Ravishankar Jayadevappa, Philadelphia, PA
Written by: Thenappan Chandrasekar, MD (Clinical Instructor, Thomas Jefferson University) (twitter: @tchandra_uromd, @JEFFUrology) at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois