Local Coverage Determination Policy and the Use of Stereotactic Body Radiation Therapy for Prostate Cancer

Abstract

Introduction Local coverage determinations (LCDs) are local decisions that regulate healthcare coverage. We evaluated the impact of LCDs as well as patient, tumor, and market characteristics on the adoption of stereotactic body radiation therapy (SBRT) for prostate cancer. Methods Using Surveillance, Epidemiology, and End Results (SEER)-Medicare, we identified men treated with SBRT, intensity-modulated radiotherapy (IMRT), and robotic prostatectomy. We compared demographics, clinical characteristics, and market factors among these three treatments. Our primary exposure was LCD policy; using the Medicare Coverage Database, we categorized LCDs as favorable (SBRT covered), neutral (SBRT covered in the context of a clinical trial or registry), unfavorable (SBRT not covered), or absent (i.e., SBRT not governed by an LCD at the time of treatment). We fit a multivariable multinomial logistic regression model and generated predicted probabilities to examine the relation between LCDs and SBRT. Results During this early period of SBRT adoption, IMRT was the most common of the three treatments followed by robotic prostatectomy and then SBRT. SBRT use was high when governed by favorable and neutral LCDs and lowest when governed by unfavorable LCDs. Compared with favorable LCDs, areas where LCDs were absent were associated with higher SBRT use compared with IMRT (odds ratio [OR] 1.56; 95%CI, 1.07–2.25) and robotic prostatectomy (OR 1.84; 95%CI, 1.25–2.69). Conclusions When present, LCDs appear to regulate early SBRT adoption, but, when absent, are associated with increased SBRT use. Although SBRT use was uncommon, it varied across a wide range of patient, tumor, and market characteristics.

The early adoption of intensity‐modulated radiotherapy and stereotactic body radiation treatment among older Medicare beneficiaries with prostate cancer

“…Especially early in the SBRT adoption period, health policies and insurance providers often made it difficult to get SBRT approved for prostate cancer. 27 Perhaps more importantly, there were substantial differences in physician reimbursements. IMRT had favorable reimbursement rates shortly after it was introduced.…”

“…26 Prior work demonstrated that local coverage determinations influenced the adoption of SBRT to some extent. 27 On the basis of the evidence available at the time, they often restricted the use of SBRT to low-risk and intermediate-risk prostate cancers, which would result in decreased receipt among patients with poorly differentiated tumors.…”

Radiation oncologists’ attitudes and beliefs about intensity-modulated radiation therapy and stereotactic body radiation therapy for prostate cancer

“…Some policies encourage this practice by requiring enrollment to qualify for insurance coverage. For example, some local coverage determinations will only endorse SBRT if patients enroll in a clinical trial or registry [27]. Such a registry currently exists in Florida-the Multi-Institutional Registry for Prostate Cancer Radiosurgery (NCT01226004) [28].…”