Physician variation in management of XXXX : a population-based cohort study.

@entity1 @entity263 @entity5
IMPORTANCE: Up-front treatment of older @entity1 with @entity263 can cause morbidity without clear survival benefit; however, most such @entity1 receive treatment instead of observation. The impact of physicians on the management approach is uncertain. OBJECTIVE: To determine the impact of physicians on the management of @entity263 with up-front treatment vs observation. DESIGN, SETTING, AND @entity1 : Retrospective cohort of @entity1 66 years and older with @entity263 diagnosed from 2006 through 2009. @entity1 and @entity5 characteristics were obtained from the Surveillance, Epidemiology, and End Results @entity5 registries. The diagnosing urologist, consulting radiation oncologist, @entity5 -directed therapy, and comorbid medical conditions were determined from linked Medicare claims. Physician characteristics were obtained from the American Medical Association Physician Masterfile. Mixed-effects models were used to evaluate management variation and factors associated with observation. MAIN OUTCOMES AND MEASURES: No @entity5 -directed therapy within 12 months of diagnosis (observation). RESULTS: A total of 2145 urologists diagnosed @entity263 in 12,068 @entity1 , of whom 80.1% received treatment and 19.9% were observed. The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of @entity1 . The diagnosing urologist accounted for 16.1% of the variation in up-front treatment vs observation, whereas @entity1 and @entity5 characteristics accounted for 7.9% of this variation. After adjustment for @entity1 and @entity5 characteristics, urologists who treat non- @entity263 (adjusted odds ratio [aOR], 0.71 [95% CI, 0.55-0.92]; P =   .01) and graduated in earlier decades (P =   .004) were less likely to manage low-risk disease with observation. Treated @entity1 were more likely to undergo prostatectomy (aOR, 1.71 [95% CI, 1.45-2.01]; P <   .001), cryotherapy (aOR, 28.2 [95% CI, 19.5-40.9]; P <   .001), brachytherapy (aOR, 3.41 [95% CI, 2.96-3.93]; P <   .001), or external-beam radiotherapy (aOR, 1.31 [95% CI, 1.08-1.58]; P =   .005) if their urologist billed for that treatment. Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2% to 46.8% of @entity1 . CONCLUSIONS AND RELEVANCE: Rates of management of @entity263 with observation varied widely across urologists and radiation oncologists. @entity1 whose diagnosis was made by urologists who treated @entity263 were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians' @entity5 management profiles would enable informed selection of physicians to diagnose and manage @entity263 .
