Should Your Practice Join a Provider-Based Research Network: March 31, 2014

Ronald Chen, MD, MPH

Provider-based research networks (PBRNs) make clinical trials available to community-based practices.

This is important because community- based practices are where most oncology patients receive their cancer care. But before joining these networks, oncologists and practice managers must consider the financial impact and return on investment (ROI) or business case. Researchers at Ohio State University reviewed the National Cancer Institute’s (NCI’s) community oncology program in a recent study.

Paula H. Song, PhD, who was an assistant professor in the Division of Health Services Management and Policy at The Ohio State University College of Public Health when the study was conducted, and colleagues, applied a multiple case study approach to the 5 NCI sites. Their findings were published in a recent issue of Health Care Management Review and suggest a method to document the business case for a provider when they consider joining a PBRN.

“The community oncologist could take what we’ve modeled to calculate his own practice’s ROI,” said Song. “The model can help the oncologist think through what are the resources that the practice is expending to participate and what kind of financial benefits the practice is getting.”

In addition, community oncologists can use the model “to generate buy-in from the other partners or even administration, to show that this effort is important and isn’t going to be a total financial drain on the practice,” said Song. “I think it can be used to help generate the support for getting involved in the CCOP or PBRNs.”

The NCI’s Community Clinical Oncology Program (CCOP) is a long-standing federally funded clinical trial program, but there currently is little practical guidance in the literature to assist provider organizations in analyzing the business case for establishing and operating a PBRN. Song and colleagues conducted this research because of the lack of evidence to help providers explore this potential revenue stream further.

The researchers conducted 41 semi-structured interviews, then developed a spreadsheet-based tool that included advice for evaluating the business case for provider participation. They identified key themes that were used to develop the financial tool.

Key concerns that community oncologists and practice managers should consider include startup costs, direct revenue from the NCI CCOP grant, direct expenses required to maintain CCOP research infrastructure, and incidental benefits— notably downstream revenue from CCOP patients.

In the study, the authors noted the importance of this downstream revenue to the oncology practice, which was a significant contributor to the business case for the CCOP.

Song and colleagues concluded that “Providing a method for documenting the business case for CCOP or other PBRN involvement will contribute to the long-term sustainability and expansion of these programs by improving providers’ understanding of the financial implications of participation.”

The researchers wrote that the lack of knowledge concerning the benefits of joining a CCOP could result in provider reluctance and affect patient access to new oncology therapies.

Inappropriate Use of Bone Scans in Low-, Intermediate-, and High-risk Patients With Prostate Cancer

Researchers in the Department of Radiation Oncology at the University of North Carolina Hospitals found that almost one-third of low-risk and almost one-half of intermediate-risk prostate cancer patients receive a staging bone scan at the time of diagnosis. That’s surprising because these patients have almost no chance of having metastatic disease. A metastatic work-up for patients with low- and intermediate-risk cancer, which costs Medicare $11.3 million each year, is unlikely to yield useful clinical information. Of these low- and intermediate-risk patients who received a bone scan, 21% had subsequent X-rays, 7% had a CT scan, and 3% underwent an MRI scan.

“Prostate cancer guidelines suggest that lowand intermediate-risk prostate cancer patients do not need a staging bone scan because at the time of diagnosis, the chance of metastasis is very low,” said Ronald Chen, MD, MPH, assistant professor in Radiation Oncology and senior author on the study.

On the other hand, bone scans were used in only 62% of high-risk patients. This is in contrast to published guidelines, which recommend staging scans for this population. Among high-risk patients who received a bone scan in the study, 14% were diagnosed with metastatic disease. “Essentially, we found that there is overuse of bone scans in patients who don’t need it, and a lot of underuse of scans in patients who actually need it,” said Chen.

The researchers write that physicians should be “judicious when ordering tests and procedures to spare patients from unnecessary procedures and to help curb rising health care costs.” Those patients with apparent low- and intermediate-risk prostate cancer “almost never have metastatic disease at the time of diagnosis, the positive predictive value of a bone scan is low, and the risk of false-positive results is high.” Despite the low yield in clinically useful data, bone imaging studies are frequently performed on these patients.

The findings demonstrate how reflexive it is “to order a bone scan every time a patient is first diagnosed with prostate cancer,” said Chen. “It’s a very expensive and potentially wasteful use of health care resources.”

Overall, bone scans for all prostate cancer patients costs Medicare $19.3 million annually, including $9.3 million for low- and intermediate- risk patients. An additional $2 million is spent annually on downstream imaging after a bone scan for low- and intermediate-risk patients.

Patients were drawn from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The authors note that patients younger than 65 years were not included. However, because the median age for diagnosis of prostate cancer is 67 years, this disease and its associated costs are highly relevant to Medicare.

The authors conclude that the results demonstrate “a pervasive lack of adherence to guidelines, and a common overuse and underuse of this test in prostate cancer.” These findings were published in the International Journal of Radiation Oncology, Biology, Physics.