Urologist practice styles in the initial evaluation of elderly men with benign prostatic hyperplasia

Abstract

Objectives: To investigate the degree to which expenditures on symptom evaluations vary among urologists and the factors associated with such variation. As the medical and surgical specialists for men with lower urinary tract symptoms (LUTS), urologists provide testing to evaluate symptoms and determine therapy.

Methods: We developed a cohort of men with an initial urologist visit for benign prostatic hyperplasia (BPH) from a 5% sample of Medicare patients (1999-2007) and established a physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style.

Results: A nearly 15-fold variation in urologists' average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P < .01 all examined variables) and patient (P < .01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P < .01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P < .01).

Conclusions: Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs.

Figure 1. Evaluative Care Testing across AUA Guideline Recommended Levels of Care

Figure 1A Differences in utilization of recommended care across quintiles of practice style were largely driven by urinalysis: 171/100 patients lowest, 214/100 patients middle, 237/100 patients highest. Figure 1B Cytology utilization plateaus across urologist quintiles: 4/100 patients lowest, 10/100 patient middle, 13/100 patients highest. Uroflow grows exponentially across the quintiles: 7, 9, 15, 25, and 38 per 100 patients lowest to highest. Figure 1C Serum creatinine measurements drive the use of not-recommended care: 129, 155, 164, 192, and 182 per 100 patients lowest to highest quintiles of practice style. Figure 1D Use of procedures increases with increasing practice style quintile with the exception of upper tract imaging where a plateau develops (12, 16, 18, 20, 22 procedures per 100 patients lowest to highest quintile).

Figure 2. Expenditures per Patient across Quintiles of Urologist Practice Style

Expenditures ranged from $155 to $351 per patient in the lowest and highest practice style urologists respectively. Recommended care expenditures were fairly stable across the quintiles ($23 lowest to $29 highest). Optional care expenditures were over three times as high in the high expenditure practice style urologists compared to urologists with low expenditure practice styles ($18 to $58). Not-recommended care expenditures were over two times higher in high expenditure practice style urologists compared to low expenditure urologists ($114 to $264).