Urologists show low adherence to value-based care pathway

Urologists’ adherence to value-based care pathways (VBCP) for BPH surgery is extremely low and only modestly improved when they are given individualized feedback on patient outcomes, costs, and practice patterns relative to peers, according to a study presented by University of California Los Angeles (UCLA) researchers at the AUA annual meeting.

“Since passage of the Affordable Care Act, there has been a lot of talk about the need to transition from fee-for-service to value-based care. The results of our study show that we still have a long way to go before we reach that goal,” said first author Alan L. Kaplan, MD, of UCLA.

“Furthermore, our research indicates that merely showing surgeons how they are performing compared to their colleagues, a strategy that might drive change through competition, is not enough to meaningfully move behavior toward a VBCP for BPH surgery. Clearly, more powerful incentives than data feedback are needed.”

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A VBCP for BPH surgery was introduced at UCLA in April 2014. Designed to include the mix of preoperative testing and surgery that would provide the highest quality care at the lowest cost, it requires PSA testing when indicated, urinalysis, and post-void residual measurement preoperatively and use of bipolar transurethral resection or vaporization as the surgical option.

“Cystoscopy and urodynamics are not included in the VBCP as UCLA data, which were presented at this year’s AUA meeting, show these invasive tests fail to improve outcomes but greatly increase cost,” Dr. Kaplan said.

Since the BPH surgery VBCP was released, all urologists receive a confidential, quarterly report card by email that contains data on their outcomes, costs, and practice pattern (VBCP adherence) compared to de-identified colleagues.

To study adherence to the BPH surgery VBCP and determine if it was affected by the surgeon-specific feedback, adherence rates for 18 urologists were analyzed at baseline, 6 months, and 12 months after implementation of the quarterly report program. A similar analysis was performed for adherence to the AUA-recommended pathway for BPH, which is less stringent than the UCLA VBCP because it is silent on both preoperative invasive testing and operation of choice.

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Compliance rates at baseline for the AUA-recommended pathway and the UCLA VBCP were 1.8% and 0%, respectively. Six months later, both rates increased significantly, but adherence was still only 9.2% for the AUA pathway and 5% for the UCLA VBCP.

Although the provision of surgeon-specific feedback had a minimal impact on urologists’ adherence to the BPH surgery VBCP, the quarterly report program has not been abandoned because increasing data transparency is the right thing to do, Dr. Kaplan told Urology Times.

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“If we are going to continue the conversation about driving the health care system toward a value-based care model, then data transparency is important, regardless of what our study showed. At the same time, however, we are starting to explore alternative means of incentivizing physicians to modify their practice patterns toward value-based care,” he said.

“Historically, it has been challenging to get physicians to adopt VBCPs, especially in an environment where there is no financial incentive. Giving a financial incentive has not been an option at our institution, and we also think that additional study is needed to understand its effectiveness.”

The authors are also beginning to look at redesigning VBCPs across other clinical service lines, including management for localized prostate cancer, small renal masses, and stone disease.

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