title: Local coverage determination policy and the use of stereotactic body radiation therapy for prostate cancer.
abstract: BACKGROUND
  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.
authors: Department of Urology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
authors: Bruce L
authors: BL
authors: Jacobs
authors: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
authors: Robert
authors: R
authors: Sunderland
authors: Division of General Internal Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Center for Research on Health Care, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
authors: Jonathan
authors: J
authors: Yabes
authors: Department of Urology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
authors: Joel B
authors: JB
authors: Nelson
authors: Division of General Internal Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Center for Research on Health Care, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
authors: Amber E
authors: AE
authors: Barnato
authors: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
authors: Justin E
authors: JE
authors: Bekelman
keywords: SEER-Medicare; health policy; local coverage determination; prostate cancer; stereotactic body radiation therapy