Average per patient expenditures attributable to BPH testing and visits to urologists ranged from $35 to $527 per month (: Median $92, 20th percentile $72, 40th percentile $85, 60th percentile $100, 80th percentile $123). At the patient level, patient age did not differ (p=0.63), while comorbidities, race, and area socioeconomic status varied significantly across the quintiles of urologist practice style (p<0.01 for each). Patients with high comorbidity burdens were more likely to be treated by urologists with higher expenditure practice styles than were low comorbidity patients (p < 0.01). Black patients and patients with lower socioeconomic status were more likely to be seen by urologists with lower expenditure practice styles than were white patients or those of higher socioeconomic status (p < 0.01).
At the urologist level, practice structure, geographic location, and years in practice were different across the quintiles of practice style. Solo practice and hospital based practice were associated with higher expenditure practice styles. 23.6% of solo urologists were highest quintile and 23.1% of hospital based urologists were highest quintile. This compared to only 16.2% of group practice urologists being in the highest quintile of practice style (overall p<0.01 for differences among groups). Urologists in the Midwest were more likely to be in the lowest quintile of practice style than Northeastern and Western urologists (28.9% Midwest; 17.2% West; 10.5% Northeast). Urologists in the Northeast were skewed towards the high and highest quintiles of practice style, with 55.6% of urologists falling into these categories (p<0.01 for the overall differences among the groups). Duration of practice was also related to practice style. Urologists in practice for less than 15 years were more likely to be in the highest quintile of practice style than urologists in practice for longer amounts of time (28.3% compared to 18.6% and 17.1%; overall p < 0.01 for difference among the groups).
By definition, practice styles with higher expenditures were related to increased use of evaluative care tests. However, much variation exists within the categories of care (). While the lowest quintile urologists provided significantly less recommended care (226/100 patients) than highest quintile urologists a plateau of utilization develops, with middle to highest quintile urologists having similar practice styles (279, 301, and 306 procedures per 100 patients respectively). Among the optional care tests, a more exponential trend of increasing use across the practice styles is seen (47, 68, 81, 100, and 128 per 100 patients for lowest to highest). In contrast, not recommended care follows a roughly linear pattern of increasing use with increasing practice style quintile (175, 213, 233, 274, and 299 per 100 patients for lowest to highest practice style).
Evaluative Care Testing across AUA Guideline Recommended Levels of Care
When the individual tests making up the categories of care are examined, the patterns of care are shown to be more variable (). For recommended care, little difference exists in use of serum PSA testing (56/100 lowest, 65/100 middle, 68/100 highest); the difference in utilization across quintiles is largely driven by urinalysis (: 171/100 lowest, 214/100 middle, 237/100 highest). For optional care, cytology utilization plateaus across practice styles (4/100 lowest, 10/100 middle, 13/100 highest), whereas uroflow grows exponentially across the categories (: 7, 9, 15, 25, and 38 per 100 patients lowest to highest). Serum creatinine measurements () drive not recommended care use among all urologists, with patients seen by urologists in the higher quintiles receiving the most testing (129, 155, 164, 192, and 182 per 100 patients lowest to highest). In the remainder of not-recommended care, use of testing increases across the quintiles of practice style (), with the exception of upper tract imaging where a plateau develops (12, 16, 18, 20, and 22 procedures per 100 patients lowest to highest practice style).
The impact of infrequently performed, high expense procedures on categorization of urologists into practice style quintiles is shown in . Recommended care accounted for little variation among urologists with adjusted Medicare expenditures of $23 per patient in the lowest quintile urologists compared to $29 per patient among highest quintile urologists. In contrast, the absolute difference in adjusted optional care expenditures was $40 ($18 in lowest quintile versus $58 in highest). PVR contributed little to this difference ($9 versus $19 lowest to highest), while uroflow accounted for the majority of the expenditures ($5 lowest versus $26 highest). Not-recommended care had the highest absolute difference in expenditures, from $114 in the lowest quintile to $264 in the highest quintile. Of these adjusted expenditures, the commonly performed serum creatinine measurement contributed only $15 dollars of expenditures per patient in the lowest quintile and $22 per patient in the highest quintile. Cystoscopy provided the most impact on expenditures with $44 per patient in the lowest quintile and $100 per patient in the highest quintile.
Expenditures per Patient across Quintiles of Urologist Practice Style