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Vertical Integration and Oncologists' Adoption of Immune Checkpoint Inhibitors in Non-Small Cell Lung Cancer
Xin Hu1, Changchuan Jiang2, K Robin Yabroff3
1Department of Radiation Oncology, Emory University School of Medicine, and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.
Objective:
To examine the trend in Immune Checkpoint Inhibitor (ICI) use before and after FDA approval in 2015 for patients with metastatic non-small cell lung cancer (NSCLC), and whether vertical integration of oncologists affected ICI use.
Study Setting And Design:
We conducted a retrospective cohort study of patients with metastatic NSCLC from 21 population-based cancer registries in the United States. We measured whether patients' treating oncologists were vertically integrated based on ≥ 10% of total services billed through hospital outpatient departments. We described the percentage of ICI recipients annually in 2010-2019, stratified by oncologists' integration status each year. In the post-FDA approval period (2015-2019), we used difference-in-differences (DID) modeling to compare the probability of patients' receiving ICI before and after oncologists became integrated relative to those whose oncologists remained non-integrated.
Data Sources And Analytic Sample:
Using the SEER-Medicare linkage, we identified Medicare Fee-For-Service beneficiaries aged ≥ 65.5 years diagnosed with metastatic NSCLC in 2010-2019 and followed them from diagnosis until ICI receipt, death, or end of 2019.
Principal Findings:
The overall percentage of patients receiving ICI increased from 0% before 2015 to 4.0% in 2015, and further increased to 29.2% in 2019. The percent of ICI recipients was higher among integrated (6.9%) than non-integrated oncologists (2.0%, p < 0.001) in 2015, but by 2017 adoption rates converged (19.8% vs. 19.8%, p = 0.91). DID analysis showed non-significant changes in the probability of ICI use after oncologists became integrated (1.7 percentage points, 95% CI = -1.0 to 4.4) relative to oncologists who remained non-integrated.
Conclusions:
Integrated oncologists were quicker to adopt ICIs in the first year after FDA approval, but this lead was not sustained over time. Vertically integrating into health systems was not associated with significant changes in ICI use. Further research is needed on the factors influencing equitable dissemination of novel cancer therapies across practice settings.
Insights
Immune Checkpoint Inhibitors (ICIs) use in metastatic non-small cell lung cancer (NSCLC) increased significantly post-FDA approval. Vertical integration of oncologists did not impact long-term ICI use, despite initial faster adoption.
Area of Science:
- Oncology
- Health Services Research
- Cancer Treatment
Background:
- Immune Checkpoint Inhibitors (ICIs) represent a significant advancement in treating metastatic non-small cell lung cancer (NSCLC).
- The landscape of cancer care delivery is evolving, with increasing vertical integration of oncology practices within health systems.
- Understanding factors influencing the adoption and dissemination of novel therapies like ICIs is crucial for equitable patient access.
Purpose of the Study:
- To analyze the trend of ICI utilization in metastatic NSCLC patients before and after FDA approval in 2015.
- To investigate the association between the vertical integration of oncologists and the adoption patterns of ICIs.
- To assess whether oncologists' integration status influences ICI use over time.
Main Methods:
- Retrospective cohort study utilizing SEER-Medicare data (2010-2019) for patients aged ≥65.5 years with metastatic NSCLC.
- Oncologist vertical integration defined as ≥10% of services billed through hospital outpatient departments.
- Difference-in-differences (DID) modeling employed to compare ICI use probability post-integration relative to non-integrated oncologists.
Main Results:
- Overall ICI use increased from 0% pre-2015 to 4.0% in 2015 and 29.2% by 2019.
- In 2015, integrated oncologists showed higher ICI use (6.9%) compared to non-integrated (2.0%), but adoption rates converged by 2017 (19.8% vs. 19.8%).
- DID analysis revealed no significant change in ICI use probability associated with oncologists becoming integrated (1.7 percentage points, 95% CI: -1.0 to 4.4).
Conclusions:
- Integrated oncologists initially adopted ICIs more rapidly post-FDA approval, but this lead diminished over time.
- Vertical integration into health systems was not significantly associated with changes in ICI utilization.
- Further research is warranted to identify factors promoting equitable access to novel cancer therapies across diverse practice settings.
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