Physician practice variability in the use of extended-fraction radiation therapy for bone metastases: Are we choosing wisely?

Arjun Gupta, Peiqi Wang, Ramy Sedhom, Fumiko Chino, Mark R. Waddle, Robert C. Miller, David H. Johnson, Nina N. Sanford, Amol Narang, Sara R. Alcorn, Martin A. Makary

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


PURPOSE Routine use of extended-fraction (. 10 fractions) radiation therapy (RT) for palliation of bone metastases is recognized as a low-value intervention by the American Society for Radiation Oncology. We examined contemporary practice patterns of, and physician characteristics associated with extended-fraction RT use. MATERIALS AND METHODS We conducted a retrospective cohort study using Medicare fee-for-service data. We included patients who underwent 2- or 3-dimensional external-beam RT for bone metastases between January 1, 2016, and December 31, 2018. Physicians treating . 10 patients over the study period were analyzed for their individual practice. Hierarchic logistic regression modeling was used to identify patient- and physician-level factors associated with extended-fraction RT use. RESULTS A total of 12,221 patients (median age, 75.6 years; 40.9% women, 87.6% white) were included. The rate of extended-fraction RT was 23.4%. A total of 1,432 physicians treated any patient. Among the 382 physicians treating . 10 patients, 127 (33.2%) used extended-fraction RT . 30% (consensus threshold). Physician factors associated with decreased odds of extended-fraction RT were years since medical school graduation (# 10 years and 11-20 years v $ 31 years: adjusted odds ratio [aOR], 0.32 [95% CI, 0.20 to 0.51] and 0.64 [95% CI, 0.44 to 0.93]) and practicing in the Northeast or Midwest versus the South (aOR, 0.36 [95% CI, 0.22 to 0.58] and 0.48 [95% CI, 0.31 to 0.74]). Physicians treating . 20 patients (v 11-14 patients) over the study period had increased odds of delivering extended-fraction RT (aOR, 1.53 [95% CI, 1.10 to 2.12]). CONCLUSION In this study, almost one fourth of patients received extended-fraction RT, and one third of physicians had an extended-fraction RT use rate of . 30%. Personalized feedback of performance data, clinical pathways and peer review, and updated reimbursement models are potential mechanisms to address this low-value care.

Original languageEnglish (US)
Pages (from-to)E758-E769
JournalJCO Oncology Practice
Issue number8
StatePublished - 2020

ASJC Scopus subject areas

  • Health Policy
  • Oncology(nursing)
  • Oncology


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