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Urologist's Research Aims at Codifying Excellence of Care, Increasing Access

Neff Newitt, Valerie

doi: 10.1097/01.COT.0000554317.35971.18

Urologist Liam Macleod, MD, MPH, has zig-zagged across the country in the course of his training and expanding career, and has built a broad purpose for his clinical and research work, partially based on his exposure to different populations and locations. “Access to high-quality cancer care differs drastically depending on who you are and where you are,” he told Oncology Times. He is putting a lot of effort into trying to level that medical playing field.

The son of British parents who relocated to Northern California, MacLeod lived the dream of many an American youth—leisure hours at the beach, surfing waves near his hometown of Santa Cruz. But when it came time to select a university he wanted to experience the epicenter of the Northeast—the Big Apple.

“I decided to go to Columbia University in New York City to get a different perspective and get a taste of Manhattan. I studied sociology and public health there, and it was a great urban tapestry for studying socioeconomic variations and how they impact health,” he declared. “Though I eventually decided to go into surgery, specifically urology, the relationship between socioeconomic status and health care remains a big interest for me. My time in New York impacted my perception of how health can vary dramatically, even in such confined geography, due to a variety of factors and access to expert health care.”

MacLeod returned to California to attend Stanford Medical School then spent 6 years at the University of Washington in Seattle doing a surgical residency in urology.

For the last 2 years he has been doing a postdoctoral fellowship in urologic oncology, a Society of Urologic Oncology accredited program, at UPMC Hillman Cancer Center and the University of Pittsburgh. “University of Pittsburgh Medical Center is a great health care system,” he said, “because there are over 40 hospitals in the health system. The patient capacity is approximately 8,000 licensed beds and there is a huge regional component in terms of a referral network.

“Plus, within the system there are different sized hospitals in different towns throughout Pennsylvania. I have worked in 12 of them, which has provided a great case study in how smaller centers can integrate with larger regional centers of excellence like the Hillman Cancer Center in Pittsburgh, with a greater array of diagnostic and therapeutic tools. It is fascinating to see what works well, and what remains a work in progress in terms of moving patients within the system, to the right provider or services, at the right time.”

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Examining Health Services

Although Macleod spends a great deal of time in clinical work, he vigorously maintains his research interests. “My research interests fall under the broad category of health services research, which uses a variety of methods drawn from epidemiology, biostatistics, health economics, and sociology,” he explained. “The goal is to use observational data to draw policy-relevant conclusions about health care delivery and access, and how that is impacted by socioeconomic factors such as race, gender, insurance status, etc. We want to find out how those things affect the actual quality of care, and how quality of care varies from place to place.”

It is information ripe for the picking, but such research has been somewhat overlooked in the past. “I think this area has been underfunded, possibly because it may appear to some to be less costly and easy to just ‘data-mine’ to do this kind of work,” said Macleod. “However, to study health policy issues using large datasets, we need a great deal of computational and human power to carry this out, to obtain datasets, to clean them, to analyze them, to get the datasets to actually ‘speak’ and not be just a mish-mash of inappropriately interpreted numbers.

“I have a deep respect for people who do basic research, balancing clinical work and a lab. I've been a witness to a lot of major breakthroughs that came out of the lab to the bedside since starting my path in medicine,” he noted. “However, when the medical research community comes up with a highly effective cure, but it costs too much or is inaccessible to most of the people who need it, then the impact is diminished or delayed. Thus, the work that health services researchers do to inform policies about delivery and access is equally important.”

Macleod and fellow researchers use a variety of databases, including the Surveillance Epidemiology and End Results-Medicare database, to carry out their investigations. From the files that are amassed, “We must develop ways to identify what we are looking for with some degree of validity,” said Macleod.

Currently working on a kidney cancer project for which he earned a Conquer Cancer grant, Macleod explained, “We looked at 30 quality indicators that should be considered or offered to patients with kidney cancer across different stages of disease. They are things like whether part, or all, of the kidney is removed, use of minimally invasive surgery, and appropriate mobilization of an interdisciplinary team.

“We are looking at hospitals and their adherence rates to these standards. We are also looking at access to hospitals meeting the benchmark for excellence and whether this varies by income, race, urban, or rural status.”

The answers are not totally straightforward, nor easy to identify in a claims-based dataset. “A lot of it is based on billing codes and looking at the chronology of when things happened following diagnosis,” said Macleod. “There is a massive amount of data and you have to be very thoughtful about what is retained for analysis. We use procedural codes to identify different surgical procedures. We use provider taxonomy codes to identify if a patient with kidney cancer was treated by an interdisciplinary team or just saw a surgeon who cut out the mass but never referred the patient to an oncologist, radiation oncologist, or palliative care provider as appropriate.

“We can identify hospitals where specific surgeries are being done and what volume of that surgery is performed. For kidney cancer, there are various types of surgery that depend on how advanced the tumor is and patient factors,” he outlined. “We can determine if the patient is getting a kidney removed at a hospital that does 500 of those a year, or at a hospital that does just one of those a year. We can also look at the surgeon level within each hospital. For example, at a hospital doing 500 cases a year, the majority may be done by two or three surgeons, with the others doing the procedure much less frequently.

“Once we figure out all these things that may be important in the delivery of kidney cancer care, then we can start to do analyses on the rates of people getting what they are supposed to get for their stage of disease, and whether these markers of appropriate care impact the perioperative complication rate and patient survival.”

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Emerging Findings

Asked to detail some of the important findings that the larger body of his research has surfaced, Macleod said he is learning a lot about financial toxicity in cancer treatment and the incredible amount of stress it imposes on patients.

“Physicians say to a patient, ‘You need this drug’ or ‘You need this marker to figure out what the prognosis is for your disease.’ In the meantime, patients are worried about basic things, like finding transportation, getting time off from work to undergo therapy, and how they are going to pay for what we tell them they need. As clinicians, we need to look at all the angles and stressors that come to bear on a patient as they try to navigate the therapies or diagnostics we recommend,” advised Macleod.

When he first arrived at Pitt, Macleod joined a very productive health services group including team members Benjamin Davies, MD, and Bruce Jacobs, MD, MPH, with whom he continues to work. “While we are still building all the variables we want and the code and algorithms to do the kidney cancer project—and there will be more to report soon—we've made a lot of headway in other disease sites,” he clarified.

He noted that in the late 2000s there was a change in the way clinicians risk-stratify patients at the time of prostate biopsy. “This is important as a large proportion of prostate cancer is slow growing and there is a huge momentum shift to monitoring prostate cancer and deferring treatment. However, to agree to monitoring, patients and physicians must agree that their cancer is lower risk.

“Clinicians started to use MRI in conjunction with biopsy. Instead of doing the traditional systematic but semi-random biopsy of the prostate, we can now do an MRI ahead of the biopsy and use MRI imaging to target precise lesions in the prostate. This creates a greater sensitivity for higher-risk prostate cancer,” explained Macleod. “We were interested in how this was used in prostate cancer surveillance and we looked at trends and uptake of this imaging modality with biopsy during prostate cancer surveillance.

“We found that initially MRI utilization was low—around 11 percent—but from 2008 to 2013 it increased to about 15 percent. We found that patients were much more likely to have an MRI as part of management in active surveillance and around the time of prostate biopsy if they lived in a high-income area, in a highly educated zip code, and were Caucasian. It gave us a snapshot of how technologies can impact care and yet not be distributed equitably.” (Two papers on these findings will be published in Urology and European Urology Focus this year.)

While the findings came as no surprise to the researchers, Macleod said now the job at hand is to find out exactly why the modality was not offered in a more widespread fashion. “Why is it offered less in certain areas? We don't totally know. One reason may be where patients are being treated; MRIs are only available at select centers. Alternatively, there may be some inherent bias in the providers when they discuss available modalities. It may also be established referral patterns where certain subgroups of patients are just much more likely to be seen at the tertiary referral center.”

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Now married and a father of a daughter, 5, and an infant son, Macleod remains an outdoor enthusiast and plans on yet again crisscrossing the country having accepted a new position at Asante Rogue Regional Medical Center and its cancer center in Southern Oregon beginning in July. Asante is a 5-hour drive from the nearest university, presenting a geographical burden on patients. The medical center has a huge, nine-county geographic referral base and a high need for urologists. Many patients would prefer to receive care closer to home.

“I will be joining four urologists but will be the only urologic oncologist. My goal will be to take the things I've seen and worked on at major academic centers with me to the already-thriving oncology team at the Asante Cancer Center and put it even more firmly on the map in the cancer care landscape. The center is a Southwest Oncology Group (SWOG) site and works closely with the Knight Cancer Center at OHSU in Portland. Asante has a lot of great resources for excellence in cancer care; prostate MRI has been acquired recently and I will be joining a great team of oncologists and radiation oncologists. I want to play a role in ensuring a sustainable, well-attended genitourinary tumor board and be involved in patient support groups for bladder, kidney, and prostate cancers, as well as serve as a conduit of information and collaborative treatment plans between regional centers such as Knight Cancer Center,” said an enthusiastic Macleod.

“I will continue to carry my perspective into my future practice about problems impacting patients who are underinsured, and the financial toxicity affecting patients who are dealing with cancer, which is so destabilizing. I also plan to continue to be involved in research with the health services group at University of Pittsburgh Medical Center and Hillman Cancer Center as part of their brain trust,” he said as he looked to the future. “It is not a typical academic, high-powered, ivory tower approach that I am taking. There are high urology and urologic oncology needs among the rural population in the Rogue Valley, where Asante is located. The ability to share my specialized cancer insights with a population in need of urologic cancer care in a focused way really appeals to me.”

Macleod feels duty-bound to remind fellow oncologists that because access to high-quality cancer care differs drastically depending on whom and where a patient is, work must be done to integrate local community care with expert regional care to increase access to outstanding care for the greatest number of eligible patients.

“To do this, we need to create codified ways to make big data more accessible and more useable so we can understand care patterns and use them to form infrastructure and support systems that can improve communication between community and regional sites of care,” he noted. “We must reframe the importance of some of the more basic things such as transportation, time off from work, and the luxury of taking time to seek out a well-qualified surgeon or hospital as very important components of an interdisciplinary cancer approach.”

Valerie Neff Newitt is a contributing writer.

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