The quality of surgical pathology care for men undergoing radical prostatectomy in the U.S

Urologist practice structure and quality of prostate cancer care

Objective

To examine three aspects of urologist practice structure that may affect quality of prostate cancer care: practice size, ownership of an intensity modulated radiation therapy (IMRT) device, participation within a multi-specialty group (MSG). Health care reforms focused on improving quality are particularly relevant for prostate cancer given its prevalence and concerns for overdiagnosis and overtreatment.

Methods

Using data from the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked registry, we examined quality of prostate cancer treatment according to each treating urologist's practice size, type (single-specialty vs. MSG) and ownership of IMRT. Mixed models were used to adjust for patient differences.

Results

We identified 22,412 men with newly diagnosed prostate cancer treated by 2,199 urologists during the study. We observed minimal differences for most quality metrics according to practice size, type, and ownership of IMRT. Adherence to all eligible quality metrics was better among MSGs compared to single specialty groups (20.0% adherence versus 18.2%, p=0.01) whereas there was no significant difference by ownership of IMRT (17.1% adherence in owners versus 18.9% non-owners, p=0.09).

Conclusion

Differences in quality across practice size, type and ownership of IMRT were modest, with substantial room for improvement regardless of practice structure.

Quality indicators of clinical cancer care for prostate cancer: a population-based study in southern Switzerland

Background

Quality of cancer care (QoCC) has become an important item for providers, regulators and purchasers of care worldwide. Aim of this study is to present the results of some evidence-based quality indicators (QI) for prostate cancer (PC) at the population-based level and to compare the outcomes with data available in the literature.

Methods

The study included all PC diagnosed on a three years period analysis (01.01.2011–31.12.2013) in the population of Canton Ticino (Southern Switzerland) extracted from the Ticino Cancer Registry database. 13 QI, approved through the validated Delphi methodology, were calculated using the “available case” approach: 2 for diagnosis, 4 for pathology, 6 for treatment and 1 for outcome. The selection of the computed QI was based on the availability of medical documentation. QI are presented as proportion (%) with the corresponding 95% confidence interval.

Results

700 PC were detected during the three-year period 2011–2013: 78.3% of them were diagnosed through a prostatic biopsy and for 72.5% 8 or more biopsy cores were taken. 46.5% of the low risk PC patients underwent active surveillance, while 69.2% of high risk PC underwent a radical treatment (radical prostatectomy, radiotherapy or brachytherapy) and 73.5% of patients with metastatic PC were treated with hormonal therapy. The overall 30-day postoperative mortality was 0.5%.

Conclusions

Results emerging from this study on the QoCC for PC in Canton Ticino are encouraging: the choice of treatment modalities seems to respect the international guidelines and our results are comparable to the scarce number of available international studies. Additional national and international standardisation of the QI and further QI population-based studies are needed in order to get a real picture of the PC diagnostic-therapeutic process progress through the definition of thresholds of minimal standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4604-2) contains supplementary material, which is available to authorized users.

Health Care Integration and Quality among Men with Prostate Cancer

PURPOSE

The delivery of high quality prostate cancer care is increasingly important for health systems, physicians and patients. Integrated delivery systems may have the greatest ability to deliver high quality, efficient care. We sought to understand the association between health care integration and quality of prostate cancer care.

MATERIALS AND METHODS

We used SEER-Medicare data to perform a retrospective cohort study of men older than age 65 with prostate cancer diagnosed between 2007 and 2011. We defined integration within a health care market based on the number of discharges from a top 100 integrated delivery system, and compared rates of adherence to well accepted prostate cancer quality measures in markets with no integration vs full integration (greater than 90% of discharges from an integrated system).

RESULTS

The average man treated in a fully integrated market was more likely to receive pretreatment counseling by a urologist and radiation oncologist (62.6% vs 60.3%, p=0.03), avoid inappropriate imaging (72.2% avoided vs 60.6%, p <0.001), avoid treatment when life expectancy was less than 10 years (23.7% vs 17.3%, p <0.001) and avoid multiple hospitalizations in the last 30 days of life (50.2% vs 43.6%, p=0.001) than when treated in markets with no integration. Additionally, patients treated in fully integrated markets were more likely to have complete adherence to all eligible quality measures (OR 1.38, 95% CI 1.27-1.50).

CONCLUSIONS

Integrated systems are associated with improved adherence to several prostate cancer quality measures. Expansion of the integrated health care model may facilitate greater delivery of high quality prostate cancer care.

Using a population-based observational cohort study to address difficult comparative effectiveness research questions: the CEASAR study

BACKGROUND

While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large.

METHODS

CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis.

RESULTS

We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey.

CONCLUSION

Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.

Understanding variation in the quality of the surgical treatment of prostate cancer

More than 80% of men with prostate cancer undergo active treatment, which can be associated with significant morbidity. Outcomes of surgical treatment vary widely depending on who treated the patient and where the patient was treated, implying that there is room for improvement. Factors influencing outcomes include patient characteristics as well as some measure of procedure volume. Although relationships between volume and outcomes for prostatectomy can most likely be explained by differences between surgeons (e.g., experience, technical skill), the hospital environment (e.g., team communication, safety culture) has the potential to either amplify or dampen the effects. Although most patient factors are immutable, these other aspects of surgical care and the delivery environment provide opportunities for quality improvement. Collaborative quality improvement initiatives may prove to be an important vehicle for achieving better prostate cancer care. These grass roots organizations, driven largely by urologists dedicated to providing prostate cancer care, have had initial successes in improving some aspects of quality in prostate cancer care, including reducing unwarranted use of imaging and perioperative morbidity. However, much of the variation in functional outcomes after prostate cancer surgery arises from differences in technical skill. Evaluating and improving intraoperative surgeon performance will inevitably be challenging, as they require acquisition and interpretation of data collected in the operating room. To this end, several methods have been described to objectively assess what happens in the operating room.

Racial variation in the pattern and quality of care for prostate cancer in the USA: mind the gap

OBJECTIVE

To review the literature on racial variation in the pattern of care (PoC) and quality of care (QoC) for prostate cancer, as there are known racial disparities in the incidence and outcomes of prostate cancer. While there are some biological explanations for these differences, they do not completely explain the variation. Differences in the appropriateness and QoC delivered to men of different racial groups may contribute to disparities in outcome.

METHODS

We searched the USA National Library of Medicine PubMed system for articles pertaining to quality indicators in prostate cancer and racial disparities in QoC for prostate cancer.

RESULTS

While standards for appropriate treatment are not clearly defined, racial variation in the PoC has been reported in several studies, suggesting that African-American men may receive less aggressive treatment. There are validated QoC indicators in prostate cancer, and researchers have begun to evaluate racial variation in adherence to these quality indicators. Further quality comparisons, particularly in structural measures, may need to be performed to fully evaluate differences in QoC.

CONCLUSIONS

There is mounting evidence for racial variation in the PoC and QoC for prostate cancer, which may contribute to observed differences in outcome. While some of the sources of racial variation in quality and outcome have been identified through the development of evidence-based guidelines and validated quality indicators, opportunities exist to identify, study and attempt to resolve other components of the quality gap.

Facilitating Clinical Outcomes Assessment through the automated identification of quality measures for prostate cancer surgery

OBJECTIVES

The College of American Pathologists (CAP) Category 1 quality measures, tumor stage, Gleason score, and surgical margin status, are used by physicians and cancer registrars to categorize patients into groups for clinical trials and treatment planning. This study was conducted to evaluate the effectiveness of an application designed to automatically extract these quality measures from the postoperative pathology reports of patients having undergone prostatectomies for treatment of prostate cancer.

DESIGN

An application was developed with the Clinical Outcomes Assessment Toolkit that uses an information pipeline of regular expressions and support vector machines to extract CAP Category 1 quality measures. System performance was evaluated against a gold standard of 676 pathology reports from the University of California at Los Angeles Medical Center and Brigham and Women's Hospital. To evaluate the feasibility of clinical implementation, all pathology reports were gathered using administrative codes with no manual preprocessing of the data performed.

MEASUREMENTS

The sensitivity, specificity, and overall accuracy of system performance were measured for all three quality measures. Performance at both hospitals was compared, and a detailed failure analysis was conducted to identify errors caused by poor data quality versus system shortcomings.

RESULTS

Accuracies for Gleason score were 99.7%, tumor stage 99.1%, and margin status 97.2%, for an overall accuracy of 98.67%. System performance on data from both hospitals was comparable. Poor clinical data quality led to a decrease in overall accuracy of only 0.3% but accounted for 25.9% of the total errors.

CONCLUSION

Despite differences in document format and pathologists' reporting styles, strong system performance indicates the potential of using a combination of regular expressions and support vector machines to automatically extract CAP Category 1 quality measures from postoperative prostate cancer pathology reports.