Adherence to performance measures and outcomes among men treated for prostate cancer

Association Between Urologist Merit-Based Incentive Payment System Performance and Quality of Prostate Cancer Care

INTRODUCTION

We performed a study to evaluate the association between urologist performance in the Merit-Based Incentive Payment System (MIPS), and quality and spending for prostate cancer care.

METHODS

Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019 were assigned to their primary urologist. Associated MIPS scores were identified and categorized based on thresholds for payment adjustment as low (worst), moderate, and high (best). Multivariable mixed effects models were used to measure the association between MIPS performance and adherence to quality measures and price standardized spending for prostate cancer.

RESULTS

Adherence to quality measures did not vary across MIPS performance groups for pretreatment counselling by both a urologist and radiation oncologist (low-76%, [95% CI 73%-80%], moderate-77% [95% CI 74%-79%], and high-75% [95% CI 74%-76%]) and avoiding treatment in men with a high risk of noncancer mortality within 10 years of diagnosis (low-40% [95% CI 35%-45%], moderate-39% [95% CI 36%-43%], high-38% [95% CI 36%-39%]). Men on active surveillance managed by high performers more likely received a confirmatory test (44% [95% CI 43%-46%]) compared to those managed by moderate (38% [95% CI 33%-42%]) performers, but not low performers (36% [95% CI 29%-44%]). There was no difference in adjusted spending across MIPS performance groups.

CONCLUSIONS

Better performance in MIPS is associated with a higher rate of confirmatory testing in men initiating active surveillance for prostate cancer. However, performance was not associated with other dimensions of quality nor spending.

Quality Indicators in the Clinical Specialty of Urology: A Systematic Review

CONTEXT

In health care, monitoring of quality indicators (QIs) in general urology remains underdeveloped in comparison to other clinical specialties.

OBJECTIVE

To identify, synthesise, and appraise QIs that monitor in-hospital care for urology patients.

EVIDENCE ACQUISITION

This systematic review included peer-reviewed articles identified via Embase, MEDLINE, Web of Science, CINAHL, Global Health, Google Scholar, and grey literature from 2000 to February 19, 2021. The review was carried out under the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used the Appraisal of Indicators through Research and Evaluation (AIRE) tool for quality assessment.

EVIDENCE SYNTHESIS

A total of 5111 articles and 62 government agencies were screened for QI sets. There were a total of 57 QI sets included for analysis. Most QIs focused on uro-oncology, with prostate, bladder, and testicular cancers the most represented. The most common QIs were surgical QIs in uro-oncology (positive surgical margin, surgical volume), whereas in non-oncology the QIs most frequently reported were for treatment and diagnosis. Out of 61 articles, only four scored a total of ≥50% on the AIRE tool across four domains. Aside from QIs developed in uro-oncology, general urological QIs are underdeveloped and of poor methodological quality and most lack testing for both content validity and reliability.

CONCLUSIONS

There is an urgent need for the development of methodologically robust QIs in the clinical specialty of general urology for patients to enable standardised quality of care monitoring and to improve patient outcomes.

PATIENT SUMMARY

We investigated a range of quality indicators (QIs) that provide health care professionals with feedback on the quality of their care for patients with general urological diseases. We found that aside from urological cancers, there is a lack of QIs for general urology. Hence, there is an urgent need for the development of robust and disease-specific QIs in general urology.

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.

Hospital-level Effects Contribute to Variations in Prostate Cancer Quality of Care

A paucity of real-world data exists highlighting whether variations in prostate cancer quality of care occur at a hospital level, independent of differences in case mix. To overcome this knowledge gap, we benchmarked hospital-level quality (n = 1245 hospitals) across a broad multidisciplinary panel of previously reported disease-specific, expert-defined quality indicators (QIs), adjusting for differences in patient case mix by indirect standardization. A composite measure of prostate cancer quality-the prostate cancer quality score (PC-QS)-was derived, and associations between PC-QS and hospital volume, academic status, and location as well as patient all-cause mortality were determined. After adjusting for the case mix, of the total of 1245 hospitals evaluated, 2-37% were identified as those performing significantly below the national average for a given QI. Hospitals with a higher PC-QS displayed larger patient volumes, were more commonly academic affiliated, and had lower overall mortality. Collectively, our data-driven benchmarking analysis reveals that widespread hospital-level variations exist in prostate cancer quality of care after adjusting for differences in case mix, with the PC-QS serving as a novel, validated, quality benchmarking tool. PATIENT SUMMARY: Our statistical benchmarking method shows that the quality of prostate cancer care varies between hospitals, after accounting for differences in patient characteristics. The prostate cancer quality score is a novel, validated, quality benchmarking tool.

Identifying Performance Outliers for Stroke Care Based on Composite Score of Process Indicators: an Observational Study in China

BACKGROUND

Variability in the quality of stroke care is widespread. Identifying performance-based outlier hospitals based on quality indicators (QIs) has become a common practice.

OBJECTIVES

To develop a tool for identifying performance-based outlier hospitals based on risk-adjusted adherence rates of process indicators.

DESIGN

Hospitals were classified into five-level outliers based on the observed-to-expected ratio and P value. The composite quality score was derived by summation of the points for each indicator for each hospital, and associations between outlier status and outcomes were determined.

PARTICIPANTS

Patients diagnosed with acute ischemic stroke, January 1, 2011-May 31, 2017.

INTERVENTION

N/A MAIN OUTCOME MEASURES: Independence at discharge (the modified Rankin Scale = 0-2).

KEY RESULTS

A total of 501,132 patients from 519 hospitals were identified. From 0.39 to 19.65% of hospitals were identified as high outliers according to various QIs. Composite quality scores ranged from - 20 to 16. Providers that were high outliers based on QI2, QI8, QI9, and QI11 had higher independent rates. For composite quality score, each point increase corresponded to an 8% increase in the odds of independent rate.

CONCLUSION

Nationwide variation in the quality of acute stroke care exists at the hospital level. Variability in the quality of stroke care can be captured by our proposed quality score. Applying this quality score as a benchmarking tool could provide audit-level feedback to policymakers and hospitals to aid quality improvement.

The Role of Provider Characteristics in the Selection of Surgery or Radiation for Localized Prostate Cancer and Association With Quality of Care Indicators

INTRODUCTION

We sought to identify the role of provider and facility characteristics in receipt of radical prostatectomy (RP) or external beam radiation therapy (EBRT) and adherence to quality of care measures in men with localized prostate cancer (PCa).

MATERIALS AND METHODS

Subjects included 2861 and 1630 men treated with RP or EBRT, respectively, for localized PCa whose records were reabstracted as part of the Centers for Disease Control and Prevention Breast and Prostate Patterns of Care Study. We utilized multivariable generalized estimating equation regression analysis to assess patient, clinical, and provider (year of graduation, urologist density) and facility (group vs. solo, academic/teaching status, for-profit status, distance to treatment facility) characteristics that predicted use of RP versus EBRT as well as quality of care outcomes.

RESULTS

Multivariable analysis revealed that group (vs. solo) practice was associated with a decreased risk of RP (odds ratio, 0.47; 95% confidence interval, 0.25-0.91). Among RP patients with low-risk disease, receipt of a bone scan that was not recommended was significantly predicted by race and insurance status. Surgical quality of care measures were associated with physician's year of graduation and receiving care at a teaching facility.

CONCLUSIONS

In addition to demographic factors, we found that provider and facility characteristics were associated with treatment choice and specific quality of care measures. Long-term follow-up is required to determine whether quality of care indicators are related to PCa outcomes.

Utilization of Prostate Cancer Quality Metrics for Research and Quality Improvement: A Structured Review

BACKGROUND

The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature.

METHODS

The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018. A gray literature search for other documents was also conducted. After the selection process of the pertinent articles, measure characteristics were abstracted, and uses were summarized for the 10 most frequently utilized measures in the literature.

RESULTS

A total of 26 articles were identified for review. Of the 71 proposed prostate cancer quality measures, only 47 were used, and less than 10% of these were endorsed by the National Quality Forum. Process measures were most frequently reported (84.5%). Only 6 outcome measures (8.5%) were proposed-none of which were among the most frequently utilized.

CONCLUSION

Although a high number of proposed prostate cancer quality measures are reported in the literature, few were assessed, and the majority of these were non-endorsed process measures. Process measures were most commonly assessed; outcome measures were rarely evaluated. In a step to close the quality chasm, a "top 5" core set of quality measures for prostate cancer care, including structure, process, and outcomes measures, is suggested. Future studies should consider this comprehensive set of quality measures.

Receipt of best care according to current quality of care measures and outcomes in men with prostate cancer

PURPOSE

We evaluated whether patients with prostate cancer who received best care according to a set of 5 nationally endorsed quality measures had decreased treatment related morbidity and improved cancer control.

MATERIALS AND METHODS

In this retrospective cohort study we included 38,055 men from the SEER (Surveillance, Epidemiology and End Results)-Medicare database treated for localized prostate cancer between 2004 and 2010. We determined whether each patient received best care, defined as care adherent to all applicable measures. We measured associations of best care with the need for interventions, addressing treatment related morbidity, and with the need for secondary cancer therapy using Cox proportional hazards models.

RESULTS

Only 3,412 men (9.0%) received best care. Five years after treatment these men and men who did not receive best care had a similar likelihood of undergoing procedures for urinary morbidity (prostatectomy subset 10.7% vs 12.9%, p = 0.338) and secondary cancer therapy (prostatectomy for high risk prostate cancer subset 40.9% vs 37.3%, p = 0.522). However, they were more likely to be treated with a procedure for sexual morbidity (prostatectomy 17.3% vs 10.8%, p <0.001). Similar trends were observed in men treated with radiotherapy.

CONCLUSIONS

Overall men who received best care did not fare better in regard to treatment related morbidity or cancer control. Collectively our findings suggest that the current process of care measures are not tightly linked to outcomes and further research is needed to identify better measures that are meaningful and important to patients.