Improving appropriate selection of radical prostatectomy for prostate cancer

Effectiveness of interventions for reducing the frequency of radical prostatectomy procedures in the elderly: an evaluation

Between 1993 and 1997, the Peer Review Organizations (PROs) implemented interventions for reducing radical prostatectomy rates in 50 selected hospitals in 10 states and all hospitals in an additional 4 states. Control hospitals and states were matched with the intervention hospitals and states. Prostate cancer incidence rates were used to estimate the number of Medicare beneficiaries aged 75 years and older with prostate cancer, the denominators for the procedure rates, in the hospital service area of each intervention and control hospital, and in each state and their controls. After interventions, significant reductions in the state-specific radical prostatectomy rates were achieved in the intervention hospitals in 2 states and in 1 of the 4 intervention states where statewide interventions had been implemented. Similar reductions were seen in the control hospitals in 3 other individual states and 8 states combined where hospital-based interventions were implemented. These changes in the procedure rates were most likely due to the national decline in the incidence of prostate cancer, not the PRO interventions.

Prostate cancer detection, characterization, and clinical outcomes in men aged 70 years and older referred for transrectal ultrasound and prostate biopsies

OBJECTIVES

To evaluate the diagnostic findings and treatment options chosen in men aged 70 years and older referred for prostate biopsy.

METHODS

Age, prostate-specific antigen (PSA), biopsy pathology, clinical stage, treatment pursued, and treatment outcome were analyzed in 210 men age 70 years and older referred for transrectal ultrasound and prostate biopsies. All patients were followed for a mean of 46.9 months (range 28 to 63).

RESULTS

Cancer was found in 120 (56.8%) of the patients. The cancer detection rate was significantly higher (81.0%) in patients aged 80 years and older than those younger than 80 years. Cancer patients aged 80 years and older had a higher rate of poorly differentiated cancer (64.7%) compared with the 70 to 74-year-olds (33.3%) and 75 to 79-year-olds (32.1%). The patients aged 80 years and older also had a larger proportion of high-stage cancer. The patients younger than 80 years had a significantly higher incidence of stable/falling PSA with treatment compared with the older patients. Of the 210 patients, 41 (19.4%) died within 5 years of the diagnostic procedure; 3 died of prostate cancer. The death rate was not significantly different among the three age groups evaluated. None of the patients aged 80 years and older died of prostate cancer.

CONCLUSIONS

Patients aged 80 years and older who are diagnosed with prostate cancer are less likely to respond well to treatment and usually die of unrelated causes. Aggressive diagnosis, staging, and treatment in octogenarians should be guided by the patients' symptoms, overall health, and personal preferences.

The empowering potential of quality improvement data

Data are being used to redefine, transform, and empower the roles of providers, payers, and patients. The empowering potential of data on these three groups, and their changing roles are reviewed. The use of data to transform care and increase equality is not new, yet the comprehensive application of principles of continuous quality improvement to the delivery processes is just beginning. The approach to the quality improvement processes employed by peer review organizations includes idea capture, development of intuitively appealing quality indicators, formulating the intervention, formalizing the research architecture, and quantifying the impact of the interventions. The multifaceted interventions for improvement are discussed. The future of medicine includes a greater use of data and the quantitative sciences to inspire improvement across the health care delivery continuum.