Variations in the quality of care at radical prostatectomy

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.

Influence of the facility caseload on the subsequent survival of men with localized prostate cancer undergoing radical prostatectomy

BACKGROUND

Several studies have investigated the relationship between experience measured by caseload and oncological outcomes, economics, and access to care for prostate cancer care. Oncological outcomes have been limited to biochemical failure after radical prostatectomy. Questions remain regarding the more definitive measures of outcomes and their relationship with caseload.

METHODS

The National Cancer Database was used to investigate the outcomes of radical prostatectomy in the United States. With overall survival (OS) as the primary outcome, the relationship between the facility annual caseload (FAC) for all prostate cancer encounters and the facility annual surgical caseload (FASC) for those requiring radical prostatectomy was examined with a Cox proportional hazards model. Four volume groups were defined by caseload: <50th percentile (volume group 1 [VG1]), 50th to 74th percentiles (volume group 2 [VG2]), 75th to 89th percentiles (volume group 3 [VG3]), and ≥90th percentile (volume group 4 [VG4]). By FAC/FASC, 11%/8%, 17%/18%, 25%/26%, and 47%/49% of patients were treated in VG1 through VG4, respectively.

RESULTS

Between 2004 and 2014, 488,389 patients underwent radical prostatectomy. At a median follow-up of 60.75 months, the median OS was not reached. There was a significant OS benefit as the caseload increased. For FAC, the adjusted OS difference between VG1 and VG4 at 90th percentile survivorship reached 13.2 months (hazard ratio [HR], 1.30; 95% CI, 1.23-1.36; P < .0001). For FASC, this was 11.3 months (HR, 1.25; 95% CI, 1.192-1.321; P < .0001).

CONCLUSIONS

There is a statistically significant OS advantage from performing radical prostatectomy at a facility with a high annual caseload. Caseload measured by all prostate cancer encounters is a better predictor of favorable outcomes than the number of surgeries performed at a facility.

LAY SUMMARY

An in-depth analysis of 488,389 cases of radical prostatectomy performed in more than 1000 facilities over a 10-year period showed better survival when surgery was performed in facilities with more experience and greater caseload. A survival difference of up to 13 months was observed when comparing patients treated at less experienced versus more experienced centers.   Experience across all stages of prostate cancer was a stronger predictor of survival outcome than just the number of surgeries performed.

Quantifying severe urinary complications after radical prostatectomy: the development and validation of a surgical performance indicator using hospital administrative data

OBJECTIVES

To develop and validate a surgical performance indicator based on severe urinary complications that require an intervention within 2 years of radical prostatectomy (RP), identified in hospital administrative data.

PATIENTS AND METHODS

Men who underwent RP between 2008 and 2012 in England were identified using hospital administrative data. A transparent coding framework based on procedure codes was developed to identify severe urinary complications which were grouped into 'stricture', 'incontinence' and 'other'. Their validity as a performance indicator was assessed by evaluating the consistency with diagnosis codes and association with patient and surgical characteristics. Kaplan-Meier methods were used to assess time to first occurrence and multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for patient and surgical characteristics.

RESULTS

A total of 17 299 men were included, of whom 2695 (15.6%) experienced at least one severe urinary complication within 2 years. High proportions of men with a complication had relevant diagnosis codes: 86% for strictures and 93% for incontinence. Urinary complications were more common in men from poorer socio-economic backgrounds (OR comparing lowest with highest quintile: 1.45; 95% confidence interval [CI] 1.26-1.67) and in those with prolonged length of hospital stay (OR 1.54, 95% CI 1.40-1.69), and were less common in men who underwent robot-assisted surgery (OR 0.65, 95% CI 0.58-0.74).

CONCLUSION

These results show that severe urinary complications identified in administrative data provide a medium-term performance indicator after RP. They can be used for research assessing outcomes of treatment methods and for service evaluation comparing performance of prostate cancer surgery providers.

Variation in guideline adherence in non-Hodgkin's lymphoma care: impact of patient and hospital characteristics

BACKGROUND

The objective of this observational study was to assess the influence of patient, tumor, professional and hospital related characteristics on hospital variation concerning guideline adherence in non-Hodgkin's lymphoma (NHL) care.

METHODS

Validated, guideline-based quality indicators (QIs) were used as a tool to assess guideline adherence for NHL care. Multilevel logistic regression analyses were used to calculate variation between hospitals and to identify characteristics explaining this variation. Data for the QIs regarding diagnostics, therapy, follow-up and organization of care, together with patient, tumor and professional related characteristics were retrospectively collected from medical records; hospital characteristics were derived from questionnaires and publically available data.

RESULTS

Data of 423 patients diagnosed with NHL between October 2010 and December 2011 were analyzed. Guideline adherence, as measured with the QIs, varied considerably between the 19 hospitals: >20 % variation was identified in all 20 QIs and high variation between the hospitals (>50 %) was seen in 12 QIs, most frequently in the treatment and follow-up domain. Hospital variation in NHL care was associated more than once with the characteristics age, extranodal involvement, multidisciplinary consultation, tumor type, tumor aggressiveness, LDH level, therapy used, hospital region and availability of a PET-scanner.

CONCLUSION

Fifteen characteristics identified at the patient level and at the hospital level could partly explain hospital variation in guideline adherence for NHL care. Particularly age was an important determinant: elderly were less likely to receive care as measured in the QIs. The identification of determinants can be used to improve the quality of NHL care, for example, for standardizing multidisciplinary consultations in daily practice.

Does a surgeon's annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up? Findings from a prospective national study

OBJECTIVE

This study aimed to assess the prevalence of positive surgical margins (PSM) and urinary incontinence (UI) in relation to surgeons' annual radical prostatectomy (RP) volume.

MATERIAL AND METHODS

This national study prospectively assessed 521 preoperatively continent patients with prostate cancer (PCa), scheduled for RP by surgeons with high (>50), medium (20-50) or low annual volume (<20) at 14 urological departments in Norway. Patients responded to UI questions from the Expanded Composite prostate cancer index (EPIC-50) before and 1 year after RP. UI was defined as "use of pad(s)" and/or "a moderate or severe urinary leakage problem (ULP)". Preoperative prediction of PSMs and UI was explored in multivariate regression analyses with the following independent variables: surgeons' annual RP volume, type of hospital (university versus community), patient's health, sociodemographic features and PCa characteristics.

RESULTS

Based on histopathological reports, the overall PSM rate was 26%, with differences between the high- (18%), medium- (28%) and low-volume (44%) groups. Increasing PSM rates were predicted by surgeons belonging to the low- and medium-volume categories, prostate-specific antigen> 10 µg/l, Gleason score >7, patient age >65 years and <12 years of education. At 1-year follow-up 40% reported UI, without significant differences between the volume groups. Only 46% of those who used pad(s) experienced ULP. UI was predicted by clinical category ≥T2 and community type of hospital, but not by surgeons' annual RP volume. CONCLUSIONS. Preoperative counselling should take into account the relationship between surgeon's annual RP volume and PSM rate and the current knowledge about UI and ULP.