Quality-of-care indicators for early-stage prostate cancer

Initial Quality of Life and Toxicity Analysis of a Randomized Phase 3 Study of Moderately Hypofractionated Radiation Therapy With or Without Androgen Suppression for Intermediate-Risk Adenocarcinoma of the Prostate: PCG GU003

Purpose

Our objective was to report the quality of life (QoL) analysis and toxicity in patients with intermediate-risk prostate cancer treated with or without androgen deprivation therapy (ADT) in Proton Collaborative Group (PCG) GU003.

Methods and Materials

Between 2012 and 2019, patients with intermediate-risk prostate cancer were enrolled. Patients were randomized to receive moderately hypofractionated proton beam therapy (PBT) to 70 Gy relative biologic effectiveness in 28 fractions to the prostate with or without 6 months of ADT. Expanded Prostate Cancer Index Composite, Short-Form 12, and the American Urological Association Symptom Index instruments were given at baseline and 3, 6, 12, 18, and 24 months after PBT. Toxicities were assessed according to Common Terminology Criteria for Adverse Events (version 4).

Results

One hundred ten patients were randomized to PBT either with 6 months of ADT (n = 55) or without ADT (n = 55). The median follow-up was 32.4 months (range, 5.5-84.6). On average, 101 out of 110 (92%) patients filled out baseline QoL and patient-reported outcome surveys. The compliance was 84%, 82%, 64%, and 42% at 3, 6, 12, and 24 months, respectively. Baseline median American Urological Association Symptom Index was comparable between arms (6 [11%] ADT vs 5 [9%] no ADT, P = .359). Acute and late grade 2+ genitourinary and gastrointestinal toxicity were similar between arms. The ADT arm experienced a QoL decline of mean scores in the sexual (-16.1, P < .001) and hormonal (-6.3, P < .001) domains, with the largest time-specific hormonal differences at 3 (-13.8, P < .001) and 6 (-11.2, P < .001) months. The hormonal QoL domain returned to baseline 6 months after therapy. There was a trend to baseline in sexual function 6 months after completion of ADT.

Conclusions

After 6 months of ADT, sexual and hormonal domains returned to baseline 6 months after completion of treatment for men with intermediate-risk prostate cancer.

Global and regional quality of care index for prostate cancer: an analysis from the Global Burden of Disease study 1990-2019

BACKGROUND

Prostate cancer (PCa) is one of the most prevalent cancers worldwide, with a significant burden on societies and healthcare providers. We aimed to develop a metric for PCa quality of care that could demonstrate the disease's status in different countries and regions (e.g., socio-demographic index (SDI) quintiles) and assist in improving healthcare policies.

METHODS

Basic burden of disease indicators for various regions and age-groups were retrieved from Global Burden of Disease Study 1990-2019, which then were used to calculate four secondary indices: mortality to incidence ratio, DALYs to prevalence ratio, prevalence to incidence ratio, and YLLs to YLDs ratio. These four indices were combined through a principal component analysis (PCA), producing the quality of care index (QCI).

RESULTS

PCa's age-standardized incidence rate increased from 34.1 in 1990 to 38.6 in 2019, while the age-standardized death rate decreased in the same period (18.1 to 15.3). From 1990 to 2019, global QCI increased from 74 to 84. Developed regions (high SDI) had the highest PCa QCIs in 2019 (95.99), while the lowest QCIs belonged to low SDI countries (28.67), mainly from Africa. QCI peaked in age groups 50 to 54, 55 to 59, or 65 to 69, depending on the socio-demographic index.

CONCLUSIONS

Global PCa QCI stands at a relatively high value (84 in 2019). Low SDI countries are affected the most by PCa, mainly due to the lack of effective preventive and treatment methods in those regions. In many developed countries, QCI decreased or stopped rising after recommendations against routine PCa screening in the 2010-2012 period, highlighting the role of screening in reducing PCa burden.

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.

Guideline-based indicators for adult patients with myelodysplastic syndromes

Myelodysplastic syndromes (MDSs) represent a heterogeneous group of hematological stem cell disorders with an increasing burden on health care systems. Evidence-based MDS guidelines and recommendations (G/Rs) are published but do not necessarily translate into better quality of care if adherence is not maintained in daily clinical practice. Guideline-based indicators (GBIs) are measurable elements for the standardized assessment of quality of care and, thus far, have not been developed for adult MDS patients. To this end, we screened relevant G/Rs published between 1999 and 2018 and aggregated all available information as candidate GBIs into a formalized handbook as the basis for the subsequent consensus rating procedure. An international multidisciplinary expert panel group (EPG) of acknowledged MDS experts (n = 17), health professionals (n = 7), and patient advocates (n = 5) was appointed. The EPG feedback rates for the first and second round were 82% (23 of 28) and 96% (26 of 27), respectively. A final set of 29 GBIs for the 3 domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7) achieved the predefined agreement score for selection (>70%). We identified shortcomings in standardization of patient-reported outcomes, toxicity, and geriatric assessments that need to be optimized in the future. Our GBIs represent the first comprehensive consensus on measurable elements addressing best practice performance, outcomes, and structural resources. They can be used as a standardized instrument with the goal of assessing, comparing, and fostering good quality of care within clinical development cycles in the daily care of adult MDS patients.

Quality indicators for hyperthermia treatment: Italian survey analysis

AIM

Nowadays, no Quality Indicators (QI) have been proposed for Hyperthermia treatments. Starting from radiotherapy experience, the aim of this work is to adapt radiotherapy indicators to Hyperthermia and to propose a new specific set of QI in Hyperthermia field.

MATERIAL AND METHODS

At first, radiotherapy quality indicators published in literature have been adapted to hyperthermia setting. Moreover, new specific indicators for the treatment of hyperthermia have been defined. To obtain the standard reference values of quality indicators, a questionnaire was sent to 7 Italian hyperthermia Institutes with a list of questions on physical and clinical hyperthermia treatment in order to highlight the different therapeutic approaches.

RESULTS

Three structure, five process and two outcome QI were selected. It has been possible to adapt seven indicators from radiotherapy, while three indicators have been defined as new specific indicators for hyperthermia. Average values used as standard reference values have been obtained and proposed.

CONCLUSION

The survey performed on 7 Italian centres allowed to derive the standard reference value for each indicator. The proposed indicators are available to be investigated and applied by a larger number of Institutes in which hyperthermia treatment is performed in order to monitor the operational procedures and to confirm or modify the reference standard value derived for each indicator.

The European Prostate Cancer Centres of Excellence: A Novel Proposal from the European Association of Urology Prostate Cancer Centre Consensus Meeting

BACKGROUND

High-quality management of prostate cancer is needed in the fields of clinics, research, and education.

OBJECTIVE

The objective of this project was to develop the concept of "European Prostate Cancer Centres of Excellence" (EPCCE), with the specific aim of identifying European centres characterised by high-quality cancer care, research, and education.

DESIGN, SETTING, AND PARTICIPANTS

A task force of experts aimed at identifying the general criteria to define the EPCCE. Discussion took place in conference calls and by e-mail from March 2017 to November 2017, and the final consensus meeting named "European Association of Urology (EAU) Prostate Cancer Centre Consensus Meeting" was held in Barcelona on November 16, 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The required criteria were grouped into three main steps: (1) clinics, (2) research, and (3) education. A quality control approach for the three steps was defined.

RESULTS AND LIMITATIONS

The definition of EPCCE consisted of the following steps: (1) clinical step-five items were identified and classified as core team, associated services, multidisciplinary approach, diagnostic pathway, and therapeutic pathway; (2) research step-internal monitoring of outcomes was required; clinical data had to be collected through a prespecified database, clinical outcomes had to be periodically assessed, and prospective trials had to be conducted; (3) educational step-it consists of structured fellowship programmes of 1yr, including 6mo of research and 6mo of clinics; and (4) quality assurance and quality control procedures, related to the quality assessment of the previous three steps. A limitation of this project was that the definition of standards and items was mainly based on a consensus among experts rather than being an evidence-based process.

CONCLUSIONS

The EAU Prostate Cancer Centre Consensus Meeting defined the criteria for the identification of the EPCCE in the fields of clinics, research, and education. The inclusion of a quality control approach represents the novelty that supports the excellence of these centres.

PATIENT SUMMARY

A task force of experts defined the criteria for the identification of European Prostate Cancer Centres of Excellence, in order to certify the high-quality centres for prostate cancer management.

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.

Feasibility of a Mobile Health Application To Monitor Recovery and Patient-reported Outcomes after Robot-assisted Radical Prostatectomy

A mobile application (app) designed on the basis of a literature review and interviews with urologic oncologists was created to help streamline robot-assisted radical prostatectomy care and in compliance with quality indicators. Use of the app was limited to English-speaking men with iPhones; 20 of 43 men approached (47%) agreed to participate. Lack of an iPhone was the most common reason for non-enrollment (52%). Preoperatively, men received daily push notifications to perform Kegel exercises and 19 men (95%) completed an Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) questionnaire using the app. After hospital discharge, men completed a postoperative pain questionnaire and received push notifications to ambulate and increase their fluid intake. After catheter removal, daily notifications to perform Kegel exercises and complete weekly EPIC-CP surveys were pushed to monitor recovery of functional outcomes. EPIC-CP and postoperative pain assessment response rates were 75% and 90%, respectively. 85% of the men complied with notifications to ambulate, hydrate, and perform Kegel exercises. The 15 men (75%) who completed the satisfaction survey found the app easy to use and understand, which suggests that mobile apps can be easily implemented perioperatively. Mobile apps have the potential to improve compliance with perioperative instructions and allow more frequent capture of patient-reported outcomes with minimal resource utilization. Patient summary: We examined the use of a mobile application designed to capture patient-reported outcomes and guide postoperative care after major urologic surgery. Mobile apps can be implemented with relative ease and high patient satisfaction.

The effect of selection and referral biases for the treatment of localised prostate cancer with surgery or radiation

Background

Consultation with radiation oncologists, in addition to urologists, is advocated for patients diagnosed with prostate cancer. Treatment patterns for patients receiving consultation from radiation oncologists in addition to urologists have not previously been described.

Methods

We conducted a matched cohort study of men with newly diagnosed non-metastatic prostate cancer in Ontario, Canada. Patients who underwent consultation with a radiation oncologist prior to treatment were matched 1:1 with patients managed by a urologist alone based on tumour and patient characteristics. We examined rates of active treatment (surgery or radiotherapy) within one year following diagnosis.

Results

Among 5708 matched pairs (11,416 patients), those who received radiation oncology consultation were more likely to undergo active treatments whether they had intermediate or high-risk disease (88.6% vs. 65.9%, p < 0.0001; adjusted odds ratio 4.0, 95% CI: 3.6–4.4) or low-risk disease (56.1% vs. 13.3%, p < 0.0001; adjusted odds ratio 8.4, 95% CI: 6.7–10.6). This effect persisted after considering age, comorbidity, tumour volume and year of diagnosis.

Conclusions

Patients newly diagnosed with prostate cancer who receive radiation oncology consultation are associated with a higher rate of active treatment, compared to patients managed by urologists only. Selection and referral biases, and unmeasured confounding such as patient preference must be considered as important factors attributing this association.

Hospital Quality Factors Influencing the Mobility of Patients for Radical Prostate Cancer Radiation Therapy: A National Population-Based Study

Purpose

To investigate whether patients requiring radiation treatment are prepared to travel to alternative more distant centers in response to hospital choice policies, and the factors that influence this mobility.

Methods and Materials

We present the results of a national cohort study using administrative hospital data for all 44,363 men who were diagnosed with prostate cancer and underwent radical radiation therapy in the English National Health Service between 2010 and 2014. Using geographic information systems, we investigated the extent to which men choose to travel beyond (“bypass”) their nearest radiation therapy center, and we used conditional logistic regression to estimate the effect of hospital and patient characteristics on this mobility.

Results

In all, 20.7% of men (n=9161) bypassed their nearest radiation therapy center. Travel time had a very strong impact on where patients moved to for their treatment, but its effect was smaller for men who were younger, more affluent, and from rural areas (P for interaction always <.001). Men were prepared to travel further to hospitals that offered hypofractionated prostate radiation therapy as their standard schedule (odds ratio 3.19, P<.001), to large-scale radiation therapy units (odds ratio 1.56, P<.001), and to hospitals that were early adopters of intensity modulated radiation therapy (odds ratio 1.37, P<.001).

Conclusions

Men with prostate cancer are prepared to bypass their nearest radiation therapy centers. They are more likely to travel to larger established centers and those that offer innovative technology and more convenient radiation therapy schedules. Indicators that accurately reflect the quality of radiation therapy delivered are needed to guide patients' choices for radiation therapy treatment. In their absence, patient mobility may negatively affect the efficiency and capacity of a regional or national radiation therapy service and offer perverse incentives for technology adoption.

The AUA Quality Registry: Engaging Stakeholders to Improve the Quality of Care for Patients with Prostate Cancer

INTRODUCTION

Determining the most effective treatments for complex medical conditions requires robust clinical data. Clinical registries comprise real-world observational data, which allow rapid assessment of the effectiveness of treatments and care processes. In 2014 the AUA (American Urological Association) launched the AQUA (AUA Quality) Registry, a national urological disease registry intended to measure and report health care quality and patient outcomes, and support health services and comparative effectiveness research. The initial focus of the registry is newly diagnosed prostate cancer. In July 2014 the AUA convened a Stakeholder Forum with more than 20 organizations interested in improving the quality of care provided to patients with prostate cancer.

METHODS

We discuss the rationale and need for the AQUA Registry, define quality of care for prostate cancer, prioritize data and information needs, and identify potential future uses for AQUA data beyond quality improvement.

RESULTS

AQUA data will provide high quality data on effective treatments. Good quality of care for prostate cancer focuses on patient centered outcomes based on current evidence. The highest priority data collection needs are patient characteristics, evaluation and intervention utilization data, clinical and patient reported outcomes, and cost and resource use. In the future the registry data may be used to fulfill urologist quality reporting requirements. The AQUA Registry will also allow for a range of local and national quality improvement, and health services research efforts driven by urologists.

CONCLUSION

The AQUA Registry will provide an essential platform to improve health care quality and support the next generation of clinical urology research and policy initiatives.

Using graphical representations to enhance the quality-of-care for colorectal cancer patients

The study was to enhance adherence to quality-of-care guidelines for colorectal cancer (CRC) patients through plotting graphical representations. Rasch analysis was performed to examine the unidimensional measurement of the 13 core indicators. An author-made Excel module was applied to plot the so-called Wright map and KIDMAP in education field to report physicians' adherence to the quality-of-life guidelines. We found that the scale of the quality-of-care guidelines for patients with colon cancer is unidimensional. A total of 15 (3.8%) and 14 (3.5%) persons' response patterns (i.e., Outfit MNSQs >2.0 and 4.0, respectively) are aberrantly dispersed from the majority of sample according to their estimated parameters of persons and indicators. It can be used for investigating the root cause of the 1ow measures and/or the most unexpected aberrant pattern of responses using Rasch analysis once any one indicator of unexpectedly aberrant treatment (p < .05) presents. The Rasch model can deal with these binary and/or missing data frequently seen in clinical settings. We confirm this computer module can contribute to ensuring that hospitals adhere to the treatment guidelines for patients with colon cancer.

Evaluating disparities in inpatient surgical cancer care among American Indian/Alaska Native patients

BACKGROUND

American Indian/Alaska Native (AI/AN) patients with cancer have the lowest survival rates of all racial and ethnic groups, possibly because they are less likely to receive "best practice" surgical care than patients of other races.

METHODS

Prospective cohort study comparing adherence with generic and cancer-specific guidelines on processes of surgical care between AI/AN and non-Hispanic white (NHW) patients in Washington State (2010 to 2014) was conducted.

RESULTS

A total of 156 AI/AN and 6,030 NHW patients underwent operations for 10 different cancers, and had similar mean adherence to generic surgical guidelines (91.5% vs 91.9%, P = .57). AI/AN patients with breast cancer less frequently received preoperative diagnostic core needle biopsy (81% vs 94%, P = .004). AI/AN patients also less frequently received care adherent to prostate cancer-specific guidelines (74% vs 92%, P = .001).

CONCLUSION

Although AI/ANs undergoing cancer operations in Washington receive similar overall best practice surgical cancer care to NHW patients, there remain important, modifiable disparities that may contribute to their lower survival.

Impact of Adherence to Quality Measures for Localized Prostate Cancer on Patient-reported Health-related Quality of Life Outcomes, Patient Satisfaction, and Treatment-related Complications

BACKGROUND AND OBJECTIVE

Quality measures used in pay-for-performance systems are intended to address specific quality goals, such as safety, efficiency, effectiveness, timeliness, equity, and patient-centeredness. Given the small number of narrowly focused measures in prostate cancer care, we sought to determine whether adherence to any of the available payer-driven quality measures influences patient-centered outcomes, including health-related quality of life (HRQOL), patient satisfaction, and treatment-related complications.

METHODS

The Comparative Effectiveness Analysis of Surgery and Radiation study is a population-based, prospective cohort study that enrolled 3708 men with clinically localized prostate cancer during 2011 and 2012, of whom 2601 completed the 1-year survey and underwent complete chart abstraction. Compliance with 6 quality indicators endorsed by national consortia was assessed. Multivariable regression was used to determine the relationship between indicator compliance and Expanded Prostate Cancer Index Composite (EPIC-26) instrument summary scores, satisfaction scale scores (service satisfaction scale for cancer care), and treatment-related complications.

RESULTS

Overall rates of compliance with these quality measures ranged between 64% and 88%. Three of the 6 measures were weakly associated with 1-year sexual function and bowel function scores (β=-4.6, 1.69, and 2.93, respectively; P≤0.05), whereas the remaining measures had no significant relationship with patient-reported HRQOL outcomes. Satisfaction scores and treatment-related complications were not associated with quality measure compliance.

CONCLUSIONS

Compliance with available nationally endorsed quality indicators, which were designed to incentivize effective and efficient care, was not associated with clinically important changes in patient-centered outcomes (HRQOL, satisfaction, or complications) within 1-year.

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.

New Paradigms for Patient-Centered Outcomes Research in Electronic Medical Records: An Example of Detecting Urinary Incontinence Following Prostatectomy

Introduction:

National initiatives to develop quality metrics emphasize the need to include patient-centered outcomes. Patient-centered outcomes are complex, require documentation of patient communications, and have not been routinely collected by healthcare providers. The widespread implementation of electronic medical records (EHR) offers opportunities to assess patient-centered outcomes within the routine healthcare delivery system. The objective of this study was to test the feasibility and accuracy of identifying patient centered outcomes within the EHR.

Methods:

Data from patients with localized prostate cancer undergoing prostatectomy were used to develop and test algorithms to accurately identify patient-centered outcomes in post-operative EHRs – we used urinary incontinence as the use case. Standard data mining techniques were used to extract and annotate free text and structured data to assess urinary incontinence recorded within the EHRs.

Results

A total 5,349 prostate cancer patients were identified in our EHR-system between 1998–2013. Among these EHRs, 30.3% had a text mention of urinary incontinence within 90 days post-operative compared to less than 1.0% with a structured data field for urinary incontinence (i.e. ICD-9 code). Our workflow had good precision and recall for urinary incontinence (positive predictive value: 0.73 and sensitivity: 0.84).

Discussion.

Our data indicate that important patient-centered outcomes, such as urinary incontinence, are being captured in EHRs as free text and highlight the long-standing importance of accurate clinician documentation. Standard data mining algorithms can accurately and efficiently identify these outcomes in existing EHRs; the complete assessment of these outcomes is essential to move practice into the patient-centered realm of healthcare.

Design and feasibility of integrating personalized PRO dashboards into prostate cancer care

OBJECTIVE

Patient-reported outcomes (PROs) are a valued source of health information, but prior work focuses largely on data capture without guidance on visual displays that promote effective PRO use in patient-centered care. We engaged patients, providers, and design experts in human-centered design of "PRO dashboards" that illustrate trends in health-related quality of life (HRQOL) reported by patients following prostate cancer treatment.

MATERIALS AND METHODS

We designed and assessed the feasibility of integrating dashboards into care in 3 steps: (1) capture PRO needs of patients and providers through focus groups and interviews; (2) iteratively build and refine a prototype dashboard; and (3) pilot test dashboards with patients and their provider during follow-up care.

RESULTS

Focus groups (n = 60 patients) prioritized needs for dashboards that compared longitudinal trends in patients' HRQOL with "men like me." Of the candidate dashboard designs, 50 patients and 50 providers rated pictographs less helpful than bar charts, line graphs, or tables (P < .001) and preferred bar charts and line graphs most. Given these needs and the design recommendations from our Patient Advisory Board (n = 7) and design experts (n = 7), we built and refined a prototype that charts patients' HRQOL compared with age- and treatment-matched patients in personalized dashboards. Pilot testing dashboard use (n = 12 patients) improved compliance with quality indicators for prostate cancer care (P < .01).

CONCLUSION

PRO dashboards are a promising approach for integrating patient-generated data into prostate cancer care. Informed by human-centered design principles, this work establishes guidance on dashboard content, tailoring, and clinical use that patients and providers find meaningful.

Socioeconomic inequalities in prostate cancer survival: A review of the evidence and explanatory factors

Although survival rates after prostate cancer diagnosis have improved in the past two decades, survival analyses regarding the socioeconomic status (SES) suggest inequalities indicating worse prognosis for lower SES groups. An overview of the current literature is lacking and moreover, there is an ongoing discussion about the underlying causes but evidence is comparatively sparse. Several patient, disease and health care related factors are discussed to have an important impact on disparities in survival. Therefore, a systematic review was conducted to sum up the current evidence of survival inequalities and the contribution of different potential explanatory factors among prostate cancer patients. The PubMed database was screened for relevant articles published between January 2005 and September 2014 revealing 330 potentially eligible publications. After systematic review process, 46 papers met the inclusion criteria and were included in the review. About 75% of the studies indicate a significant association between low SES and worse survival among prostate cancer patients in the fully adjusted model. Overall, hazard ratios (low versus high SES) range from 1.02 to 3.57. A decrease of inequalities over the years was not identified. 8 studies examined the impact of explanatory factors on the association between SES and survival by progressive adjustment indicating mediating effects of comorbidity, stage at diagnosis and treatment modalities. Eventually, an apparent majority of the obtained studies indicates lower survival among patients with lower SES. The few studies that intend to explain inequalities found out instructive results regarding different contributing factors but evidence is still insufficient.

Technology diffusion and prostate cancer quality of care

OBJECTIVE

To evaluate the association of technological capacity with prostate cancer quality of care. Technological capacity was conceptualized as a market's ability to provide prostate cancer treatment with new technology, including robotic prostatectomy and intensity-modulated radiotherapy (IMRT).

METHODS

In this retrospective cohort study, we used data from the Surveillance, Epidemiology, and End Results-Medicare linked database from 2004 to 2009 to identify men with newly diagnosed prostate cancer (n = 46,274). We measured technological capacity as the number of providers performing robotic prostatectomy or IMRT per population in a health care market. We used multilevel logistic regression analysis to assess the association of technological capacity with receiving quality care according to a set of nationally endorsed quality measures, while adjusting for patient and market characteristics.

RESULTS

Overall, our findings were mixed with only subtle differences in quality of care comparing high-tech with low-tech markets. High robotic prostatectomy capacity was associated with better adherence to some quality measures, such as avoiding unnecessary bone scans (79.8% vs 73.0%; P = .003) and having follow-up with urologists (67.7% vs 62.6%; P = .023). However, for most measures, neither high robotic prostatectomy nor high-IMRT capacity was associated with significant increases in adherence rates. In fact, for 1 measure (treatment by a high-volume provider), high-IMRT capacity was associated with lower performance (23.4% vs 28.5%; P <.001).

CONCLUSION

Our findings suggest that new technology is not clearly associated with higher quality of care. To improve quality, more specific efforts will be needed.

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.

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.

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

PURPOSE

We assessed the relationship between health care system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes.

MATERIALS AND METHODS

This retrospective cohort study included 48,050 men from SEER-Medicare linked data diagnosed with localized prostate cancer between 2004 and 2009, and followed through 2010. Based on a composite quality measure we categorized the health care systems in which these men were treated into 1-star (bottom 20%), 2-star (middle 60%) and 3-star (top 20%) systems. We then examined the association of health care system level quality of care with outcomes using multivariable logistic and Cox regression.

RESULTS

Patients who underwent prostatectomy in 3-star vs 1-star health care systems were at lower risk for perioperative complications (OR 0.80, 95% CI 0.64-1.00). However, they were more likely to undergo a procedure addressing treatment related morbidity, eg for sexual morbidity (11.3% vs 7.8%, p = 0.043). In patients who received radiotherapy star ranking was not associated with treatment related morbidity. In all patients star ranking was not significantly associated with all-cause mortality (HR 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20).

CONCLUSIONS

We found no consistent association between health care system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on developing more discriminative quality measures.

User-centered design of quality of life reports for clinical care of patients with prostate cancer

BACKGROUND

Primary treatment of localized prostate cancer can result in bothersome urinary, sexual, and bowel symptoms. Yet clinical application of health-related quality-of-life (HRQOL) questionnaires is rare. We employed user-centered design to develop graphic dashboards of questionnaire responses from patients with prostate cancer to facilitate clinical integration of HRQOL measurement.

METHODS

We interviewed 50 prostate cancer patients and 50 providers, assessed literacy with validated instruments (Rapid Estimate of Adult Literacy in Medicine short form, Subjective Numeracy Scale, Graphical Literacy Scale), and presented participants with prototype dashboards that display prostate cancer-specific HRQOL with graphic elements derived from patient focus groups. We assessed dashboard comprehension and preferences in table, bar, line, and pictograph formats with patient scores contextualized with HRQOL scores of similar patients serving as a comparison group.

RESULTS

Health literacy (mean score, 6.8/7) and numeracy (mean score, 4.5/6) of patient participants was high. Patients favored the bar chart (mean rank, 1.8 [P = .12] vs line graph [P < .01] vs table and pictograph); providers demonstrated similar preference for table, bar, and line formats (ranked first by 30%, 34%, and 34% of providers, respectively). Providers expressed unsolicited concerns over presentation of comparison group scores (n = 19; 38%) and impact on clinic efficiency (n = 16; 32%).

CONCLUSION

Based on preferences of prostate cancer patients and providers, we developed the design concept of a dynamic HRQOL dashboard that permits a base patient-centered report in bar chart format that can be toggled to other formats and include error bars that frame comparison group scores. Inclusion of lower literacy patients may yield different preferences.

Quality-of-care indicators for pelvic organ prolapse: development of an infrastructure for quality assessment

INTRODUCTION AND HYPOTHESIS

A paucity of data exists addressing the quality of care provided to women with pelvic organ prolapse (POP). We sought to develop a means of measuring this quality through the development of quality-of-care indicators (QIs).

METHODS

QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. The indicators were then presented to a panel of nine experts. Using the RAND Appropriateness Method, we analyzed each indicator's preliminary rankings. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which panelists individually re-rated the indicators. QIs with median scores of at least 7 were considered valid.

RESULTS

QIs were developed that addressed screening, diagnosis, work-up, and both nonsurgical and surgical management. Areas of controversy included whether screening should be performed to identify prolapse, whether pessary users should undergo a vaginal examination by a health professional every 6 months versus annually, and whether a colpocleisis should be offered to older women planning to undergo surgery for POP. Fourteen out of 21 potential indicators were rated as valid for pelvic organ prolapse (median score ≥7).

CONCLUSION

We developed and rated 14 potential quality indicators for the care of women with POP. Once these QIs are tested for feasibility they can be used on a larger scale to measure and compare the care provided to women with prolapse in different clinical settings.

Development of quality indicators for women with urinary incontinence

AIMS

To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs).

METHODS

We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale.

RESULTS

QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale.

CONCLUSIONS

We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States.

Regional variation in quality of prostate cancer care

PURPOSE

Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement.

MATERIALS AND METHODS

For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures.

RESULTS

Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001).

CONCLUSIONS

We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement.

The future of bladder cancer care in the USA

Bladder cancer is the fifth most common malignancy in the USA and the most expensive to treat on a per-patient basis. Despite its prevalence, morbidity, mortality and associated cost of management, bladder cancer remains grossly under-recognized as a public health concern and underfunded scientifically. Although 5-year survival rates for patients with prostate or kidney cancer have improved tremendously in the past 30 years, progress in bladder cancer has stalled. A renewed interest from the clinical and research communities, as well as a young and eager advocacy network, are raising the profile of bladder cancer. As awareness and funding of bladder cancer increase, improved diagnostics, therapeutics and health services for patients with the disease will develop accordingly.

Involving patients in quality indicator development - a systematic review

BACKGROUND

Quality indicators (QI) are used in many health care areas to measure, compare, and improve the quality of care. Ideas of quality differ between health care providers and patients, yet patients are not regularly involved in QI development nor does a methodological standard for patient involvement in QI development exist. In this study we systematically reviewed the medical journal articles and gray literature for published approaches for involving patients in QI development.

METHODS

We searched medical literature databases (Medline, Excerpta Medica database, and Cumulative Index to Nursing and Allied Health Literature), screened websites, and contacted experts in the field of QI development for publications on approaches to patient involvement in QI development.

RESULTS

Eleven relevant journal articles and four web-published documents were included. Four major approaches to patient involvement were extracted from the literature: (1) focus group interviews, (2) self-administered questionnaires, (3) individual interviews, and (4) participation in panels during systematic consensus processes. Patients' views were collected by involving patients, patient representatives, or family members.

CONCLUSION

Although there is a large body of literature on QI, publications that describe approaches to patient involvement in QI development are scarce. In principle, indirect and direct methods of patient involvement can be distinguished, and it seems most promising to combine different approaches. However, the limited number of publications identified clearly shows that further research in this field is overdue and that the quality of reporting found in studies within this field needs to be improved.

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.

The Prostate Cancer Registry: monitoring patterns and quality of care for men diagnosed with prostate cancer

OBJECTIVE

To establish a pilot population-based clinical registry with the aim of monitoring the quality of care provided to men diagnosed with prostate cancer.

PATIENTS AND METHODS

All men aged >18 years from the contributing hospitals in Victoria, Australia, who have a diagnosis of prostate cancer confirmed by histopathology report notified to the Victorian Cancer Registry are eligible for inclusion in the Prostate Cancer Registry (PCR). A literature review was undertaken aiming to identify existing quality indicators and source evidence-based guidelines from both Australia and internationally.

RESULTS

A Steering Committee was established to determine the minimum dataset, select quality indicators to be reported back to clinicians, identify the most effective recruitment strategy, and provide a governance structure for data requests; collection, analysis and reporting of data; and managing outliers. A minimum dataset comprising 72 data items is collected by the PCR, enabling ten quality indicators to be collected and reported. Outcome measures are risk adjusted according to the established National Comprehensive Cancer Network and Cancer of the Prostate Risk Assessment Score (surgery only) risk stratification model. Recruitment to the PCR occurs concurrently with mandatory notification to the state-based Cancer Registry. The PCR adopts an opt-out consent process to maximize recruitment. The data collection approach is standardized, using a hybrid of data linkage and manual collection, and data collection forms are electronically scanned into the PCR. A data access policy and escalation policy for mortality outliers has been developed.

CONCLUSIONS

The PCR provides potential for high-quality population-based data to be collected and managed within a clinician-led governance framework. This approach satisfies the requirement for health services to establish quality assessment, at the same time as providing clinically credible data to clinicians to drive practice improvement.

Quality indicators in radiation oncology

Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, the field of radiation oncology has a long history of organized quality assessment efforts and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. This report provides a comprehensive review of the current state of quality assessment in radiation oncology. Specifically, this report highlights implications of the healthcare quality movement for radiation oncology and reviews existing efforts to define and measure quality in the field, with focus on dimensions of quality specific to radiation oncology within the "big picture" of oncologic quality assessment efforts.

Racial variation in the quality of surgical care for prostate cancer

PURPOSE

Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among black men compared with white men. We determined whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the use of high volume surgeons and facilities, and in the quality of certain outcome measures of care.

MATERIALS AND METHODS

We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project all-payer State Inpatient Databases, encompassing all nonfederal hospitals in Florida, Maryland and New York State from 1996 to 2007. Included in analysis were men 18 years old or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared the use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay between black and white patients.

RESULTS

Of 105,972 patients 81,112 (76.5%) were white, 14,006 (13.2%) were black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were all other. In mixed effects multivariate models, black men had markedly lower use of high volume hospitals (OR 0.73, 95% CI 0.70-0.76) and surgeons (OR 0.67, 95% CI 0.64-0.70) compared to white men. Black men also had higher odds of blood transfusion (OR 1.08, 95% CI 1.01-1.14), longer length of stay (OR 1.07, 95% CI 1.06-1.07) and inpatient mortality (OR 1.73, 95% CI 1.02-2.92).

CONCLUSIONS

Using an all-payer data set, we identified concerning potential quality of care gaps between black and white men undergoing radical prostatectomy for prostate cancer.

Variations in the quality of care at radical prostatectomy

Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority.

Blood transfusions in radical prostatectomy: a contemporary population-based analysis

OBJECTIVE

To examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP).

METHODS

The Nationwide Inpatient Sample was queried. Multivariable logistic regression models focused on all three transfusion types. Covariables consisted of procedure specific annual hospital caseload (AHC), year of surgery, age, Charlson Comorbidity Index, and region.

RESULTS

Overall, 119,966 patients underwent radical prostatectomy between 1998 and 2007. The HBT, ABT, and IOBCT rates were 6.2%, 6.0%, and 1.2%, respectively. HBT rates ranged from 5.1-5.1% between 1998 and 2007 (P=.49) vs 9.4-2.7% (P<.001) for ABT vs 1.9-0.9% (P=.003) for IOBCT in the same time period, respectively. In multivariable analyses, ORP patients treated at intermediate (odds ratio [OR] 1.48, P=.003) and low (OR 2.73, P<.001) AHC institutions were more likely to receive an HBT than ORP patients treated at high AHC institutions. Conversely, MIRP patients treated at high (OR 0.46, P=.040), intermediate (OR 0.27, P=.001), and low (OR 0.59, P=.015) AHC institutions were less likely to receive an HBT than ORP patients treated at high AHC institutions.

CONCLUSION

Our results indicate that the overall transfusion rate at radical prostatectomy decreased within the last decade because of a substantial decline in ABT use. Moreover, MIRP protects from HBT, even when performed at low AHC Centers.

Quality assessment in oncology

The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.

National trends in the use of partial nephrectomy: a rising tide that has not lifted all boats

PURPOSE

Treatment of organ confined renal masses with partial nephrectomy has durable oncologic outcomes comparable to radical nephrectomy. Partial nephrectomy is associated with lower risk of chronic kidney disease and in some series with better overall survival. We report a contemporary analysis on national trends of partial nephrectomy use to determine partial nephrectomy use over time, and whether nontumor related factors such as structural attributes of the treating institution or patient characteristics are associated with the underuse of partial nephrectomy.

MATERIALS AND METHODS

We performed an analysis of the NIS (National Inpatient Sample), which contains 20% of all United States inpatient hospitalizations. We included patients who underwent radical or partial nephrectomy for a renal mass between 2002 and 2008. Survey weights were applied to obtain national estimates of nephrectomy use and to evaluate nonclinical predictors of partial nephrectomy.

RESULTS

A total of 46,396 patients were included in the study for a weighted sample of 226,493. There was an increase in partial nephrectomy use from 15.3% in 2002 to 24.7% in 2008 (p <0.001). On multivariate analysis hospital attributes (urban teaching status, nephrectomy volume, geographic region) and patient socioeconomic status (higher income ZIP code and private/HMO payer) were independent predictors of partial nephrectomy use.

CONCLUSIONS

Since 2002 the national use of partial nephrectomy for the management of renal masses has increased. However, the adoption of partial nephrectomy at smaller, rural and nonacademic hospitals lags behind that of larger hospitals, urban/teaching hospitals and higher volume centers. A lower rate of partial nephrectomy use among patients without private insurance and those living in lower income ZIP code areas highlights the underuse of partial nephrectomy as a quality of care concern.

Prostate cancer survivorship: lessons from caring for the uninsured

Since 2001, UCLA has operated

IMPACT

Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (CaP). Funded by the California Department of Public Health, with a cumulative budget of over $80 million, the program provides comprehensive care for low-income, uninsured Californian men with biopsy-proven CaP. Health services research conducted with program enrollees, through the UCLA Men's Health Study, yields an opportunity to perform qualitative and quantitative assessments of patient-reported outcomes in these men, all members of historically underserved, primarily minority populations. This review summarizes data from several studies in which validated instruments were administered longitudinally in 727 participants, prospectively measuring health-related quality of life (HRQOL), self-efficacy in interactions with physician interactions, social and emotional health, symptom distress, satisfaction with care, and other patient-reported outcomes.

Quality of care in non-small-cell lung cancer: findings from 11 oncology practices in Florida

BACKGROUND

Limited data on the quality of care in non-small-cell lung cancer (NSCLC) are available. This study aims to assess the quality of care in NSCLC among 11 medical oncology practices in Florida and to explore the impact of practice volume on care.

METHODS

Clinical guidelines and existing indicators were reviewed, and an expert survey was conducted to identify a set of process-based quality of care indicators (QI). Medical records of new patients with NSCLC seen in 2006 were retrospectively reviewed for the adherence to these QIs.

RESULTS

We reviewed the compliance with a set of 11 QIs (four general and seven NSCLC specific) among 531 patients. The patient median age was 68 years; 51% were male, and 49% had advanced NSCLC. The median adherence rates to general QIs and NSCLC-specific QIs were 95% (range 69% to 99%) and 69% (range 29% to 91%), respectively. We identified three main areas of deficiencies: chemotherapy consenting (69%), brain staging for stage III NSCLC (59%), and performance status assessment for advanced stages (42%). Significant variation in the adherence rates across practice sites was observed in five of 11 QIs.

CONCLUSION

On the basis of this data set of participating institutions in Florida, several areas in the care of patients with NSCLC were identified as targets for future quality improvement efforts.