Improving patient journey and quality of care: Summary from the second Bladder Cancer Canada-Canadian Urological Association-Canadian Urologic Oncology Group (BCC-CUA-CUOG) bladder cancer quality of care consensus meeting

Real-life benchmarking bladder cancer care: A population-based study

INTRODUCTION

Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators, with associated benchmarks created using available evidence and expert opinion to inform and measure future performance. Herein, we report real-life benchmark performance for the management of muscle-invasive bladder cancer (MIBC) relative to expert opinion guidance.

METHODS

This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009-2013. Electronic records of treatment from 1573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators, first as median values obtained across hospitals or providers, as well as a "pared-mean" approach to identify a benchmark population of "top performance," as defined as the best outcome accomplished for at least 10% of the population.

RESULTS

Overall, performance in Ontario across all indicators fell short of expert opinion-determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark >6, percent of institutions meeting benchmark=20%), percent of patients with MIBC referred preoperatively to medical oncology (MO; benchmark>90%, percent of institutions meeting benchmark=2%) and radiation oncology (RO; benchmark>50%, percent of institutions meeting benchmark=0%), time to cystectomy within six weeks of transurethral resection of bladder tumor (TURBT) in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark=0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark>85%, percent of institutions meeting benchmark=0%), percent of patients with positive margins post-RC (benchmark <10%, percent of institutions meeting benchmark=46%), and 90-day mortality (benchmark<5%, percent of institutions meeting benchmark=37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly underestimated benchmarks that were possible by top-performing hospitals.

CONCLUSIONS

Performance through most bladder cancer quality-of-care indicators fall short of benchmarks proposed by expert opinion. Different methodologies, such as a paredmean approach of top performers, may provide more realistic benchmarking.

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.

Collaboration Between Oncology Social Workers and Nurses: A Patient-Centered Interdisciplinary Model of Bladder Cancer Care

OBJECTIVES

We propose a bladder cancer patient-centered, interdisciplinary collaboration model of care adapted from an earlier model by Black, Dornan, and Allegrante (1986). The Bladder Patient-Centered Interdisciplinary Team (BPIT) model provides a conceptual foundation for assembling interdisciplinary teams and emphasizes the patient as an active participant in treatment and member of the care team, along with oncology nurses, wound ostomy and continence nurses, and oncology social workers.

DATA SOURCES

This model integrates scopes of practice and practice standards from nursing and social work professional organizations, findings from peer-reviewed articles, and expert clinical opinion in conceptualizing interdisciplinary bladder cancer care.

CONCLUSION

BPIT is not meant to be an exhaustive or proscriptive catalog of roles and responsibilities. Future research is needed in this area to further refine and delineate the oncology social worker and nursing scopes of practice and standards for collaborative teamwork.

IMPLICATIONS FOR NURSING PRACTICE

The unmet supportive care needs of patients with bladder cancer across all phases of the cancer continuum are well documented. Oncology and wound ostomy and continence nurses are of critical importance to holistically addressing these needs and enhancing the health-related quality of life. The BPIT model provides a broad overview of the discipline-specific and interdisciplinary team-specific roles and responsibilities for bladder cancer care.

A Narrative Review of the Patient Journey Through the Lens of Non-communicable Diseases in Low- and Middle-Income Countries

Low- and middle-income countries (LMICs) are challenged with a disproportionately high burden of noncommunicable diseases (NCDs) and limited healthcare resources at their disposal to tackle the NCD epidemic. Understanding the patient journey for NCDs from the patients' perspective can help healthcare systems in these settings evolve their NCD care models to address the unmet needs of patients, enhance patient participation in their management, and progress towards better outcomes and quality of life. This paper aims to provide a theoretical framework outlining common touchpoints along the patient journey for NCDs in LMICs. It further aims to review influencing factors and recommend strategies to improve patient experience, satisfaction, and disease outcomes at each touchpoint. The co-occurrence of major NCDs makes it possible to structure the patient journey for NCDs into five broad touchpoints: awareness, screening, diagnosis, treatment, and adherence, with integration of palliative care along the care continuum pathway. The patients' perspective must be considered at each touchpoint in order to inform interventions as they experience first-hand the impact of NCDs on their quality of life and physical function and participate substantially in their disease management. Collaboratively designed health communication programs, shared decision-making, use of appropriate risk assessment tools, therapeutic alliances between the patient and provider for treatment planning, self-management tools, and improved access to palliative care are some strategies to help improve the patient journeys in LMICs. Long-term management of NCDs entails substantial self-management by patients, which can be augmented by pharmacists and nurse-led interventions. The digital healthcare revolution has heralded an increase in patient engagement, support of home monitoring of patients, optimized accurate diagnosis, personalized care plans, and facilitated timely intervention. There is an opportunity to integrate digital technology into each touchpoint of the patient journey, while ensuring minimal interruption to patients' care in the face of global health emergencies.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Building a Canadian Translational Bladder Cancer Research Network

Bladder cancer research has historically lagged behind efforts in other disease sites with substantial underfunding relative to the heavy morbidity and mortality suffered by patients. Alongside increasing advocacy however, more recent advances in our understanding of the molecular biology of bladder cancer has ushered in a period of renaissance with exciting prospects for novel, precise diagnostics and therapeutics. Given significant and diverse assets within the research community across Canada, an inaugural translational research forum was convened to identify research gaps and strengths, and to formalize investigational themes that would be apposite for multi-institutional collaboration. The virtual meeting brought together a multi-disciplinary network of genitourinary cancer researchers, including clinicians and basic scientists, and entailed detailed environmental scans of the Canadian clinical and translational research landscape as well as selected “elevator pitches” of potential research themes. The results of these discussions are detailed herein and have provided the impetus to formalize the Canadian Bladder Cancer Research Network (CBCRN). Working groups have been created to focus future multi-institutional collaborations in four inter-related initiatives: biomarker development, epigenetic targeting, immuno-oncology and the microbiome.