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Schroeck FR, Grubb R, MacKenzie TA, Ould Ismail AA, Jensen L, Tsongalis GJ, Lotan Y. Clinical Trial Protocol for "Replace Cysto": Replacing Invasive Cystoscopy with Urine Testing for Non-muscle-invasive Bladder Cancer Surveillance-A Multicenter, Randomized, Phase 2 Healthcare Delivery Trial Comparing Quality of Life During Cancer Surveillance with Xpert Bladder Cancer Monitor or Bladder EpiCheck Urine Testing Versus Frequent Cystoscopy. EUR UROL SUPPL 2024; 63:19-30. [PMID: 38558761 PMCID: PMC10981003 DOI: 10.1016/j.euros.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
"Replace Cysto" is a multisite randomized phase 2 trial including 240 participants with low-grade intermediate-risk non-muscle-invasive bladder cancer, in which participants will be randomized 1:1:1 to one of two urine marker-based approaches alternating a urine marker test (Xpert Bladder Cancer Monitor or Bladder EpiCheck) with cystoscopy or to frequent scheduled cystoscopy. The primary objective is to determine whether urinary quality of life after surveillance is significantly improved in the urine marker arms. The primary outcome will be the patient-reported urinary quality of life domain score of the validated QLQ-NMIBC24 instrument, measured 1-3 d after surveillance. Exploratory outcomes include discomfort after surveillance, the number of invasive procedures that participants undergo per 1000 person years, complications from these procedures per 1000 person years, nonurinary quality of life, acceptability of surveillance, and bladder cancer recurrence and progression. Comparators include surveillance using (1) the Xpert Bladder Cancer Monitor test, (2) the Bladder EpiCheck urinary marker, or (3) frequent cystoscopy alone. After a negative cystoscopy ≤4 mo following bladder tumor resection, all the participants will undergo surveillance at 6, 12, 18, and 24 mo (with time zero defined as the date of the most recent bladder tumor resection). In the urine marker arms, surveillance at 6 and 18 mo will be performed with the marker. Regardless of the arm, participants will undergo cystoscopy at 12 and 24 mo. End of study for each participant will be their 24-mo cystoscopy. Overall trial duration is estimated at 5 yr from when the study opens to enrollment until completion of data analyses. The trial is registered at clinicaltrials.gov (NCT05796375).
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Affiliation(s)
- Florian R. Schroeck
- White River Junction VA Medical Center, White River Junction, VT, USA
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Robert Grubb
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
- Department of Biomedical Data Science, Dartmouth College, Lebanon, NH, USA
| | | | - Laura Jensen
- White River Junction VA Medical Center, White River Junction, VT, USA
| | - Gregory J. Tsongalis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Lyall V, Ould Ismail AA, Haggstrom DA, Issa MM, Siddiqui MM, Tosoian J, Schroeck FR. Accurate Documentation Contributes to Guideline-concordant Surveillance of Nonmuscle Invasive Bladder Cancer: A Multisite Department of Veterans Affairs Study. Urology 2023; 181:92-97. [PMID: 37660946 PMCID: PMC10901298 DOI: 10.1016/j.urology.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE To determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines among patients with nonmuscle invasive bladder cancer (NMIBC). METHODS We prospectively collected data from cystoscopy encounter notes from four Department of Veterans Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline-concordant surveillance interval. Accurate documentation was a clinician-recorded risk classification matching a gold standard assigned by the research team. Clinician recommendations were guideline-concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline. RESULTS Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk NMIBC. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, P < .05). Guideline-concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, P < .05). Accurate documentation was associated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk disease, respectively (P < .05). CONCLUSION Accurate risk documentation was associated with more guideline-concordant surveillance recommendations among low- and intermediate-risk patients. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce overuse of surveillance in this group and to prevent unnecessary cost, anxiety, and procedural harms.
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Affiliation(s)
- Vikram Lyall
- White River Junction VA Healthcare System, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | | | - David A Haggstrom
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Regenstrief Institute, & Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Muta M Issa
- Atlanta VA Medical Center & Emory University School of Medicine, Atlanta, GA
| | | | | | - Florian R Schroeck
- White River Junction VA Healthcare System, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH.
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Schroeck FR, Ould Ismail AA, Haggstrom DA, Sanchez SL, Walker DR, Zubkoff L. Data-driven approach to implementation mapping for the selection of implementation strategies: a case example for risk-aligned bladder cancer surveillance. Implement Sci 2022; 17:58. [PMID: 36050742 PMCID: PMC9438061 DOI: 10.1186/s13012-022-01231-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation Mapping is an organized method to select implementation strategies. However, there are 73 Expert Recommendations for Implementing Change (ERIC) strategies. Thus, it is difficult for implementation scientists to map all potential strategies to the determinants of their chosen implementation science framework. Prior work using Implementation Mapping employed advisory panels to select implementation strategies. This article presents a data-driven approach to implementation mapping, in which we systematically evaluated all 73 ERIC strategies using the Tailored Implementation for Chronic Diseases (TICD) framework. We illustrate our approach using implementation of risk-aligned bladder cancer surveillance as a case example. METHODS We developed objectives based on previously collected qualitative data organized by TICD determinants, i.e., what needs to be changed to achieve more risk-aligned surveillance. Next, we evaluated all 73 ERIC strategies, excluding those that were not applicable to our clinical setting. The remaining strategies were mapped to the objectives using data visualization techniques to make sense of the large matrices. Finally, we selected strategies with high impact, based on (1) broad scope, defined as a strategy addressing more than the median number of objectives, (2) requiring low or moderate time commitment from clinical teams, and (3) evidence of effectiveness from the literature. RESULTS We identified 63 unique objectives. Of the 73 ERIC strategies, 45 were excluded because they were not applicable to our clinical setting (e.g., not feasible within the confines of the setting, not appropriate for the context). Thus, 28 ERIC strategies were mapped to the 63 objectives. Strategies addressed 0 to 26 objectives (median 10.5). Of the 28 ERIC strategies, 10 required low and 8 moderate time commitments from clinical teams. We selected 9 strategies based on high impact, each with a clearly documented rationale for selection. CONCLUSIONS We enhanced Implementation Mapping via a data-driven approach to the selection of implementation strategies. Our approach provides a practical method for other implementation scientists to use when selecting implementation strategies and has the advantage of favoring data-driven strategy selection over expert opinion.
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Affiliation(s)
- Florian R Schroeck
- White River Junction VA Medical Center, White River Junction, VT, USA. .,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. .,Dartmouth Cancer Center, Lebanon, NH, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, USA.
| | | | - David A Haggstrom
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
| | - Steven L Sanchez
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - DeRon R Walker
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - Lisa Zubkoff
- Birmingham/Atlanta VA Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL, USA.,Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Rezaee ME, Atwater BL, Bihrle W, Schroeck FR, Seigne JD. Ileal Conduit versus Continent Urinary Diversion in Radical Cystectomy: A Retrospective Cohort Study of 30-day Complications, Readmissions, and Mortality. Urology 2022; 170:139-145. [PMID: 36007686 DOI: 10.1016/j.urology.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To quantify the short-term burden associated with continent diversion relative to ileal conduit creation. METHODS Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences. RESULTS Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs. 71 years, p< 0.01) and less likely to have diabetes (13.6% vs. 20.1%, p<0.01), COPD (3.7% vs. 7.1%, p<0.01), and prior pelvic radiation (5.5% vs. 13.1%, p<0.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs. 48.9%, p<0.01) and all-cause readmission (30.3% vs. 20.4%, p<0.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1 - 1.7) and 1.7 (95% CI: 1.4 - 2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5 - 2.9). CONCLUSIONS Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion.
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Affiliation(s)
- Michael E Rezaee
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | | | - William Bihrle
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Florian R Schroeck
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; White River Junction, VA Medical Center, White River Junction, VT; Geisel School of Medicine at Dartmouth College, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John D Seigne
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth College, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Okorie CL, Gatsby E, Schroeck FR, Ould Ismail AA, Lynch KE. Using electronic health records to streamline provider recruitment for implementation science studies. PLoS One 2022; 17:e0267915. [PMID: 35560153 PMCID: PMC9106149 DOI: 10.1371/journal.pone.0267915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/18/2022] [Indexed: 11/19/2022] Open
Abstract
Background Healthcare providers are often targeted as research participants, especially for implementation science studies evaluating provider- or system-level issues. Frequently, provider eligibility is based on both provider and patient factors. Manual chart review and self-report are common provider screening strategies but require substantial time, effort, and resources. The automated use of electronic health record (EHR) data may streamline provider identification for implementation science research. Here, we describe an approach to provider screening for a Veterans Health Administration (VHA)-funded study focused on implementing risk-aligned surveillance for bladder cancer patients. Methods Our goal was to identify providers at 6 pre-specified facilities who performed ≥10 surveillance cystoscopy procedures among bladder cancer patients in the 12 months prior to recruitment start on January 16, 2020, and who were currently practicing at 1 of 6 pre-specified facilities. Using VHA EHR data (using CPT, ICD10 procedure, and ICD10 diagnosis codes), we identified cystoscopy procedures performed after an initial bladder cancer diagnosis (i.e., surveillance procedures). Procedures were linked to VHA staff data to determine the provider of record, the number of cystoscopies they performed, and their current location of practice. To validate this approach, we performed a chart review of 105 procedures performed by a random sample of identified providers. The proportion of correctly identified procedures was calculated (Positive Predictive Value (PPV)), along with binomial 95% confidence intervals (CI). Findings We identified 1,917,856 cystoscopies performed on 703,324 patients from October 1, 1999—January 16, 2020, across the nationwide VHA. Of those procedures, 40% were done on patients who had a prior record of bladder cancer and were completed by 15,065 distinct providers. Of those, 61 performed ≥ 10 procedures and were currently practicing at 1 of the 6 facilities of interest in the 1 year prior to study recruitment. The random chart review of 7 providers found 101 of 105 procedures (PPV: 96%; 95% CI: 91% to 99%) were surveillance procedures and were performed by the selected provider on the recorded date. Implications These results show that EHR data can be used for accurate identification of healthcare providers as research participants when inclusion criteria consist of both patient- (temporal relationship between diagnosis and procedure) and provider-level (frequency of procedure and location of current practice) factors. As administrative codes and provider identifiers are collected in most, if not all, EHRs for billing purposes this approach can be translated from provider recruitment in VHA to other healthcare systems. Implementation studies should consider this method of screening providers.
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Affiliation(s)
- Chiamaka L. Okorie
- From Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - Elise Gatsby
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT, United States of America
| | - Florian R. Schroeck
- From Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- Section of Urology Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America
- Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
| | - A. Aziz Ould Ismail
- White River Junction VA Medical Center, White River Junction, VT, United States of America
| | - Kristine E. Lynch
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT, United States of America
- * E-mail:
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Yang R, Zhu D, Howard LE, De Hoedt A, Schroeck FR, Klaassen Z, Freedland SJ, Williams SB. Context-Based Identification of Muscle Invasion Status in Patients With Bladder Cancer Using Natural Language Processing. JCO Clin Cancer Inform 2022; 6:e2100097. [PMID: 35073149 DOI: 10.1200/cci.21.00097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Mortality from bladder cancer (BC) increases exponentially once it invades the muscle, with inherent challenges delineating at the population level. We sought to develop and validate a natural language processing (NLP) model for automatically identifying patients with muscle-invasive bladder cancer (MIBC). METHODS All patients with a Current Procedural Terminology code for transurethral resection of bladder tumor (TURBT; n = 76,060) were selected from the Department of Veterans Affairs (VA) database. A sample of 600 patients (with 2,337 full-text notes) who had TURBT and confirmed pathology results were selected for NLP model development and validation. The NLP performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, F1 score, and overall accuracy at the individual note and patient levels. RESULTS In the validation cohort, the NLP model had average overall accuracies of 94% and 96% at the note and patient levels. Specifically, the F1 score and overall accuracy for predicting muscle invasion at the patient level were 0.87% and 96%, respectively. The model classified nonmuscle-invasive bladder cancer (NMIBC) with overall accuracies of 90% and 93% at the note and patient levels. When applying the model to 71,200 patients VA-wide, the model classified 13,642 (19%) as having MIBC and 47,595 (66%) as NMIBC and was able to identify invasion status for 96% of patients with TURBT at the population level. Inherent limitations include a relatively small training set, given the size of the VA population. CONCLUSION This NLP model, with high accuracy, may be a practical tool for efficiently identifying BC invasion status and aid in population-based BC research.
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Affiliation(s)
- Ruixin Yang
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Di Zhu
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Lauren E Howard
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC.,Duke Cancer Institute, Duke University School of Medicine, Durham, NC
| | - Amanda De Hoedt
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Florian R Schroeck
- White River Junction VA Medical Center, White River Junction, VT.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia at Augusta University, Augusta, GA.,Georgia Cancer Center, Augusta, GA
| | - Stephen J Freedland
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC.,Division of Urology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA.,Center for Integrated Research in Cancer and Lifestyle, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen B Williams
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC.,Department of Surgery, Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX
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Schroeck FR, Ould Ismail AA, Perry GN, Haggstrom DA, Sanchez SL, Walker DR, Young J, Zickmund S, Zubkoff L. Determinants of Risk-Aligned Bladder Cancer Surveillance-Mixed-Methods Evaluation Using the Tailored Implementation for Chronic Diseases Framework. JCO Oncol Pract 2022; 18:e152-e162. [PMID: 34464159 PMCID: PMC8835627 DOI: 10.1200/op.21.00226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites). METHODS We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type. RESULTS There were 14 participants from risk-aligned sites and 26 participants from need improvement sites. Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at need improvement sites were a lack of resources ("the next available without overbooking is probably seven to eight weeks out") and an absence of routines to incorporate risk-aligned surveillance ("I have my own guidelines that I've been using for 35 years"). CONCLUSION Knowledge, resources, and lack of routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more risk-aligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may improve their routines.
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Affiliation(s)
- Florian R. Schroeck
- From the White River Junction VA Medical Center, White River Junction, VT,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH,Florian R. Schroeck, MD, MS, VA Outcomes Group, WRJ VA Medical Center, 215 N Main St, White River Junction, VT 05009; e-mail:
| | | | - Grace N. Perry
- Department of Medicine, University of Utah, Salt Lake City, UT
| | - David A. Haggstrom
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN,Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN,Regenstrief Institute, Indianapolis, IN
| | - Steven L. Sanchez
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN
| | - DeRon R. Walker
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN
| | - Jeanette Young
- VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Susan Zickmund
- Department of Medicine, University of Utah, Salt Lake City, UT,VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Lisa Zubkoff
- Birmingham/Atlanta VA Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL,Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Kukreja JB, Schroeck FR, Lotan Y, Gore JL, Ullman R, Lipman RR, Murray MBB, Chisolm S, Smith AB. Discomfort and relieving factors among patients with bladder cancer undergoing office-based cystoscopy. Urol Oncol 2021; 40:9.e19-9.e27. [PMID: 34162499 DOI: 10.1016/j.urolonc.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the degree of discomfort among patients with bladder cancer undergoing office-based cystoscopy and identify factors and interventions that influence discomfort and anxiety. METHODS We conducted a survey of the Bladder Cancer Advocacy Network Patient Survey Network (BCAN PSN) to investigate the degree of discomfort associated with office-based cystoscopy and prevalence of interventions used to reduce discomfort. All patients had undergone at least one previous cystoscopy. Bivariable and multivariable logistic regression were used to identify factors associated with moderate-to-severe cystoscopy discomfort. RESULTS Among 488 BCAN PSN respondents (50% response rate), 392 responded with demographic data and discomfort score. Cystoscopy was associated with moderate-to-severe discomfort in 52% of patients. Respondents who reported moderate-to-severe discomfort were more likely to describe their most recent cystoscopy discomfort as worse than prior (P<0.001) and to be interested in planning discomfort mitigation for cystoscopy (P<0.001). On multivariable analysis, gender was the only factor independently associated with discomfort, with women reporting less discomfort than men (OR 0.59, 95%CI 0.37-0.95,P=0.03). Patients reported a wide variety of cystoscopy-specific interventions with differing perceived effectiveness, the most common being intraurethral lidocaine. CONCLUSIONS Over half of patients undergoing office-based cystoscopy for bladder cancer report moderate-to-severe discomfort, constituting a substantial problem among patients undergoing the procedure. Future large pragmatic comparative effectiveness trials are needed to better understand which interventions work most effectively to reduce discomfort associated with cystoscopy.
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Affiliation(s)
| | - Florian R Schroeck
- Section of Urology and VA Outcomes Group, White River Junction VA Medical Center, Vermont; Section of Urology, Norris Cotton Cancer Center, and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - John L Gore
- Department of Urology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| | - Ralph Ullman
- Bladder Cancer Advocacy Network, Research Patient Advocate
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- Bladder Cancer Advocacy Network, Research Patient Advocate
| | - Angela B Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Rezaee ME, Ismail AAO, Okorie CL, Seigne JD, Lynch KE, Schroeck FR. Partial Versus Complete Bacillus Calmette-Guérin Intravesical Therapy and Bladder Cancer Outcomes in High-risk Non-muscle-invasive Bladder Cancer: Is NIMBUS the Full Story? EUR UROL SUPPL 2021; 26:35-43. [PMID: 34337506 PMCID: PMC8317819 DOI: 10.1016/j.euros.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 01/09/2023] Open
Abstract
Background It is important to understand the implications of reduced bacillus Calmette-Guérin (BCG) treatment intensity, given global shortages and early termination of the NIMBUS trial. Objective To assess the association of partial versus complete BCG induction with outcomes. Design, setting, and participants This is a retrospective cohort study of veterans diagnosed with high-risk non–muscle-invasive bladder cancer (NMIBC; high grade [HG] Ta, T1, or carcinoma in situ) between 2005 and 2011 with follow-up through 2014. Intervention Patients were categorized into partial versus complete BCG induction (one to five vs five or more instillations). Partial BCG induction subgroups were defined for comparison with the NIMBUS trial. Outcome measurements and statistical analysis Propensity score–adjusted regression models were used to assess the association of partial BCG induction with risk of recurrence and bladder cancer death. Results and limitations Among 540 patients, 114 (21.1%) underwent partial BCG induction. Partial versus complete BCG induction was not significantly associated with the risk of recurrence in HG Ta (cumulative incidence [CIn] 46.6% vs 53.9% at 5 yr, p = 0.38) or T1 (CIn 47.1% vs 56.7 at 5 yr, p = 0.19) disease. Similarly, we found no increased risk of bladder cancer death (HG Ta: CIn 4.7%7vs 5.4% at 5 yr, p = 0.87; T1: CIn 10.0% vs 11.4% at 5 yr, p = 0.77). NIMBUS-like induction was associated with an increased risk of recurrence in patients with HG Ta disease, although not statistically significant. Unmeasured confounding is a limitation. Conclusions Cancer outcomes were similar among high-risk NMIBC patients who underwent partial versus complete BCG induction, suggesting that future research is needed to determine how to optimize BCG delivery for the greatest number of patients, especially during global shortages. Patient summary Outcomes were similar between patients receiving partial and complete courses of bacillus Calmette-Guérin (BCG) therapy. Future research is needed to determine how to best deliver BCG to the greatest number of patients, particularly during medication shortages.
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Affiliation(s)
- Michael E Rezaee
- White River Junction VA Medical Center, White River Junction, VT, USA.,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | - John D Seigne
- White River Junction VA Medical Center, White River Junction, VT, USA.,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Kristine E Lynch
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT, USA
| | - Florian R Schroeck
- White River Junction VA Medical Center, White River Junction, VT, USA.,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
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10
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Check DK, Zullig LL, Davis MM, Davies L, Chambers D, Fleisher L, Kaplan SJ, Proctor E, Ramanadhan S, Schroeck FR, Stover AM, Koczwara B. Improvement Science and Implementation Science in Cancer Care: Identifying Areas of Synergy and Opportunities for Further Integration. J Gen Intern Med 2021; 36:186-195. [PMID: 32869193 PMCID: PMC7859137 DOI: 10.1007/s11606-020-06138-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 08/11/2020] [Indexed: 12/30/2022]
Abstract
Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.
| | - Leah L Zullig
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Melinda M Davis
- Oregon Rural Practice-based Research Network and Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | - Louise Davies
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Department of Surgery - Otolaryngology Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - David Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | | | - Samantha J Kaplan
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Enola Proctor
- The Brown School at Washington University in St. Louis, St. Louis, MO, USA
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Florian R Schroeck
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Section of Urology and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, PA, USA
| | - Angela M Stover
- Department of Health Policy and Management, Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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11
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Aboumrad M, Shiner B, Mucci L, Neupane N, Schroeck FR, Klaassen Z, Freedland SJ, Young-Xu Y. Posttraumatic stress disorder and suicide among veterans with prostate cancer. Psychooncology 2020; 30:581-590. [PMID: 33247977 DOI: 10.1002/pon.5605] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/06/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide. METHODS We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors. RESULTS Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96). CONCLUSION Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk.
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Affiliation(s)
- Maya Aboumrad
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lorelei Mucci
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nabin Neupane
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Florian R Schroeck
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Zachary Klaassen
- Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Stephen J Freedland
- Cedars-Sinai Medical Center, Los Angeles, California, USA.,Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Yinong Young-Xu
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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12
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Schroeck FR, St Ivany A, Lowrance W, Makarov DV, Goodney PP, Zubkoff L. Patient Perspectives on the Implementation of Risk-Aligned Bladder Cancer Surveillance: Systematic Evaluation Using the Tailored Implementation for Chronic Diseases Framework. JCO Oncol Pract 2020; 16:e668-e677. [PMID: 32119595 PMCID: PMC10841578 DOI: 10.1200/jop.19.00576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors. PARTICIPANTS AND METHODS Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories. RESULTS Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories. CONCLUSION Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.
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Affiliation(s)
- Florian R. Schroeck
- White River Junction VA Medical Center, White River Junction, VT
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
- Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Amanda St Ivany
- Department of Community and Family Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - William Lowrance
- Salt Lake City VA Healthcare System, Salt Lake City, UT
- Department of Urology, University of Utah, Salt Lake City, UT
| | - Danil V. Makarov
- New York Harbor VA Healthcare System, New York, NY
- Departments of Urology and Population Health, New York University, New York, NY
| | - Philip P. Goodney
- White River Junction VA Medical Center, White River Junction, VT
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Lisa Zubkoff
- White River Junction VA Medical Center, White River Junction, VT
- Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
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13
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Rezaee ME, Lynch KE, Li Z, MacKenzie TA, Seigne JD, Robertson DJ, Sirovich B, Goodney PP, Schroeck FR. The impact of low- versus high-intensity surveillance cystoscopy on surgical care and cancer outcomes in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). PLoS One 2020; 15:e0230417. [PMID: 32203532 PMCID: PMC7089561 DOI: 10.1371/journal.pone.0230417] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/28/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC). Materials & methods A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1–5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death. Results Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5–10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4–11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002). Conclusions Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.
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Affiliation(s)
- Michael E. Rezaee
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- Section of Urology Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Kristine E. Lynch
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT, United States of America
| | - Zhongze Li
- Biomedical Data Science Department, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - Todd A. MacKenzie
- Biomedical Data Science Department, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - John D. Seigne
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Douglas J. Robertson
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - Brenda Sirovich
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - Philip P. Goodney
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
| | - Florian R. Schroeck
- White River Junction VA Medical Center, White River Junction, VT, United States of America
- Section of Urology Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States of America
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, United States of America
- * E-mail:
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14
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Lynch KE, Viernes B, Khader K, DuVall SL, Schroeck FR. Sex and the Diagnostic Pathway to Bladder Cancer among Veterans: No Evidence of Disparity. Womens Health Issues 2019; 30:128-135. [PMID: 31870696 DOI: 10.1016/j.whi.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/04/2019] [Accepted: 11/08/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Longer time intervals from presentation with hematuria to bladder cancer diagnosis have been reported among women compared with men. Despite women being the fastest growing cohort within the Department of Veterans Affairs, little is known about women veterans with bladder cancer. Our objectives were to quantify the time from hematuria to bladder cancer diagnosis in Department of Veterans Affairs and assess differences between sexes. METHODS This was a retrospective cohort study of patients diagnosed with bladder cancer from 2001 to 2016. Included were patients with hematuria for fewer than 365 days before a bladder cancer diagnosis and who had a record of diagnostic cystoscopy after hematuria but before diagnosis. We evaluated the number of days from hematuria to diagnostic cystoscopy (clinical appraisal), cystoscopy to bladder cancer diagnosis (surgical appraisal), and hematuria to bladder cancer diagnosis (total diagnostic appraisal). We used quantile regression models to separately evaluate the effect of sex on the three appraisal intervals. RESULTS Data from 213 women and 24,295 men were analyzed. The median clinical appraisal time was 78 days for women and 72 for men (p = .49). The median surgical appraisal time was 32 days for women and 33 for men (p = .74). The median total diagnostic appraisal time was 135 days for women and 130 for men (p = .71). Multivariable analyses showed no differences between men and women for any of the three appraisal intervals. CONCLUSIONS The majority of time from hematuria to bladder cancer diagnosis is spent in clinical appraisal, but little difference was observed between men and women in Department of Veterans Affairs.
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Affiliation(s)
- Kristine E Lynch
- VA Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah.
| | - Benjamin Viernes
- VA Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Karim Khader
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Florian R Schroeck
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire; White River Junction VA Medical Center, White River Junction, Vermont; Section of Urology and Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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15
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Schroeck FR. EDITORIAL COMMENT. Urology 2019; 131:102. [DOI: 10.1016/j.urology.2019.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/20/2019] [Indexed: 10/26/2022]
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16
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Han DS, Lynch KE, Chang JW, Sirovich B, Robertson DJ, Swanton AR, Seigne JD, Goodney PP, Schroeck FR. Overuse of Cystoscopic Surveillance Among Patients With Low-risk Non-Muscle-invasive Bladder Cancer - A National Study of Patient, Provider, and Facility Factors. Urology 2019; 131:112-119. [PMID: 31145947 DOI: 10.1016/j.urology.2019.04.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/05/2019] [Accepted: 04/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA). METHODS Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (ie low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or 2 years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression. RESULTS Overuse occurred in 75% of patients (852/1135) - with an excess of 1846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28, 0.85 unlisted race vs White), having 2 comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs 2011, and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (ie, intermediate-risk), overuse would have still occurred in 45% of patients. CONCLUSION Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data.
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Affiliation(s)
- David S Han
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH
| | - Kristine E Lynch
- VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Ji Won Chang
- VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Brenda Sirovich
- The White River Junction VA Medical Center, White River Junction, VT
| | | | - Amanda R Swanton
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John D Seigne
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- The White River Junction VA Medical Center, White River Junction, VT
| | - Florian R Schroeck
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH; The White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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17
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Schroeck FR, Lynch KE, Li Z, MacKenzie TA, Han DS, Seigne JD, Robertson DJ, Sirovich B, Goodney PP. The impact of frequent cystoscopy on surgical care and cancer outcomes among patients with low-risk, non-muscle-invasive bladder cancer. Cancer 2019; 125:3147-3154. [PMID: 31120559 DOI: 10.1002/cncr.32185] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/21/2019] [Accepted: 04/29/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Surveillance recommendations for patients with low-risk, non-muscle-invasive bladder cancer (NMIBC) are based on limited evidence. The objective of this study was to add to the evidence by assessing outcomes after frequent versus recommended cystoscopic surveillance. METHODS This was a retrospective cohort study of patients diagnosed with low-risk (low-grade Ta (AJCC)) NMIBC from 2005 to 2011 with follow-up through 2014 from the Department of Veterans Affairs. Patients were classified as having undergone frequent versus recommended cystoscopic surveillance (>3 vs 1-3 cystoscopies in the first 2 years after diagnosis). By using propensity score-adjusted models, the authors estimated the impact of frequent cystoscopy on the number of transurethral resections, the number of resections without cancer in the specimen, and the risk of progression to muscle-invasive cancer or bladder cancer death. RESULTS Among 1042 patients, 798 (77%) had more frequent cystoscopy than recommended. In adjusted analyses, the frequent cystoscopy group had twice as many transurethral resections (55 vs 26 per 100 person-years; P < .001) and more than 3 times as many resections without cancer in the specimen (5.7 vs 1.6 per 100 person-years; P < .001). Frequent cystoscopy was not associated with time to progression or bladder cancer death (3% at 5 years in both groups; P = .990). CONCLUSIONS Frequent cystoscopy among patients with low-risk NMIBC was associated with twice as many transurethral resections and did not decrease the risk for bladder cancer progression or death, supporting current guidelines.
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Affiliation(s)
- Florian R Schroeck
- Department of Veterans Affairs (VA) Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Kristine E Lynch
- VA Salt Lake City Health Care System and Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Zhongze Li
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - David S Han
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - John D Seigne
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Douglas J Robertson
- Department of Veterans Affairs (VA) Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Brenda Sirovich
- Department of Veterans Affairs (VA) Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Philip P Goodney
- Department of Veterans Affairs (VA) Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
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18
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Modi PK, Herrel LA, Kaufman SR, Yan P, Borza T, Skolarus TA, Schroeck FR, Hollenbeck BK, Shahinian VB. Urologist Practice Structure and Spending for Prostate Cancer Care. Urology 2019; 130:65-71. [PMID: 31029672 DOI: 10.1016/j.urology.2019.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership. MATERIALS AND METHODS We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics. RESULTS We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims. CONCLUSION Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest.
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Affiliation(s)
- Parth K Modi
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Phyllis Yan
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Tudor Borza
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Florian R Schroeck
- Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Brent K Hollenbeck
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Andrew AS, Karagas MR, Schroeck FR, Marsit CJ, Schned AR, Pettus JR, Armstrong DA, Seigne JD. MicroRNA Dysregulation and Non-Muscle-Invasive Bladder Cancer Prognosis. Cancer Epidemiol Biomarkers Prev 2019; 28:782-788. [PMID: 30700445 DOI: 10.1158/1055-9965.epi-18-0884] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/20/2018] [Accepted: 01/23/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The high rate of non-muscle-invasive bladder cancer recurrence is a major challenge in patient management. miRNAs functionally regulate tumor cell proliferation and invasion, and have strong potential as biomarkers because they are robust to degradation. The objective of this project was to identify reproducible prognostic miRNAs in resected non-muscle-invasive bladder tumor tissue that are predictive of the recurrent tumor phenotype. METHODS We utilized patients diagnosed with primary non-muscle-invasive bladder cancer in three independent cohorts for a biomarker discovery/validation approach. Baseline tumor tissue from patients with the clinically challenging, non-muscle-invasive primary low stage (Ta), high grade, and T1 tumors (tumors extending into the lamina propria) comprised the discovery cohort (n = 38). We isolated the tumor tissue RNA and assessed a panel of approximately 800 miRNAs. RESULTS miR-26b-5p was the top-ranking prognostic tumor tissue miRNA, with a time-to-recurrence HR 0.043 for levels above versus below median, (P adj = 0.0003). miR-26b-5p was related to a dose-response reduction in tumor recurrence, and levels above the median were also associated with reduced time-to-progression (P adj = 0.02). We used two independent longitudinal cohorts that included both low-grade and high-grade Ta and T1 tumors for validation and found a consistent relationship between miR-26b-5p and recurrence and progression. CONCLUSIONS Our results suggest that miR-26b-5p levels may be prognostic for non-muscle-invasive bladder cancer recurrence, and can feasibly be assessed in baseline tumor tissue from a wide variety of clinical settings. IMPACT Early identification of those non-muscle-invasive bladder tumor patients with refractory phenotypes would enable individualized treatment and surveillance.
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Affiliation(s)
- Angeline S Andrew
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
| | - Margaret R Karagas
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Florian R Schroeck
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and White River Junction VA Medical Center, White River Junction, Vermont
| | - Carmen J Marsit
- Department of Environmental Health and Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alan R Schned
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jason R Pettus
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - David A Armstrong
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - John D Seigne
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Han DS, Zhou W, Seigne JD, Lynch KE, Schroeck FR. Geographic Variation in Cystoscopy Rates for Suspected Bladder Cancer between Female and Male Medicare Beneficiaries. Urology 2018; 122:83-88. [PMID: 30138684 PMCID: PMC6295281 DOI: 10.1016/j.urology.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation. METHODS We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates. RESULTS Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013. CONCLUSION Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer.
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Affiliation(s)
- David S. Han
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Weiping Zhou
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - John D. Seigne
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kristine E. Lynch
- VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Florian R. Schroeck
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The White River Junction VA Medical Center, White River Junction, VT
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21
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Schroeck H, Welch TL, Rovner MS, Johnson HA, Schroeck FR. Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review. J Clin Anesth 2018; 54:89-101. [PMID: 30415150 DOI: 10.1016/j.jclinane.2018.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/28/2018] [Accepted: 10/28/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms. METHODS A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines. RESULTS Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training. DISCUSSION While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment.
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Affiliation(s)
- Hedwig Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Tasha L Welch
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Michelle S Rovner
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, 165 Ashley Avenue, Suite 525CH, Charleston, SC 29425, USA.
| | - Heather A Johnson
- Biomedical Libraries, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Florian R Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT 05009, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, USA.
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22
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Schroeck FR, Lynch KE, Chang JW, MacKenzie TA, Seigne JD, Robertson DJ, Goodney PP, Sirovich B. Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer. JAMA Netw Open 2018; 1:e183442. [PMID: 30465041 PMCID: PMC6241521 DOI: 10.1001/jamanetworkopen.2018.3442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/12/2018] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Cancer care guidelines recommend aligning surveillance frequency with underlying cancer risk, ie, more frequent surveillance for patients at high vs low risk of cancer recurrence. OBJECTIVE To assess the extent to which such risk-aligned surveillance is practiced within US Department of Veterans Affairs facilities by classifying surveillance patterns for low- vs high-risk patients with early-stage bladder cancer. DESIGN SETTING AND PARTICIPANTS US national retrospective cohort study of a population-based sample of patients diagnosed with low-risk or high-risk early-stage bladder between January 1, 2005, and December 31, 2011, with follow-up through December 31, 2014. Analyses were performed March 2017 to April 2018. The study included all Veterans Affairs facilities (n = 85) where both low-and high-risk patients were treated. EXPOSURES Low-risk vs high-risk cancer status, based on definitions from the European Association of Urology risk stratification guidelines and on data extracted from diagnostic pathology reports via validated natural language processing algorithms. MAIN OUTCOMES AND MEASURES Adjusted cystoscopy frequency for low-risk and high-risk patients for each facility, estimated using multilevel modeling. RESULTS The study included 1278 low-risk and 2115 high-risk patients (median [interquartile range] age, 77 [71-82] years; 99% [3368 of 3393] male). Across facilities, the adjusted frequency of surveillance cystoscopy ranged from 3.7 to 6.2 (mean, 4.8) procedures over 2 years per patient for low-risk patients and from 4.6 to 6.0 (mean, 5.4) procedures over 2 years per patient for high-risk patients. In 70 of 85 facilities, surveillance was performed at a comparable frequency for low- and high-risk patients, differing by less than 1 cystoscopy over 2 years. Surveillance frequency among high-risk patients statistically significantly exceeded surveillance among low-risk patients at only 4 facilities. Across all facilities, surveillance frequencies for low- vs high-risk patients were moderately strongly correlated (r = 0.52; P < .001). CONCLUSIONS AND RELEVANCE Patients with early-stage bladder cancer undergo cystoscopic surveillance at comparable frequencies regardless of risk. This finding highlights the need to understand barriers to risk-aligned surveillance with the goal of making it easier for clinicians to deliver it in routine practice.
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Affiliation(s)
- Florian R. Schroeck
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Kristine E. Lynch
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Ji won Chang
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Todd A. MacKenzie
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - John D. Seigne
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Douglas J. Robertson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Philip P. Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
| | - Brenda Sirovich
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- White River Junction VA Medical Center, White River Junction, Vermont
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23
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Koczwara B, Stover AM, Davies L, Davis MM, Fleisher L, Ramanadhan S, Schroeck FR, Zullig LL, Chambers DA, Proctor E. Harnessing the Synergy Between Improvement Science and Implementation Science in Cancer: A Call to Action. J Oncol Pract 2018; 14:335-340. [PMID: 29750579 PMCID: PMC6075851 DOI: 10.1200/jop.17.00083] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bogda Koczwara
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Angela M. Stover
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Louise Davies
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Melinda M. Davis
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Linda Fleisher
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Shoba Ramanadhan
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Florian R. Schroeck
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Leah L. Zullig
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - David A. Chambers
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
| | - Enola Proctor
- Flinders University, Adelaide, South Australia, Australia; University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, Chapel Hill; Durham Veterans Affairs Health Care System; Duke University Medical Center, Durham, NC; Department of Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine, Hanover; Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Hitchcock Medical Center, Lebanon, NH; Oregon Health & Science University, Portland, OR; Children’s Hospital of Philadelphia, Philadelphia; Fox Chase Cancer Center, Cheltenham, PA; Dana-Farber Cancer Institute; Harvard T.H. Chan School of Public Health, Boston, MA; National Cancer Institute, Bethesda, MD; and Washington University in St Louis, St Louis, MO
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Welch HG, Schroeck FR. Uncoupling Diagnosis and Treatment of Incidentally Imaged Renal Masses-Reply. JAMA Intern Med 2018; 178:729. [PMID: 29801139 DOI: 10.1001/jamainternmed.2018.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- H Gilbert Welch
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Florian R Schroeck
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont
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25
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Schroeck FR, Smith N, Shelton JB. Implementing risk-aligned bladder cancer surveillance care. Urol Oncol 2018; 36:257-264. [PMID: 29395957 DOI: 10.1016/j.urolonc.2017.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/04/2017] [Accepted: 12/24/2017] [Indexed: 11/18/2022]
Abstract
Implementation science is a rapidly developing field dedicated to the scientific investigation of strategies to facilitate improvements in healthcare delivery. These strategies have been shown in several settings to lead to more complete and sustained change. In this essay, we discuss how refined surveillance recommendations for non-muscle-invasive bladder cancer, which involve a complex interplay between providers, healthcare facilities, and patients, could benefit from use of implementation strategies derived from the growing literature of implementation science. These surveillance recommendations are based on international consensus and indicate that the frequency of surveillance cystoscopy should be aligned with each patient's risk for recurrence and progression of disease. Risk-aligned surveillance entails cystoscopy at 3 and 12 months followed by annual surveillance for low-risk cancers, with surveillance every 3 months reserved for high-risk cancers. However, risk-aligned care is not the norm. Implementing risk-aligned surveillance could curtail overuse among low-risk patients, while curbing underuse among high-risk patients. Despite clear direction from respected and readily available clinical guidelines, there are multiple challenges to implementing risk-aligned surveillance in a busy clinical setting. Here, we describe how implementation science methods can be systematically used to understand determinants of care and to develop strategies to improve care. We discuss how the tailored implementation for chronic diseases framework can facilitate systematic assessment and how intervention mapping can be used to develop implementation strategies to improve care. Taken together, these implementation science methods can help facilitate practice transformation to improve risk-aligned surveillance for bladder cancer.
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Affiliation(s)
- Florian R Schroeck
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH.
| | | | - Jeremy B Shelton
- Department of Urology, UCLA, Los Angeles, CA; Greater Los Angeles VA Medical Center, Los Angeles, CA
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Abstract
IMPORTANCE While computed tomography (CT) represents a tremendous advance in diagnostic imaging, it also creates the problem of incidental detection-the identification of tumors unrelated to the clinical symptoms that initiate the test. OBJECTIVE To determine the geographic variation in the United States in CT imaging and the corresponding association with one of the most consequential sequelae of incidental detection: nephrectomy. DESIGN, SETTING, AND PARTICIPANTS This study is a cross-sectional analysis of age-, sex-, and race-adjusted Medicare data (January 2010-December 2014) from 306 hospital referral regions (HRRs) in the United States and includes information from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years. EXPOSURES Regional CT risk (ie, the proportion of the population receiving either a chest or abdominal CT over 5 years). MAIN OUTCOMES AND MEASURES Five-year risk of nephrectomy (partial or total). RESULTS Data from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years were gathered and illustrate that 43% of Medicare beneficiaries age 65 to 85 years received either a chest or abdominal CT from January 2010 to December 2014. This risk varied across the HRRs, ranging from 31% in Santa Cruz, California, to 52% in Sun City, Arizona. Increased regional CT risk was associated with a higher nephrectomy risk (r = 0.38; 95% CI, 0.28-0.47), particularly among HRRs with more than 50 000 beneficiaries (r = 0.47; 95% CI, 0.31-0.61). After controlling for HRR adult smoking rates, imaging an additional 1000 beneficiaries was associated with 4 additional nephrectomies (95% CI, 3-5). Case-fatality rates for those who underwent nephrectomy were 2.1% at 30 days and 4.3% at 90 days. CONCLUSIONS AND RELEVANCE Fee-for-service Medicare beneficiaries are commonly exposed to CT imaging. Those residing in high-scanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses. Additional surgery should be considered one of the risks of excessive CT imaging.
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Affiliation(s)
- H Gilbert Welch
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Jonathan S Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Economics, Dartmouth College, Hanover, New Hampshire
| | - Florian R Schroeck
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont.,Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Urology Service, Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Weiping Zhou
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire
| | - William C Black
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Radiology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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27
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Schroeck FR, Patterson OV, Alba PR, Pattison EA, Seigne JD, DuVall SL, Robertson DJ, Sirovich B, Goodney PP. Development of a Natural Language Processing Engine to Generate Bladder Cancer Pathology Data for Health Services Research. Urology 2017; 110:84-91. [PMID: 28916254 DOI: 10.1016/j.urology.2017.07.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/13/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To take the first step toward assembling population-based cohorts of patients with bladder cancer with longitudinal pathology data, we developed and validated a natural language processing (NLP) engine that abstracts pathology data from full-text pathology reports. METHODS Using 600 bladder pathology reports randomly selected from the Department of Veterans Affairs, we developed and validated an NLP engine to abstract data on histology, invasion (presence vs absence and depth), grade, the presence of muscularis propria, and the presence of carcinoma in situ. Our gold standard was based on an independent review of reports by 2 urologists, followed by adjudication. We assessed the NLP performance by calculating the accuracy, the positive predictive value, and the sensitivity. We subsequently applied the NLP engine to pathology reports from 10,725 patients with bladder cancer. RESULTS When comparing the NLP output to the gold standard, NLP achieved the highest accuracy (0.98) for the presence vs the absence of carcinoma in situ. Accuracy for histology, invasion (presence vs absence), grade, and the presence of muscularis propria ranged from 0.83 to 0.96. The most challenging variable was depth of invasion (accuracy 0.68), with an acceptable positive predictive value for lamina propria (0.82) and for muscularis propria (0.87) invasion. The validated engine was capable of abstracting pathologic characteristics for 99% of the patients with bladder cancer. CONCLUSION NLP had high accuracy for 5 of 6 variables and abstracted data for the vast majority of the patients. This now allows for the assembly of population-based cohorts with longitudinal pathology data.
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Affiliation(s)
- Florian R Schroeck
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH.
| | - Olga V Patterson
- Department of Internal Medicine, VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT
| | - Patrick R Alba
- Department of Internal Medicine, VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT
| | - Erik A Pattison
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - John D Seigne
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Scott L DuVall
- Department of Internal Medicine, VA Salt Lake City Health Care System and University of Utah, Salt Lake City, UT
| | - Douglas J Robertson
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Brenda Sirovich
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Philip P Goodney
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
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Schroeck FR, Sirovich B, Seigne JD, Robertson DJ, Goodney PP. Assembling and validating data from multiple sources to study care for Veterans with bladder cancer. BMC Urol 2017; 17:78. [PMID: 28877694 PMCID: PMC5585934 DOI: 10.1186/s12894-017-0271-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 08/31/2017] [Indexed: 11/17/2022] Open
Abstract
Background Despite the high prevalence of bladder cancer, research on optimal bladder cancer care is limited. One way to advance observational research on care is to use linked data from multiple sources. Such big data research can provide real-world details of care and outcomes across a large number of patients. We assembled and validated such data including (1) administrative data from the Department of Veterans Affairs (VA), (2) Medicare claims, (3) data abstracted by tumor registrars, (4) data abstracted via chart review from the national electronic health record, and (5) full text pathology reports. Methods Based on these combined data, we used administrative data to identify patients with newly diagnosed bladder cancer who received care in the VA. To validate these data, we first compared the diagnosis date from the administrative data to that from the tumor registry. Second, we measured accuracy of identifying bladder cancer care in VA administrative data, using a random chart review (n = 100) as gold standard. Lastly, we compared the proportion of patients who received bladder cancer care among those who did versus did not have full text bladder pathology reports available, expecting that those with reports are significantly more likely to receive care in VA. Results Out of 26,675 patients, 11,323 (42%) had tumor registry data available. 90% of these patients had a difference of 90 days or less between the diagnosis dates from administrative and registry data. Among 100 patients selected for chart review, 59 received bladder cancer care in VA, 58 of which were correctly identified using administrative data (sensitivity 98%, specificity 90%). Receipt of bladder cancer care was substantially more common among those who did versus did not have bladder pathology available (96% vs. 43%, p < 0.001). Conclusion Merging administrative with electronic health record and pathology data offers new possibilities to validate the use of administrative data in bladder cancer research. Electronic supplementary material The online version of this article (10.1186/s12894-017-0271-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Florian R Schroeck
- White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, 05009, USA. .,Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. .,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.
| | - Brenda Sirovich
- White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, 05009, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - John D Seigne
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Douglas J Robertson
- White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, 05009, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Philip P Goodney
- White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, 05009, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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Koo K, Zubkoff L, Sirovich BE, Goodney PP, Robertson DJ, Seigne JD, Schroeck FR. The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making. Urology 2017; 108:122-128. [PMID: 28739405 DOI: 10.1016/j.urology.2017.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC). METHODS Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence. RESULTS Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care. CONCLUSION Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.
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Affiliation(s)
- Kevin Koo
- White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lisa Zubkoff
- White River Junction VA Medical Center, White River Junction, VT; Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Brenda E Sirovich
- White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Philip P Goodney
- White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Douglas J Robertson
- White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - John D Seigne
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Florian R Schroeck
- White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Schroeck FR, Bekelman JE, Kahn JM, Nelson JB, Barnato AE. The early adoption of intensity-modulated radiotherapy and stereotactic body radiation treatment among older Medicare beneficiaries with prostate cancer. Cancer 2017; 123:2945-2954. [PMID: 28301689 DOI: 10.1002/cncr.30574] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/15/2016] [Accepted: 12/23/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several new prostate cancer treatments have emerged since 2000, including 2 radiotherapies with similar efficacy at the time of their introduction: intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT). The objectives of this study were to compare their early adoption patterns and identify factors associated with their use. METHODS By using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, patients who received radiation therapy during the 5 years after IMRT introduction (2001-2005) and the 5 years after SBRT introduction (2007-2011) were identified. The outcome of interest was the receipt of new radiation therapy (ie, IMRT or SBRT) compared with the existing standard radiation therapies at that time. The authors fit a series of multivariable, hierarchical logistic regression models accounting for patients nested within health service areas to examine the factors associated with the receipt of new radiation therapy. RESULTS During 2001 to 2005, 5680 men (21%) received IMRT compared with standard radiation (n = 21,555). Men who received IMRT were older, had higher grade tumors, and lived in more populated areas (P < .05). During 2007 through 2011, 595 men (2%) received SBRT compared with standard radiation (n = 28,255). Men who received ng SBRT were more likely to be white, had lower grade tumors, lived in more populated areas, and were more likely to live in the Northeast (P < .05). Adjusting for cohort demographic and clinical factors, the early adoption rate for IMRT was substantially higher than that for SBRT (44% vs 4%; P < .01). CONCLUSIONS There is a stark contrast in the adoption rates of IMRT and SBRT at the time of their introduction. Further investigation of the nonclinical factors associated with this difference is warranted. Cancer 2017;123:2945-54. © 2017 American Cancer Society.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florian R Schroeck
- White River Junction Veterans Affairs Medical Center and The Dartmouth Institute Geisel School of Medicine, Lebanon, New Hampshire
| | - Justin E Bekelman
- Department of Radiation Oncology, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Reinstatler L, Schroeck FR, Hyams ES. Ensuring Evidence-Based Practice: A Study of Factors Associated with Nonuse of American Urological Association Guidelines. Urol Pract 2017; 4:25-29. [PMID: 37592609 DOI: 10.1016/j.urpr.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Evidence-based guidelines are published by the AUA (American Urological Association) to improve the quality and consistency of urological care. The 2014 AUA Census reported a unique field regarding provider utilization of AUA Guidelines. We sought to identify factors associated with nonuse of AUA Guidelines to understand how education and dissemination of these guidelines might be improved. METHODS Using 2014 AUA Census data providers were stratified based on self-reported use or nonuse of AUA Guidelines. Bivariate analyses and multivariable logistic regression analysis were performed to identify factors associated with nonuse. Post-stratification weights were applied to calculate national estimates with SAS®, version 9.4. RESULTS The 2,202 survey respondents represented 11,680 practicing urologists. AUA guideline use was reported by 95.0% of the weighted population. There was no significant difference in utilization based on gender, race, country of origin, practice type or fellowship completion. After controlling for other variables urologists who reported practicing in a rural area were more likely to be nonusers (OR 1.06, 95% CI 1.03-1.09). Additionally, urologists who had been practicing longer were less likely to utilize guidelines compared with those earlier in the career (practicing 10 to 20 years OR 1.15, 95% CI 1.10-1.21 and more than 20 years OR 1.13, 95% CI 1.09-1.18, p <0.05). CONCLUSIONS Despite continued publication and dissemination of AUA Guidelines about 5% of urologists do not utilize guidelines. Later career status and rural geography were associated with nonuse. These data may inform efforts to improve dissemination and education regarding evidence-based practice.
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Affiliation(s)
- Lael Reinstatler
- Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon
| | - Florian R Schroeck
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont
| | - Elias S Hyams
- Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon
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Schroeck FR, Pattison EA, Denhalter DW, Patterson OV, DuVall SL, Seigne JD, Robertson DJ, Sirovich B, Goodney PP. Early Stage Bladder Cancer: Do Pathology Reports Tell Us What We Need to Know? Urology 2016; 98:58-63. [PMID: 27590253 DOI: 10.1016/j.urology.2016.07.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess a large national sample of bladder cancer pathology reports to determine if they contained the components necessary for clinical decision-making. METHODS We examined a random sample of 507 bladder cancer pathology reports from the national Department of Veterans Affairs Corporate Data Warehouse to assess whether each included information on the 4 report components explicitly recommended by the College of American Pathologists' protocol for the examination of such specimens: histology, grade, presence vs absence of muscularis propria in the specimen, and microscopic extent. We then assessed variation in the proportion of reports lacking at least 1 component across Department of Veterans Affairs facilities. RESULTS One hundred eight of 507 reports (21%) lacked at least 1 of the 4 components, with microscopic extent and presence vs absence of muscularis propria in the specimen most commonly missing (each in 11% of reports). There was wide variation across facilities in the proportion of reports lacking at least 1 component, ranging from 0% to 80%. CONCLUSION One-fifth of bladder cancer pathology reports lack information needed for clinical decision-making. The wide variation in incomplete report rates across facilities implies that some facilities already have implemented best practices assuring complete reporting whereas others have room for improvement. Future work to better understand barriers and facilitators of complete reporting may lead to interventions that improve bladder cancer care.
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Affiliation(s)
- Florian R Schroeck
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College.
| | - Erik A Pattison
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Daniel W Denhalter
- VA Salt Lake City Health Care System, Salt Lake City, UT; University of Utah, Salt Lake City, UT
| | - Olga V Patterson
- VA Salt Lake City Health Care System, Salt Lake City, UT; University of Utah, Salt Lake City, UT
| | - Scott L DuVall
- VA Salt Lake City Health Care System, Salt Lake City, UT; University of Utah, Salt Lake City, UT
| | - John D Seigne
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Douglas J Robertson
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
| | - Brenda Sirovich
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
| | - Philip P Goodney
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
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33
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Herrel LA, Kaufman SR, Yan P, Miller DC, Schroeck FR, Skolarus TA, Shahinian VB, Hollenbeck BK. Health Care Integration and Quality among Men with Prostate Cancer. J Urol 2016; 197:55-60. [PMID: 27423758 DOI: 10.1016/j.juro.2016.07.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Lindsey A Herrel
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Phyllis Yan
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Florian R Schroeck
- White River Junction VA Medical Center, White River Junction, Vermont, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Section of Urology and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ted A Skolarus
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; VA Health Services Research & Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vahakn B Shahinian
- Kidney Epidemiology Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Dow Division for Urological Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.
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Schroeck FR, Sirovich BE. Editorial Comment. Urology 2016; 86:1198-9. [PMID: 26719119 DOI: 10.1016/j.urology.2015.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Florian R Schroeck
- Outcomes Group, Veterans Affairs Medical Center, White River Junction, VT; Section of Urology, Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Brenda E Sirovich
- Outcomes Group, Veterans Affairs Medical Center, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
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Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Zhang Y, Hollenbeck BK. Technology diffusion and prostate cancer quality of care. Urology 2014; 84:1066-72. [PMID: 25443905 DOI: 10.1016/j.urology.2014.06.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/10/2014] [Accepted: 06/21/2014] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ted A Skolarus
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI; Center for Clinical Management Research, Health Services Research and Development Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Yun Zhang
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Brent K Hollenbeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI.
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Abstract
OBJECTIVE Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of robotics is unknown. We sought to better understand the relationship between a market's managed-care penetration and the dissemination of robotic prostatectomy. METHODS We used SEER-Medicare data from 2003 through 2007 to identify men ≥66 years of age treated with radical prostatectomy for prostate cancer. We categorized Health Service Areas (HSAs) according to the degree of managed-care penetration (ie, low vs high). We assessed adoption of robotic prostatectomy and utilization among adopting HSAs using Cox proportional-hazards and Poisson regression models, respectively. RESULTS Compared with markets with little managed care, highly penetrated markets had more racial diversity (24% vs 15% nonwhite, P < .01), higher population densities (1987 vs 422 people/square mile, P < .01), and higher median incomes ($49 374 vs $36 236, P < .01). Robotic prostatectomy adoption and utilization increased over time in both HSA categories. Compared with low managed-care markets, those with high managed care adopted robotic prostatectomy more rapidly (eg, probability 0.37 [low] vs 0.52 [high] in 2007; P < .01). However, the postadoption utilization of robotic prostatectomy was constrained in these highly penetrated markets (eg, probability 0.66 [low] vs 0.52 [high] in 2007; P < .01). CONCLUSIONS High managed-care penetration was associated with more rapid robotic prostatectomy adoption. However, once adopted, utilization increased more slowly in these markets. Understanding this paradox is important as more technologies are unveiled in an increasingly cost-conscious health care environment.
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Affiliation(s)
- Yun Zhang
- University of Michigan, Ann Arbor, MI, USA
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Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Hollingsworth JM, Shahinian VB, Hollenbeck BK. Regional variation in quality of prostate cancer care. J Urol 2013; 191:957-62. [PMID: 24144685 DOI: 10.1016/j.juro.2013.10.066] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2013] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan
| | - Bruce L Jacobs
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan; HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John M Hollingsworth
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan
| | | | - Brent K Hollenbeck
- Division of Health Services Research, University of Michigan, Ann Arbor, Michigan; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.
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Schroeck FR, Wei JT. Reply by the authors. Urology 2013; 82:981. [PMID: 24075001 DOI: 10.1016/j.urology.2013.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Jacobs BL, Zhang Y, Schroeck FR, Skolarus TA, Wei JT, Montie JE, Gilbert SM, Strope SA, Dunn RL, Miller DC, Hollenbeck BK. Use of advanced treatment technologies among men at low risk of dying from prostate cancer. JAMA 2013; 309:2587-95. [PMID: 23800935 PMCID: PMC3857348 DOI: 10.1001/jama.2013.6882] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain. OBJECTIVE To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer. DESIGN, SETTING, AND PATIENTS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010. MAIN OUTCOMES AND MEASURES The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both. RESULTS In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001). CONCLUSION AND RELEVANCE Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Michigan, Ann Arbor, MI 48109-2800, USA
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Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Miller DC, Weizer AZ, Montgomery JS, Wei JT, Shahinian VB, Hollenbeck BK. Technology diffusion and diagnostic testing for prostate cancer. J Urol 2013; 190:1715-20. [PMID: 23669564 DOI: 10.1016/j.juro.2013.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 01/09/2023]
Abstract
PURPOSE While the dissemination of robotic prostatectomy and intensity modulated radiotherapy may fuel the increased use of prostatectomy and radiotherapy, these new technologies may also have spillover effects related to diagnostic testing for prostate cancer. Therefore, we examined the association of regional technology penetration with the receipt of prostate specific antigen testing and prostate biopsy. MATERIALS AND METHODS In this retrospective cohort study we included 117,857 men 66 years old or older from the 5% sample of Medicare beneficiaries living in Surveillance, Epidemiology and End Results (SEER) areas from 2003 to 2007. Regional technology penetration was measured as the number of providers performing robotic prostatectomy or intensity modulated radiotherapy per population in a health care market, ie hospital referral region. We assessed the association of technology penetration with the prostate specific antigen testing rate and prostate biopsy using generalized estimating equations. RESULTS High technology penetration was associated with an increased rate of prostate specific antigen testing (442 vs 425/1,000 person-years, p<0.01) and a similar rate of prostate biopsy (10.1 vs 9.9/1,000 person-years, p=0.69). The impact of technology penetration on prostate specific antigen testing and prostate biopsy was much less than the effect of age, race and comorbidity, eg the prostate specific antigen testing rate per 1,000 person-years was 485 vs 373 for men with only 1 vs 3+ comorbid conditions (p<0.01). CONCLUSIONS Increased technology penetration is associated with a slightly higher rate of prostate specific antigen testing and no change in the prostate biopsy rate. Collectively, our findings temper concerns that adopting new technology accelerates diagnostic testing for prostate cancer.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Jacobs BL, Zhang Y, Skolarus TA, Wei JT, Montie JE, Schroeck FR, Hollenbeck BK. Managed care and the diffusion of intensity-modulated radiotherapy for prostate cancer. Urology 2013. [PMID: 23206767 DOI: 10.1016/j.urology.2012.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To better understand associations between managed care penetration in health care markets and the adoption of intensity-modulated radiotherapy (IMRT). METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who were treated with radiotherapy (n = 55,162). We categorized managed care penetration in Health Service Areas (HSAs) as low (<3%), intermediate (3%-10%), and high (>10%), and assessed our main outcomes (ie, probability of IMRT adoption, which is the ability of a health care market to deliver IMRT, and IMRT utilization in HSA markets) using a Cox proportional hazards model and Poisson regression model, respectively. RESULTS Compared with markets with low managed care penetration, populations in highly penetrated HSAs were more racially diverse (25% vs 15% non-white, P <.01), densely populated (2110 vs 145 people/square mile, P <.01), and wealthier (median income, $48,500 vs $31,900, P <.01). The probability of IMRT adoption was greatest in markets with the highest managed care penetration (eg, 0.82 [high] vs 0.72 [low] in 2007, P = .05). Among adopting markets, the use of IMRT increased in all HSA categories. However, relative to markets with low managed care penetration, IMRT use was constrained in markets with the highest penetration (0.69 [high] vs 0.76 [low] in 2007, P <.01). CONCLUSION Markets with higher managed care penetration demonstrated a greater propensity for acquiring IMRT technology. However, after adopting IMRT, more highly penetrated markets had roughly 7% slower growth in IMRT use during the study period. These findings provide insight into the implications of delivery system reforms for cancer-related technologies.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan 48109-2800, USA.
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Abstract
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.
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Affiliation(s)
- Florian R Schroeck
- From the Divisions of Health Services Research and Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI
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Schroeck FR, Hollingsworth JM, Kaufman SR, Hollenbeck BK, Wei JT. Population based trends in the surgical treatment of benign prostatic hyperplasia. J Urol 2012; 188:1837-41. [PMID: 22999698 PMCID: PMC4006217 DOI: 10.1016/j.juro.2012.07.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Laser prostatectomy has increased in popularity in the last decade. However, traditional transurethral resection of the prostate remains common. To understand decisions about the use of laser prostatectomy vs transurethral prostate resection, we evaluated trends in transurethral surgery for benign prostatic hyperplasia in an all payer data set, focusing on patient and provider factors associated with the receipt of laser prostatectomy. MATERIALS AND METHODS Using Florida State Inpatient Database and Ambulatory Surgery Database, we identified patients who underwent laser prostatectomy or transurethral prostate resection from 2001 to 2009. We calculated surgery rates with time, stratified by procedure type. We used multilevel regression to examine patient (age, race and comorbidity level) and provider (surgeon volume) factors associated with the receipt of laser prostatectomy vs transurethral prostate resection. RESULTS While the overall rates of transurethral surgery remained stable during the study period (p = 0.227), laser prostatectomy use increased 400% from 25 to 114 procedures per 100,000 men (p <0.001), replacing about half of all transurethral prostate resections. Patients were less likely to undergo laser prostatectomy if they were older (OR 0.65, 95% CI 0.61-0.70) and less healthy (OR 0.48, 95% CI 0.45-0.51). While these factors were predictive of surgery type, most of the variation in laser prostatectomy use (69%) was determined by the urologist seen by the patient. CONCLUSIONS Laser prostatectomy use has increased in the last decade at the expense of transurethral prostate resection, driven largely by provider effects. However, elderly and more infirm patients are least likely to undergo it, raising concern about underuse in this population.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan 48109, USA
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Schroeck FR, Hollingsworth JM, Kaufman SR, Hollenbeck BK, Wei JT. Introduction of laser technology and procedure use for benign prostatic hyperplasia: data from Florida. Urology 2012; 80:678-83. [PMID: 22840735 PMCID: PMC3429633 DOI: 10.1016/j.urology.2012.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/17/2012] [Accepted: 05/17/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine the association of laser technology adoption in a market with surgery rates for benign prostatic hyperplasia. METHODS Using the Florida files from the State Ambulatory and Inpatient Surgery Databases (2001-2009), we identified all patients who underwent transurethral surgery for benign prostatic hyperplasia. We calculated rates of benign prostatic hyperplasia surgery for all markets within the state (defined by Hospital Service Area) over time. Markets were split into 3 categories: (1) Always offering, (2) never offering, or (3) initially not offering but adopting laser prostatectomy after 2001. We used multivariable regression models to estimate surgery rates adjusted for other market characteristics. Interaction terms were included in the models to examine differences in time trends between market categories. RESULTS After adjusting for market characteristics, time trends differed by market category (P < .001). Surgery rates decreased from 318 to 248 procedures per 100,000 men in markets always offering laser prostatectomy (P < .001). Markets never offering laser surgery had much lower rates that remained stable (180-187 procedures per 100,000 men, P = .805). In markets adopting laser technology, rates increased from 268 to 296 procedures per 100,000 men after adoption (P = .044), such that 4 years after adoption these markets had the highest rates among the 3 categories. CONCLUSION Adoption of laser technology is associated with rising rates of surgical intervention for benign prostatic hyperplasia. This trend appears to be induced by the introduction of laser surgery.
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Affiliation(s)
- Florian R Schroeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Schroeck FR, Hollingsworth JM, Kaufman SR, Dunn RL, Hollenbeck BK, Wei JT. 1974 POPULATION BASED TRENDS IN THE SURGICAL TREATMENT OF BENIGN PROSTATIC HYPERPLASIA. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Schroeck FR, Hollingsworth JM, Kaufman SR, Dunn RL, Hollenbeck BK, Wei JT. 428 ADOPTION OF LASER TECHNOLOGY IS ASSOCIATED WITH INCREASED BPH SURGERY RATES. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schroeck FR, Krupski TL, Stewart SB, Bañez LL, Gerber L, Albala DM, Moul JW. Pretreatment Expectations of Patients Undergoing Robotic Assisted Laparoscopic or Open Retropubic Radical Prostatectomy. J Urol 2012; 187:894-8. [DOI: 10.1016/j.juro.2011.10.135] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Florian R. Schroeck
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Tracey L. Krupski
- Department of Urology, University of Virginia, Charlottesville, Virginia
| | - Suzanne B. Stewart
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lionel L. Bañez
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Leah Gerber
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David M. Albala
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Judd W. Moul
- Duke Prostate Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Kimura M, Bañez LL, Schroeck FR, Gerber L, Qi J, Satoh T, Baba S, Robertson CN, Walther PJ, Donatucci CF, Moul JW, Polascik TJ. Factors Predicting Early and Late Phase Decline of Sexual Health‐Related Quality of Life Following Radical Prostatectomy. J Sex Med 2011; 8:2935-43. [DOI: 10.1111/j.1743-6109.2011.02387.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hammerich KH, Schroeck FR, West D, Moul JW. Simultaneously detected bilateral testicular cancer of different histopathological origin--a challenging situation for the urologist. Oncology (Williston Park) 2010; 24:757-760. [PMID: 20718257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND A 36-year-old male with a history of cryptorchidism of the right side, treated with orchidopexy at the age of 4, presented with bilateral testicular swelling. INVESTIGATIONS Investigations included laboratory workup, ultrasound of both testes, as well as CT-scan of the chest, abdomen, and pelvis. Initial treatment was bilateral orchiectomy. RESULTS Scrotal examination revealed a mass on the left side and a small right testis with a hard mass at the lower pole. One markedly enlarged right inguinal lymph node was palpable. LDH, betaHCG, and AFP were significantly elevated. Scrotal ultrasound revealed a homogeneous hypoechoic right testis without a mass and a heterogeneous mass containing multiple inhomogeneous cystic areas on the left side. A hypoechoic mass was visualized in the right groin. CT evaluation revealed an enlarged retroperitoneal lymph node on the left side. DIAGNOSIS Histopathological evaluation revealed seminoma of the right testis, nonseminomatous germ cell tumor of the left testis, and metastatic seminoma in the right groin postoperatively. CONCLUSIONS Due to improved diagnostic tools as well as the establishment of various adjuvant treatment options, the mortality of testicular cancer generally decreased in the last decades. However, metastatic bilateral testicular cancer of different histology is a challenging situation for the urologist, which warrants further discussion. Adjuvant treatment as well as postoperative follow-up should be chosen carefully.
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Affiliation(s)
- Kai H Hammerich
- Lahey Clinic Medical Center, Department of Urology, Burlington, Massachusetts, USA
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