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[ Recorded presentation ] Recorded presentation

Expectant Management Among Early-Stage Prostate Cancer Patients: The American College of Surgeons Special Study

Jamie Ritchey, MPH1, David Miller, MD, MPH2, Benjamin Spencer, MD, MPH3, Andrew Stewart, MA1, Mark S. Litwin, MD, MPH4, and John T. Wei, MD, MS2. (1) Division of Research and Optimal Care, National Cancer Database, American College of Surgeons, 633 N Saint Clair, Suite 25, Chicago, IL 60611, 312-202-5286, jritchey@facs.org, (2) Department of Urology, University of Michigan, 1500 E Medical Center Drive, Womens Trailer Room 1013, Ann Arbor, MI 48109-0759, (3) Columbia University Medical Center, 161 Fort Washington Ave. IP-11, New York, NY 10032, (4) Urology and Health Services, David Geffen School of Medicine at UCLA, Box 951738, Los Angeles, CA 90095-1738

Introduction: Given the increased attention to quality gaps and the costs of medical care, the Institute of Medicine and CMS have called for national performance measurement and reporting.  In response, the American College of Surgeons carried out a national assessment of the quality of care delivered to patients with localized prostate cancer.  The focus of this study is to investigate quality indicators among men choosing Expectant Management (EM) by race, region, hospital type and use of androgen deprivation therapy (ADT).

Methods:  Early-stage prostate cancer cases managed expectantly with or without ADT in 2000-01 were identified from the National Cancer Database.  Medical records were abstracted to determine compliance with the quality indicators.  Weighted proportions were calculated to assess overall patterns of quality indicator compliance.  Multivariate logistic regression models were fit to evaluate potential variations in quality of care by race, region and hospital type. 

Results: The hospital-based sample identified 835 (weighted n=15,843) men managed expectantly with or without ADT.  Overall, compliance with disease severity and functional assessment and patient counseling were modest to poor.  To compute weighted proportions and Odds Ratios from adjusted multivariate logistic regression models SAS 9.1 was used.  Teaching and Comprehensive Cancer hospital performance was significantly better for many of the indicators compared with Community Centers (table, p<0.05).  Significant differences in compliance were also observed by geographic region (p<0.05), but not by race

Conclusions: This study identifies under utilization of recommended processes of care as a quality concern among men with localized prostate cancer choosing EM.  The identification of disparities in quality compliance by region and hospital type suggests the presence of unwarranted variation in quality that should be investigated further.  

 

The Likelihoods of compliance for structural, pretherapy and counseling indicators

Quality Indicators

Community Cancer Center

 

 

%complaint

Comprehensive

Community Cancer

Center

%compliant

Teaching Research

Center

 

%compliant

Structural Resources

Treatment at High volume prostate cancer center

3.6

46.7*

54.6*

³ Board certified radiation oncologist

85.5

93.1*

86.7*

Conformal XRT available

78.0

94.2*

85.2

Psychological counseling available

83.6

87.2

89.1*

Pre-therapy disease severity assessment

Family history of prostate cancer

37.5

53.0**

46.4**

Comorbidity

66.9

81.0**

75.0**

Pre-therapy functional assessment

Urinary function

62.8

77.9**

71.1

Sexual function

8.2

19.5**

27.3**

Bowel function

23.4

33.3

32.9**

Counseling

Follow-up visits

25.5

24.5

41.9**

Statistically significant Odds ratios from multivariate logistic regression models:

*adjusted for region and primary payer 

**adjusted for age, baseline PSA, gleason sum, region and primary payer

Learning Objectives: At the end of the session, the learner will be able to