Candidate quality of care indicators for localized bladder cancer

Abstract

The surgical management of clinically localized bladder cancer is challenging, and the quality of care delivered to patients with bladder cancer is a subject of increasing interest. Multiple large studies have examined the association between surgical volume and outcomes after radical cystectomy. These studies generally find lower mortality and complication rates at high-volume centers, though interpretation of the data must be tempered by limitations of the datasets driving the studies. Benefits of regionalization of care also must be weighed against other measures proven to predict outcomes; a delay in time to cystectomy beyond 3 months, for example, is strongly associated with increased mortality. Other candidate process measures supported by existing literature include adequacy of lymphadenectomy as measured by nodal yield and availability or offering of orthotopic diversion when appropriate. Assessment and reporting of bladder cancer outcomes should be risk adjusted based on oncologic risk factors and patient comorbid illness. Perioperative morbidity and mortality, cause-specific survival, and overall survival are all key measures. Assessment of health-related quality of life after bladder cancer treatment should also be standardized for reporting. Multiple survey instruments have been developed in recent years, but none has yet been well validated or widely adopted. In particular, capturing variation in quality of life outcomes between patients undergoing bladder-sparing protocols vs. continent diversion vs. incontinent diversion is an important but difficult goal that has not yet been met. The urologic oncology community should take a strong lead in achieving consensus regarding the definition, assessment, and reporting of quality of care data for bladder cancer.

Treatment of Muscle Invasive Bladder Cancer: Evidence From the National Cancer Database, 2003 to 2007

“…6 Of patients who underwent radical cystectomy with an available lymph node count in SEER data the proportion with no node sampled decreased from 37% in 1988 to 16% in 2004. 7 However, the rate of missing data in the SEER database was 10% to 29%.…”

“…5 Trends toward cystectomy regionalization and increasing hospital procedural volume have been described. 5 in patients who receive surgical treatment 6 include a decrease in partial vs radical cystectomy, 5 an increasing extent of lymphadenectomy 7 and the adoption of perioperative chemotherapy. 8 Few prior groups have examined national patterns of treatment for muscle invasive bladder cancer 4,9 -12 and none have analyzed treatment patterns by race, insurance status, geographic area and facility type in a large cohort of American patients.…”

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

“…Tracking and reporting of quality measures for localized bladder cancer has been shown to improve patient outcomes and safety and identify barriers to high-quality care. 311 The process of establishing goals, times, and benchmarks was deemed to be beyond the scope of the consensus conference that has shaped the above recommendations. However, the participants at this meeting agreed that this is a worthwhile endeavor to be explored by a similar multidisciplinary group with expertise across all aspects of bladder cancer care and establish quality indicators via a Delphi process.…”

The Impact of Regionalization of Cystectomy on Racial Disparities in Bladder Cancer Care

“…22,23 Supported by data on the volume-outcome relationship but also bolstered by market forces (eg time-consuming/ technically demanding operation and shrinking reimbursement) cystectomy care has become regionalized in the United States. 9,10 However, access to higher volume cystectomy facilities by vulnerable populations has not been extensively explored.…”