Quality of Care Among Early-Stage Expectant Management (EM) Prostate Cancer Patients   Jamie Ritchey, MPH American College...
Prostate Cancer Expectant Management (EM) <ul><li>Expectant Management, also known as active surveillance is sometimes acc...
Framework for Quality Assessment 1 <ul><li>Structure:   “the settings in which medical care takes place” </li></ul><ul><li...
Andersen and Aday Conceptual Model HEALTH POLICY Federal  State Local DELIVERY SYSTEM Availability Board Certified provide...
Study Objective <ul><li>To investigate RAND  structure and process  quality indicator compliance among men choosing expect...
RAND Quality Indicators 2 <ul><li>4 Structural Indicators </li></ul><ul><ul><li>>1Board Certified Urologist </li></ul></ul...
Commission on Cancer (CoC) Hospital Type 3 <ul><li>Teaching Research (TR) </li></ul><ul><ul><li>Medical school affiliation...
Study Population <ul><li>Stratified Random Sample of men diagnosed with early stage prostate cancer in 2000-01 from the NC...
Methodology <ul><li>Primary outcome: patient-level quality indicator compliance </li></ul><ul><li>Univariate compliance pr...
Demographics  25.8% Hospital Type   TR 36.9% COMP 23.8% U.S. Census Region  NE 37.0% South 25.6% MW 67.9% Clinical stage  ...
Overall Indicator Compliance Board cert urologist Board cert rad onc   Conformal   radiation   Psychological counsel DRE P...
Structural Indicators by Hospital Type *Odds Ratios Adjusted for region, race, and primary insurance 2.1 1.01-4.2 90.3 86....
Process Indicators  by Hospital Type Digital Rectal Exam Family History pc Co morbidity Urinary function Sexual function T...
Process Indicators  by Expectant Management Type   Discussion of treatment options Discussion of treatment risks 2+ Follow...
Structure and Process Indicators by Region & Race  <ul><li>U.S. Census Region  </li></ul><ul><ul><li>Only 3 statistically ...
Study Limitations <ul><li>Selection bias and unrecognized confounding </li></ul><ul><li>Quality of documentation versus Qu...
Conclusions  <ul><li>Significant variation was observed among structural and process indicators suggesting targeted areas ...
Acknowledgements <ul><li>University of Michigan, Ann Arbor  </li></ul><ul><li>John T. Wei, MD, MS   </li></ul><ul><li>Rodn...
Upcoming SlideShare
Loading in …5
×

Prostate Cancer Quality Of Care

504 views

Published on

American Public Health Association (APHA) Annual meeting Medical Care Section: Expectant Management among Early-Stage Prostate Cancer Patients: The American College of Surgeons Special Study

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
504
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Prostate Cancer Quality Of Care

    1. 1. Quality of Care Among Early-Stage Expectant Management (EM) Prostate Cancer Patients Jamie Ritchey, MPH American College of Surgeons Commission on Cancer
    2. 2. Prostate Cancer Expectant Management (EM) <ul><li>Expectant Management, also known as active surveillance is sometimes accompanied by the use of Androgen Deprivation Therapy (ADT). </li></ul><ul><li>A deliberate management of prostate cancer through regular follow-up exams, PSA tests, and/or prostate biopsy with consideration of definitive treatment if appropriate. </li></ul><ul><li>Quality of care for EM has not been examined systematically. </li></ul>
    3. 3. Framework for Quality Assessment 1 <ul><li>Structure: “the settings in which medical care takes place” </li></ul><ul><li>Process: “a set of activities that go on between practitioners and patients” </li></ul><ul><li>Outcome: “the consequences [of structure and processes of care] to the health and welfare of individuals and society” </li></ul>1Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring vol I. The Definition of Quality and Approaches to its Assessment . Ann Arbor, Health Administration Press.
    4. 4. Andersen and Aday Conceptual Model HEALTH POLICY Federal State Local DELIVERY SYSTEM Availability Board Certified providers Conformal radiation and psychological counseling Organization Hospital type POPULATION AT RISK Predisposing Race, age, Enabling Primary payer Needs Co-morbid conditions and Clinical risk … Distributive Justice… REALIZED ACCESS Utilization Digital rectal exam, pre and post diagnosis PSA tests, pathologic grading/Gleason sum, Clinical stage, family history, urinary, bowel and sexual function, communication with PCP, discussion of treatment options and risks, 2+ follow up visits EQUITY Procedural Equal utilization of care
    5. 5. Study Objective <ul><li>To investigate RAND structure and process quality indicator compliance among men choosing expectant management by: </li></ul><ul><ul><li>Patient Race </li></ul></ul><ul><ul><li>U.S. Census Region </li></ul></ul><ul><ul><li>Hospital type </li></ul></ul><ul><ul><li>Watchful waiting alone vs. ADT use </li></ul></ul>
    6. 6. RAND Quality Indicators 2 <ul><li>4 Structural Indicators </li></ul><ul><ul><li>>1Board Certified Urologist </li></ul></ul><ul><ul><li>>1 Board Certified Radiation Oncologist </li></ul></ul><ul><ul><li>Conformal Radiation Therapy </li></ul></ul><ul><ul><li>Psychological Counseling </li></ul></ul><ul><li>13 Process Indicators </li></ul><ul><ul><li>Digital Rectal Exam </li></ul></ul><ul><ul><li>PSA </li></ul></ul><ul><ul><li>Pathologic Grade (Gleason) </li></ul></ul><ul><ul><li>Clinical Stage </li></ul></ul><ul><ul><li>Family History of Prostate Ca. </li></ul></ul><ul><ul><li>Co-morbidity </li></ul></ul><ul><ul><li>Urinary function </li></ul></ul><ul><ul><li>Sexual function </li></ul></ul><ul><ul><li>Bowel function </li></ul></ul><ul><ul><li>Communication with PCP </li></ul></ul><ul><ul><li>Discussion of Tx Options </li></ul></ul><ul><ul><li>Discussion of Risks </li></ul></ul><ul><ul><li> 2 Follow-up Visits </li></ul></ul>2 Litwin, M.S., Steinberg, M., Malin, J. et. al. Prostate Cancer Patient Outcomes and Choice of Providers: Development of an Infrastructure for Quality Assessment. RAND, Santa Monica 2000.
    7. 7. Commission on Cancer (CoC) Hospital Type 3 <ul><li>Teaching Research (TR) </li></ul><ul><ul><li>Medical school affiliation with resident training </li></ul></ul><ul><ul><li>Participate in medical research </li></ul></ul><ul><ul><li>No minimum caseload requirement </li></ul></ul><ul><li>Comprehensive Community Cancer Center (COMP) </li></ul><ul><ul><li>Minimum 650 newly diagnosed cancer cases submitted to NCDB </li></ul></ul><ul><li>Community Cancer Center (CCC) </li></ul><ul><ul><li>100-649 newly diagnosed cases submitted to NCDB </li></ul></ul><ul><li>Self designated with CoC approval </li></ul>3 Commission on Cancer. Cancer Program Standards 2004 revised. Chicago, 2003.
    8. 8. Study Population <ul><li>Stratified Random Sample of men diagnosed with early stage prostate cancer in 2000-01 from the NCDB </li></ul><ul><ul><li>Race (White & Black only), Region (4 US census regions), Hospital Type (3 types TR, COMP, CCC) </li></ul></ul><ul><li>A total of 5,655 cases from 1,047 facilities were solicited for chart abstraction </li></ul><ul><li>5,230 cases were received (92.5%), representing a weighted sample size of 108,753 men </li></ul><ul><li>Final analytic cohort of EM was 13,876 (weighted) </li></ul>
    9. 9. Methodology <ul><li>Primary outcome: patient-level quality indicator compliance </li></ul><ul><li>Univariate compliance proportions by: race, region, hospital type, and use of ADT </li></ul><ul><li>Multivariate regression models to evaluate an independent association between primary covariates and quality indicator compliance </li></ul>
    10. 10. Demographics 25.8% Hospital Type TR 36.9% COMP 23.8% U.S. Census Region NE 37.0% South 25.6% MW 67.9% Clinical stage T1 32.1% T2 37.3% CCC 13.6% West 17.1% African American Race 75.6 Mean Age (Years)
    11. 11. Overall Indicator Compliance Board cert urologist Board cert rad onc Conformal radiation Psychological counsel DRE PSA test Gleason Score Clinical Stage Family History pc Co morbidity Urinary function Bowel function Sexual function Communication PCP Discussion Rx options Discussion Rx risks 2+ follow up
    12. 12. Structural Indicators by Hospital Type *Odds Ratios Adjusted for region, race, and primary insurance 2.1 1.01-4.2 90.3 86.1-94.6 1.9 0.8-4.3 89.2 82.7-95.7 83.7 78.3-89.1 Psychological counseling available 1.8 0.9-3.4 86.8 82.2-91.4 4.3 1.7-10.7 93.7 89.2-98.2 79.5 72.1-86.9 Conformal radiation therapy available 1.1 0.6-2.3 88.0 83.8-92.3 2.3 0.98-5.5 93.2 88.8-97.5 88.4 83.4-93.4 ≥ 1 Board Certified Radiation Oncologist 1.2 0.6-2.8 90.7 86.5-95.0 1.5 0.6-3.8 91.3 85.3-97.4 89.3 83.9-94.8 ≥ 1 Board Certified Urologist OR* 95% CI TR (%) OR* 95% CI COMP (%) CCC (Reference) QUALITY INDICATOR
    13. 13. Process Indicators by Hospital Type Digital Rectal Exam Family History pc Co morbidity Urinary function Sexual function TR vs. CCC COMP vs. CCC 0 1.0 2.0 3.0 4.0 +5.0 Odds Ratios with 95% CIs Adjusted for insurance, region, race, age (quartiles), Gleason sum 2+ Follow up visits
    14. 14. Process Indicators by Expectant Management Type Discussion of treatment options Discussion of treatment risks 2+ Follow up visits ADT vs. WW WW= reference group 0 1.0 2.0 3.0 4.0 +5.0 Odds Ratios with 95% CIs Adjusted for insurance, region, race, age (quartiles), Gleason sum
    15. 15. Structure and Process Indicators by Region & Race <ul><li>U.S. Census Region </li></ul><ul><ul><li>Only 3 statistically significant indicators (Northeast = ref.) </li></ul></ul><ul><ul><ul><li>Pre-therapy DRE </li></ul></ul></ul><ul><ul><ul><li>West vs. Northeast (OR 2.8, 95% CI: 1.1-7.3) </li></ul></ul></ul><ul><ul><ul><li>Pre-Gleason Score </li></ul></ul></ul><ul><ul><ul><li>West vs. Northeast (OR 0.2, 95% CI: 0.1-0.8) </li></ul></ul></ul><ul><ul><ul><li>Communication between Primary Care Physician and treating Physician </li></ul></ul></ul><ul><ul><ul><li>South vs. Northeast (OR,0.4 95% CI: 0.2-0.8) </li></ul></ul></ul><ul><li>Race </li></ul><ul><ul><li>No statistically significant differences were observed </li></ul></ul>
    16. 16. Study Limitations <ul><li>Selection bias and unrecognized confounding </li></ul><ul><li>Quality of documentation versus Quality of Care </li></ul><ul><li>Indicators developed for surgery and radiation patients </li></ul><ul><li>Stratified sample subject to variation in the apportionment ratios </li></ul><ul><li>Results cannot be generalized to all minorities nor late stage prostate cancer </li></ul>
    17. 17. Conclusions <ul><li>Significant variation was observed among structural and process indicators suggesting targeted areas for quality improvement </li></ul><ul><li>Differences in quality were associated with Hospital Type, but mechanism remains unclear </li></ul><ul><li>Few Regional variations were observed </li></ul><ul><li>No Racial differences found </li></ul><ul><li>Use of ADT associated with higher compliance for patient provider communication and follow up </li></ul>
    18. 18. Acknowledgements <ul><li>University of Michigan, Ann Arbor </li></ul><ul><li>John T. Wei, MD, MS </li></ul><ul><li>Rodney L. Dunn, MS </li></ul><ul><li>University of California, Los Angeles </li></ul><ul><li>Mark S. Litwin, MD, MPH </li></ul><ul><li>David C. Miller, MD, MPH </li></ul><ul><li>Columbia University, NY </li></ul><ul><li>Benjamin A. Spencer, MD, MPH </li></ul><ul><li>American College of Surgeons CoC, Chicago </li></ul><ul><li>Andrew K. Stewart, MA </li></ul><ul><li>E. Greer Gay, RN, PhD, MPH </li></ul><ul><li>Sue A. Slater, BA </li></ul><ul><li>Participating Cancer Registrars </li></ul>

    ×