This document summarizes a study examining quality of care indicators for patients choosing expectant management for early-stage prostate cancer. The study found significant variation in structural and process quality indicators by hospital type, with some differences associated with the use of androgen deprivation therapy or location in the US. However, no differences were observed based on patient race. Areas of quality that could be improved were identified.

1. Quality of Care Among Early-Stage Expectant Management (EM) Prostate Cancer Patients Jamie Ritchey, MPH American College of Surgeons Commission on Cancer

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

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. 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. 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. 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. 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