You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-Based Medicine & Outcomes (I)1 Apr 201356 PRACTICE-BASED COLLABORATION TO IMPROVE THE USE OF IMMEDIATE INTRAVESICAL CHEMOTHERAPY (IVC) FOR NON-MUSCLE-INVASIVE BLADDER CANCER Daniel Barocas, James Montie, Timothy Bradford, Frank Burks, David Morris, Daniel Murtagh, Peter Knapp, Timothy Schuster, Ronald Suh, Rodney Dunn, Alice Liu, and David Miller Daniel BarocasDaniel Barocas Nashville, TN More articles by this author , James MontieJames Montie Ann Arbor, MI More articles by this author , Timothy BradfordTimothy Bradford Richmond, VA More articles by this author , Frank BurksFrank Burks Royal Oak, MI More articles by this author , David MorrisDavid Morris Nashville, TN More articles by this author , Daniel MurtaghDaniel Murtagh Toledo, OH More articles by this author , Peter KnappPeter Knapp Indianapolis, IN More articles by this author , Timothy SchusterTimothy Schuster Toledo, OH More articles by this author , Ronald SuhRonald Suh Indianapolis, IN More articles by this author , Rodney DunnRodney Dunn Ann Arbor, MI More articles by this author , Alice LiuAlice Liu Ann Arbor, MI More articles by this author , and David MillerDavid Miller Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1432AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Because its use is supported by level I evidence and clinical guidelines, the Urological Surgery Quality Collaborative (USQC) initiated a project aimed at understanding the quality improvement potential (QIP) for administration of IVC in real-world practice. METHODS Methods: USQC is a consortium of community and academic practices engaged in quality improvement activities based on shared data collection, performance feedback, and educational interventions. For both ideal (1-2 papillary tumors, clinical stage Ta or T1, completely resected) and non-ideal cases, we examined use of IVC at baseline and after an intervention that included feedback of utilization data and review of clinical guidelines.) For cases where IVC was not used, surgeons provided explanations that were classified as appropriate (e.g., non-ideal case, deep resection, allergy) or modifiable (e.g., surgeon not convinced of benefit, IVC not ordered preoperatively). From these data, we calculated measures of “judicious use” [use in ideal cases + appropriate non-use] and QI potential [use in non-ideal cases + non-use due to modifiable factors] and assessed whether these changed after the intervention. RESULTS Results: From Sept 2010 to Aug 2012, we accrued 2,794 cases from 5 USQC sites. The use of IVC varied significantly across practices before and after intervention for both ideal and non-ideal cases (p<0.01 for each) (Figure). While overall utilization in ideal (38% vs 35%, p=0.36) and non-ideal cases (15% vs 12%, p=0.08) was similar before and after the interventions, two practices achieved significant reductions in use among non-ideal cases (Figure). The high proportion of judicious use (82.9% vs 83.4%), and the relatively low QIP (17.1% vs 15.7%, p=0.785 for both) remained stable after the intervention. CONCLUSIONS Discussion: Utilization of IVC was much higher than reported previously, and non-use in ideal cases is most often for appropriate reasons. In most practices, utilization did not change after performance feedback and education, suggesting that urologists are adequately informed about the risks and benefits of MMC. The results also suggest a potential “ceiling effect”, wherein it may be difficult to significantly improve care that is relatively high quality at baseline. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e23 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Barocas Nashville, TN More articles by this author James Montie Ann Arbor, MI More articles by this author Timothy Bradford Richmond, VA More articles by this author Frank Burks Royal Oak, MI More articles by this author David Morris Nashville, TN More articles by this author Daniel Murtagh Toledo, OH More articles by this author Peter Knapp Indianapolis, IN More articles by this author Timothy Schuster Toledo, OH More articles by this author Ronald Suh Indianapolis, IN More articles by this author Rodney Dunn Ann Arbor, MI More articles by this author Alice Liu Ann Arbor, MI More articles by this author David Miller Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement Loading ...

Purpose: Perioperative instillation of intravesical chemotherapy after bladder tumor resection is supported by level I evidence showing a 30% decrease in tumor recurrence. However, studies of administrative data sets show poor use in practice.Materials and Methods: We prospectively evaluated the use of perioperative intravesical chemotherapy in a multipractice quality improvement collaborative. Cases were categorized as ideal for intravesical chemotherapy (1 or 2 papillary tumors, cTa/cT1 and completely resected) and nonideal. The reasons for not administering intravesical chemotherapy in ideal cases were classified as appropriate or modifiable. Before and after comparative feedback and educational interventions we calculated judicious use of intravesical chemotherapy (nonuse in nonideal cases plus use in ideal cases plus appropriate nonuse in ideal cases) and quality improvement potential (use in nonideal cases plus nonuse in ideal cases attributable to modifiable factors).Results: We accrued a total of 2,794 cases at the 5 sites in 22 months. The rate of use in ideal cases was 38% before and 34.8% after intervention (p = 0.36), while use in nonideal cases decreased from 15% to 12% (p = 0.08). Overall, intravesical chemotherapy was used judiciously in 83.0% to 85.7% of cases, while the remaining 14.3% to 17.0% represented quality improvement potential.Conclusions: Judicious use of perioperative intravesical chemotherapy is relatively high in routine practice. Most instances of nonuse represent appropriate clinical judgment. Utilization did not change after quality improvement interventions, suggesting that there may a ceiling effect that makes it difficult to improve care that is high quality at baseline. Moreover, decreasing unnecessary use of an intervention may be easier than encouraging appropriate use of potentially toxic therapy.

PURPOSE:Despite its established efficacy in reducing recurrence rates for patients with urothelial carcinoma, immediate intravesical chemotherapy is reportedly used infrequently. Accordingly, the Urological Surgery Quality Collaborative implemented a project aimed at understanding and improving the use of immediate intravesical chemotherapy.MATERIALS AND METHODS:Surgeons in 5 Urological Surgery Quality Collaborative practices prospectively collected clinical and baseline intravesical chemotherapy use data for patients undergoing bladder biopsy or transurethral bladder tumor resection from September 2010 through January 2012. In the second phase of data collection (June 2011 through January 2012) treating surgeons also documented reasons for not administering intravesical chemotherapy. We defined patients with 1 to 2 clinical stage Ta/T1, completely resected, papillary tumor(s) as ideal candidates for treatment with immediate intravesical chemotherapy. For ideal and nonideal patients we examined baseline use of intravesical chemotherapy across Urological Surgery Quality Collaborative practices as well as reasons for not administering therapy among ideal patients.RESULTS:Among 1,931 patients 37.2% met criteria as ideal cases for intravesical chemotherapy administration. We observed significant variation in the use of intravesical chemotherapy across Urological Surgery Quality Collaborative practices for ideal (range 27% to 50%) and nonideal cases (9% to 24%) (p <0.001). Reasons for not treating ideal candidates included lack of confirmation of malignancy (4, 2.8%), uncertainty regarding the benefits of intravesical chemotherapy (28, 19.6%) and logistic factors such as the unavailability of medication (34, 23.8%).CONCLUSIONS:Use of immediate intravesical chemotherapy by Urological Surgery Quality Collaborative practices is higher than reported elsewhere but still varies widely, even among ideal candidates. Efforts to optimize use will be aided by disseminating evidence supporting indications and benefits of intravesical chemotherapy, and by addressing local logistic factors that limit access to this evidence-based therapy.

PURPOSE:We describe findings from a Urological Surgery Quality Collaborative project focused on improving the use of radiographic staging in men with newly diagnosed prostate cancer.MATERIALS AND METHODS:From May 2009 through September 2010 Urological Surgery Quality Collaborative surgeons collected uniform data for men with newly diagnosed prostate cancer. During this period we implemented 3 phases of data collection. Unlike the baseline phase, the second and third rounds were preceded by collaborative quality improvement interventions, including comparative performance feedback, and review and dissemination of clinical guidelines. We evaluated the use of bone scans and computerized tomography across prostate cancer risk strata, Urological Surgery Quality Collaborative practice locations, and before and after quality improvement interventions.RESULTS:We collected data for 858 men with prostate cancer. Based on the D'Amico classification 44%, 39% and 17% of the men had low, intermediate and high risk cancer, respectively. Overall 25% and 22% of patients underwent staging with a bone scan or computerized tomography, respectively, ordered by a Urological Surgery Quality Collaborative urologist. Urological Surgery Quality Collaborative practices differed significantly in their baseline use of bone scans and computerized tomography for men with low and intermediate risk cancer (p<0.01). Compared with baseline practice patterns (31% bone scans, 28% computerized tomography), urologists in Urological Surgery Quality Collaborative practices ordered fewer bone and computerized tomography scans in post-intervention phases 2 (23%, 21%) and 3 (16%, 13%) of data collection (p<0.01), including a significant reduction in the use of these studies in patients with low and intermediate risk cancer (p<0.05).CONCLUSIONS:Following collaborative feedback on baseline use and review of clinical guidelines, urologists in Urological Surgery Quality Collaborative practices dramatically reduced variations in practice patterns and improved adherence with recommended staging practices.

Purpose: We evaluated the comparative effects of intraprostatic injection of cobra cardiotoxin D and botulinum toxin type A on prostate structure in the rat model.Materials and Methods: A total of 18 Sprague-Dawley (R) rats weighing 500 to 600 gm received a single 0.1 ml injection of saline (6), botulinum toxin type A (6) or the cardiotoxin D (6) component of cobra (Naja naja atra) toxin in the right and left ventral lobes of the prostate. At 14 days the rats were sacrificed. The prostate glands were harvested, weighed and processed for immunohistochemical and morphological studies.Results: Prostate glands injected with cardiotoxin D showed significantly decreased weight compared to that of prostates injected with botulinum toxin type A and the saline control. Prostatic atrophy in the glandular component with flattening of the epithelial lining was seen histologically in rats that received botulinum toxin and cardiotoxin D. Each group injected with cardiotoxin D and botulinum toxin showed a significant increase in the number of apoptotic cells compared with controls while only the botulinum toxin group showed a significant increase in the number of proliferating cells. Only rats injected with botulinum toxin had body weight loss.Conclusions: Our study shows that intraprostatic injection of cobra cardiotoxin D induces prostatic atrophy and leads to a decrease in prostatic weight greater than that of intraprostatic injection of botulinum toxin type A. No systemic effects, such as decreased body weight, were noted after cardiotoxin D injection. Further studies are warranted but the statistically significant decrease in the number of proliferating cells implies a prolonged effect of cardiotoxin D.

PURPOSE:We describe the establishment of the Urological Surgery Quality Collaborative including our pilot project to improve radiographic staging for men with prostate cancer.MATERIALS AND METHODS:The Urological Surgery Quality Collaborative comprises more than 60 urologists from 3 group practices. From May through September 2009 Urological Surgery Quality Collaborative surgeons collected a uniform set of data (eg prostate specific antigen, clinical stage) for men with newly diagnosed prostate cancer. After categorizing the cancer of each patient as low, intermediate or high risk, we analyzed baseline use of staging studies across prostate cancer risk strata and Urological Surgery Quality Collaborative practice locations.RESULTS:Of 215 men with prostate cancer 34%, 42% and 24% had low, intermediate and high risk cancer, respectively. Overall 44% and 43% of patients underwent staging with a bone scan or computerized tomography, respectively, and only 9% and 7% of these studies, respectively, were positive for metastases. Use of staging studies increased across risk strata as bone scans or computerized tomography were performed in 17% and 18%, 41% and 40%, and 88% and 86% of patients, respectively, with low, intermediate and high risk tumors (p<0.01). For men with low risk prostate cancer the use of bone scans and computerized tomography differed significantly across Urological Surgery Quality Collaborative practices (p<0.01) and for this group only 1 bone scan (and no computerized tomography) was positive for metastases.CONCLUSIONS:Use of staging evaluations varies by prostate cancer risk strata and across Urological Surgery Quality Collaborative practices. By feeding these data back to surgeons we may be able to improve practice patterns and avoid unnecessary studies in low risk patients. Attainment of this goal would establish the Urological Surgery Quality Collaborative as a viable infrastructure for collaborative quality improvement in urology.