Apoorv Dhir

Appropriateness Criteria for Active Surveillance of Prostate Cancer

Purpose: The adoption of active surveillance varies widely across urological communities, which suggests a need for more consistency in the counseling of patients. To address this need we used the RAND/UCLA Appropriateness Method to develop appropriateness criteria and counseling statements for active surveillance. Materials and Methods: Panelists were recruited from MUSIC urology practices. Combinations of parameters thought to influence decision making were used to create and score 160 theoretical clinical scenarios for appropriateness of active surveillance. Recent rates of active surveillance among real patients across the state were assessed using the MUSIC registry. Results: Low volume Gleason 6 was deemed highly appropriate for active surveillance whereas high volume Gleason 6 and low volume Gleason 3+4 were deemed appropriate to uncertain. No scenario was deemed inappropriate or highly inappropriate. Prostate specific antigen density, race and life expectancy impacted scores for intermediate and high volume Gleason 6 and low volume Gleason 3+4. The greatest degree of score dispersion (disagreement) occurred in scenarios with long life expectancy, high volume Gleason 6 and low volume Gleason 3+4. Recent rates of active surveillance use among real patients ranged from 0% to 100% at the provider level for low or intermediate biopsy volume Gleason 6, demonstrating a clear opportunity for quality improvement. Conclusions: By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community‐wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted.

Variation in Guideline Concordant Active Surveillance Followup in Diverse Urology Practices

Purpose: We examined the frequency of followup prostate specific antigen testing and prostate biopsy among men treated with active surveillance in the academic and community urology practices comprising MUSIC (Michigan Urological Surgery Improvement Collaborative). Materials and Methods: MUSIC is a consortium of 42 practices that maintains a prospective clinical registry with validated clinical data on all patients diagnosed with prostate cancer at participating sites. We identified all patients in MUSIC practices who entered active surveillance and had at least 2 years of continuous followup. After determining the frequency of repeat prostate specific antigen testing and prostate biopsy, we calculated rates of concordance with NCCN Guidelines® recommendations (ie at least 3 prostate specific antigen tests and 1 surveillance biopsy) collaborative‐wide and across individual practices. Results: We identified 513 patients who entered active surveillance from January 2012 through September 2013 and had at least 2 years of followup. Among the 431 men (84%) who remained on active surveillance for 2 years 132 (30.6%) underwent followup surveillance testing at a frequency that was concordant with NCCN® (National Comprehensive Cancer Network®) recommendations. At the practice level, the median rate of guideline concordant followup was 26.5% (range 10% to 67.5%, p <0.001). Among patients with discordant followup, the absence of followup biopsy was common and not significantly different across practices (median rate 82.0%, p = 0.35). Conclusions: Among diverse community and academic practices in Michigan, there is wide variation in the proportion of men on active surveillance who meet guideline recommendations for followup prostate specific antigen testing and repeat biopsy. These data highlight the need for standardized active surveillance pathways that emphasize the role of repeat surveillance biopsies.

Comparing Publicly Reported Surgical Outcomes With Quality Measures From a Statewide Improvement Collaborative

Comparing Publicly Reported Surgical Outcomes With Quality Measures From a Statewide Improvement Collaborative The recent release of a Surgeon Scorecard has accelerated debate around the merits of publicly reporting surgical outcomes.1 Based on Medicare claims from 2009 through 2013, this scorecard provides the public with surgeon-specific complication rates for 8 elective procedures performed by nearly 17 000 surgeons. While the intent of this effort—greater transparency leading to better outcomes—is laudable, many contend that the scorecard is misleading because it provides data for a single outcome measure that may not correlate well with other quality metrics. We used data from the statewide clinical registry maintained by the Michigan Urological Surgery Improvement Collaborative (MUSIC) to evaluate this concern for one of the scorecard procedures—radical prostatectomy (RP) for prostate cancer. We specifically examined whether surgeonspecific complication rates reported in the scorecard correlate with several perioperative quality measures endorsed by MUSIC urologists and patient advocates.2

A Statewide Intervention Improves Appropriate Imaging in Localized Prostate Cancer

Purpose: We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer. Materials and Methods: MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns. Results: A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p <0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p <0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods. Conclusions: An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.

What is the impact of a clinically related readmission measure on the assessment of hospital performance

BackgroundThe Hospital Readmission Reduction Program (HRRP) penalizes hospitals for high all-cause unplanned readmission rates. Many have expressed concern that hospitals serving patient populations with more comorbidities, lower incomes, and worse self-reported health status may be disproportionately penalized by readmissions that are not clinically related to the index admission. The impact of including clinically unrelated readmissions on hospital performance is largely unknown. We sought to determine if a clinically related readmission measure would significantly alter the assessment of hospital performance.MethodsWe analyzed Medicare claims for beneficiaries in Michigan admitted for pneumonia and joint replacement from 2011 to 2013. We compared each hospital’s 30-day readmission rate using specifications from the HRRP’s all-cause unplanned readmission measure to values calculated using a clinically related readmission measure.ResultsWe found that the mean 30-day readmission rates were lower when calculated using the clinically related readmission measure (joint replacement: all-cause 5.8%, clinically related 4.9%, p < 0.001; pneumonia: all cause 12.5%, clinically related 11.3%, p < 0.001)). The correlation of hospital ranks using both methods was strong (joint replacement: 0.95 (p < 0.001), pneumonia: 0.90 (p < 0.001)).ConclusionsOur findings suggest that, while greater specificity may be achieved with a clinically related measure, clinically unrelated readmissions may not impact hospital performance in the HRRP.

MP43-05 COMPARING PRACTICE- VERSUS PROVIDER-LEVEL VARIATION IN USE OF ACTIVE SURVEILLANCE FOR MEN WITH LOW-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Variation in the utilization of Active Surveillance (AS) across urology practices has been described, but less is known about the degree of variation among urologists in the same practice. Furthermore, the relationship between the volume of low-risk patients a urologist manages (i.e., panel size) and his/her rate of AS utilization is not well described. In this context, we compared rates of AS utilization for men with low-risk prostate cancer (CaP) both within and across practices in Michigan to clarify whether efforts to decrease variation are best focused at practices or individual surgeons. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a consortium of 43 diverse academic and community urology practices that maintains a prospective clinical registry for all patients diagnosed with CaP. From the registry, we identified all MUSIC practices with at least five urologists that each managed 5 men with newly-diagnosed low-risk CaP (i.e., clinical stage T2a, PSA <10 ng/mL, and biopsy Gleason score 6) from 1/2012 through 7/2016. We then examined the proportion of men undergoing initial AS across different practices and among surgeons within a given practice. Subsequently, a regression model was fit to determine whether a urologist0s rate of AS was correlated with individual panel size. RESULTS: We identified 124 urologists from 13 practices that managed 2,646 men with low-risk CaP. The median practice and provider panel size was 166 (range 70-524) and 16 (range 5-141) patients, respectively. The proportion of men entering initial AS varied broadly across practices (range 30.6-72.9%; median 57.7%; p <0.001) (Figure). In most practices, surgeon-specific use of initial AS also varied widely, with a maximum range of 0-100% in a practice with 38 urologists (Figure). There was no significant relationship between a urologist0s panel size and his/ her rate of AS utilization (R1⁄4 0.01, p1⁄40.17). CONCLUSIONS: The proportion of patients entering initial AS varies widely across urology practices, among surgeons in the same practice, and is not correlated with a urologist0s panel size. These data suggest that interventions aimed at optimizing AS practice patterns must be tailored to individual surgeons rather than larger organizations regardless of patient volume. Source of Funding: Blue Cross and Blue Shield of Michigan and grant 1T32-CA180984 from the National Cancer Institute.

An opportunity to improve medicare’s planned readmissions measure

In the Hospital Readmission Reduction Program (HRRP), the Centers for Medicare & Medicaid Services (CMS) utilizes a planned/unplanned algorithm to prevent hospitals from being penalized for scheduled rehospitalizations. We evaluated version 3.0 of the CMS planned readmission algorithm and hypothesized that some readmissions categorized as planned by the HRRP algorithm may actually be unplanned. We identified 143,054 index admissions and 16,116 thirty‐day readmissions for 131 hospitals. Only 1252 readmissions were considered planned according to Medicare’s readmission algorithm. The majority of these planned readmissions (723 [57.8%]) had an “emergent” or “urgent” admission type listed on the readmission claim, and many (513 [41.0%]) had emergency department charges, suggesting unanticipated returns to the hospital. HRRP should consider using the admission type variable and/or the presence of emergency department charges as a source of information when determining whether a readmission is planned or unplanned.