Benjamin A. Spencer

Quality-of-Care Indicators for Early-Stage Prostate Cancer

PURPOSE Decisions regarding treatment for early-stage prostate cancer are frustrated not only by inadequate evidence favoring one treatment modality but also by the absence of data comparing quality among providers. In fact, the choice of provider may be as important as the choice of treatment. We undertook this study to develop an infrastructure to evaluate variations in quality of care for men with early-stage prostate cancer. METHODS We enlisted several sources to develop a list of proposed quality-of-care indicators and covariates. After an extensive structured literature review and a series of focus groups with patients and their spouses, we conducted structured interviews with national academic leaders in prostate cancer treatment. We then convened an expert panel using the RAND consensus method to discuss and rate the validity and feasibility of the proposed quality indicators and covariates. RESULTS The panel endorsed 49 quality-of-care indicators and 14 covariates, which make up our final list of candidate measures. Several domains of quality are represented in the selected indicators, including patient volume, pretreatment referrals, preoperative testing, interpretation of pathology specimens, and 10-year disease-free survival. Covariates include measures of case-mix, such as patient age and comorbidity. CONCLUSION This study establishes a foundation on which to build quality-of-care assessment tools to evaluate the treatment of early-stage prostate cancer. The next step is to field-test the indicators for feasibility, reliability, validity, and clinical utility in a population-based sample. This work will begin to inform medical decision-making for patients and their physicians.

A population-based study of colorectal cancer test use: Results from the 2001 California health interview survey

Recent research has supported the use of colorectal cancer (CRC) tests to reduce disease incidence, morbidity, and mortality. A new health survey has provided an opportunity to examine the use of these tests in Californias ethnically diverse population. The authors used the 2001 California Health Interview Survey (CHIS 2001) to evaluate 1) rates of CRC test use, 2) predictors of the receipt of tests, and 3) reasons for nonuse of CRC tests.

A Population-Based Study of Colorectal Cancer Test Use Results from the 2001 California Health Interview Survey

Recent research has supported the use of colorectal cancer (CRC) tests to reduce disease incidence, morbidity, and mortality. A new health survey has provided an opportunity to examine the use of these tests in Californias ethnically diverse population. The authors used the 2001 California Health Interview Survey (CHIS 2001) to evaluate 1) rates of CRC test use, 2) predictors of the receipt of tests, and 3) reasons for nonuse of CRC tests.

Variations in Quality of Care for Men With Early-Stage Prostate Cancer

PURPOSE The commencement of quality-improvement initiatives such as Pay for Performance and the Physician Consortium for Performance Improvement has underscored calls to evaluate the quality of cancer care on a patient level for nationally representative samples. METHODS We sampled early-stage prostate cancer cases diagnosed in 2000 through 2001 from the American College of Surgeons National Cancer Data Base and explicitly reviewed medical records from 2,775 men (weighted total = 55,160 cases) treated with radical prostatectomy or external-beam radiation therapy. We determined compliance with 29 quality-of-care disease-specific structure and process indicators developed by RAND, stratified by race, geographic region, and hospital type. RESULTS Overall compliance exceeded 70% for structural and pretherapy disease assessment indicators but was lower for documentation of pretreatment functioning (46.4% to 78.4%), surgical pathology (37.1% to 86.3%), radiation technique (62.6% to 88.3%), and follow-up (55%). Geographic variations were observed as higher compliance in the South Atlantic division than the New England division for having at least one board-certified urologist (odds ratio [OR], 9.2; 95% CI, 1.9 to 45.0), at least one board-certified radiation oncologist (OR, 3.3; 95% CI, 1.2 to 9.0), use of Gleason grading (OR, 4.1; 95% CI, 1.2 to 13.8), and administering total radiation dose >or= 70 Gy (OR, 3.1; 95% CI, 1.6 to 6.1). Teaching/research hospitals and Comprehensive Cancer Centers had higher compliance than Community Cancer Centers, whereas racial differences were not observed for any indicator. CONCLUSION The significant and unwarranted variations observed for these quality indicators by census division and hospital type illustrate the inconsistencies in prostate cancer care and represent potential targets for quality improvement. The lack of racial disparities suggests equity in care once a patient initiates treatment.

Is there a language divide in pap test use

Objective:We sought to determine whether primary language use, measured by language of interview, is associated with disparities in cervical cancer screening. Data sources:We undertook a secondary data analysis of a pooled sample of the 2001 and 2003 California Health Interview Surveys. The surveys were conducted in English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese. Study Design:The study was a cross-sectional analysis of 3-year Pap test use among women ages 18 to 64, with no reported cervical cancer diagnosis or hysterectomy (n = 38,931). In addition to language of interview, other factors studied included race/ethnicity, marital status, income, educational attainment, years lived in the United States, insurance status, usual source of care, smoking status, area of residence, and self-rated health status. Data Collection/Extraction Methods:We fit weighted multivariate logit models predicting 3-year Pap test use as a function of language of interview, adjusting for the effects of specified covariates. Principal Findings:Compared with the referent English interview group, women who interviewed in Spanish were 1.65 times more likely to receive a Pap test in the past 3 years. In contrast, we observed a significantly reduced risk of screening among women who interviewed in Vietnamese (odds ratio [OR] 0.67; confidence interval [CI] 0.48–0.93), Cantonese (OR 0.44; 95% CI 0.30–0.66), Mandarin (OR 0.48; 95% CI 0.33–0.72), and Korean (OR 0.62; 0.40–0.98). Conclusions:Improved language access could reduce cancer screening disparities, especially in the Asian immigrant community.

A population‐based survey of prostate‐specific antigen testing among California men at higher risk for prostate carcinoma

Despite the lack of evidence demonstrating a survival benefit from prostate‐specific antigen (PSA) screening, its use has become widespread, organizations have encouraged physicians to discuss early detection of prostate carcinoma, and two higher risk groups have been recognized. In the current study, the authors examined whether African‐American men and men who had a family history of prostate carcinoma underwent PSA testing preferentially, and patterns of test use were examined according to age, race, and other factors.

The Association Between Operative Repair of Bladder Injury and Improved Survival: Results From the National Trauma Data Bank

PURPOSE The bladder is the most commonly injured genitourinary organ from blunt pelvic trauma. In this study we describe traumatic bladder injuries in the United States, their management and association with mortality. MATERIALS AND METHODS We queried the 2002 to 2006 National Trauma Data Bank for all subjects with bladder injury. Demographics, mechanism of injury, coexisting injuries, type of bladder injury, and operative interventions for bladder and other abdominal trauma are described. Multivariate logistic regression analysis was used to examine the relationship between bladder injury and in-hospital mortality. RESULTS Of 8,565 subjects with bladder trauma 46% had pelvic fracture and 15% had 2 or more intra-abdominal injuries. Of these subjects 54% underwent bladder surgery, including 76% with intraperitoneal injury and 51% with surgical repair of other abdominal organs. On multivariate analysis operative bladder repair reduced the likelihood of in-hospital mortality by 59%. Greater likelihood of death was seen in African-American and Native American patients, and those with pelvic injuries, triage to higher acuity care, penetrating trauma and multiple abdominal injuries. CONCLUSIONS We demonstrated that surgical repair provides a significant survival advantage for subjects with bladder trauma. With 76% of intraperitoneal bladder injuries being repaired, there appears to be underuse of a lifesaving procedure. Additional studies to refine indications for bladder repair are warranted.

Adolescent Varicocele: Influence of Tanner Stage at Presentation on the Presence, Development, Worsening and/or Improvement of Testicular Hypotrophy Without Surgical Intervention

PURPOSE Testicular asymmetry in adolescents with varicocele can worsen, remain unchanged or decrease on followup. We determined the incidence of testicular asymmetry at presentation by Tanner stage and the correlation between Tanner stage at presentation and subsequent changes in percent asymmetry (ability for catch-up growth or progressive asymmetry) without surgical intervention. MATERIALS AND METHODS We retrospectively studied the records of 115 boys with a mean age of 14.1 years (range 9.2 to 20.0) with grade 2 or 3 left varicocele who underwent testicular volume measurement at 2 visits at least that were a minimum of 6 months apart. Of the patients 92% and 8% underwent Doppler duplex ultrasound and orchidometry, respectively. Patients were divided into 2 groups, including those with less than 15% and those with 15% or greater asymmetry. Catch-up growth was defined as less than 15% asymmetry at any subsequent visit. RESULTS At presentation 58%, 64%, 67%, 35% and 39% of Tanner 1 to 5 cases showed 15% or greater testicular asymmetry, respectively. When Tanner 1 to 3 cases were combined and compared with Tanner 4 and 5 cases, the difference in initial asymmetry was significant (64% vs 38%, p = 0.007). Although it was not statistically significant, there was a trend toward more catch-up growth for the later Tanner stages, including 27% for Tanner 1 to 3 vs 53% for Tanner 4 and 5 (p = 0.06). CONCLUSIONS Slightly more than 50% of children and adolescents referred with varicocele have 15% or greater testicular asymmetry at presentation. Initial asymmetry is statistically more common in cases of earlier Tanner stages (1 to 3). Adolescents with 15% or greater testicular asymmetry who present at higher Tanner stages (4 and 5) show a trend toward a higher incidence of catch-up growth, although it is not significant.

Treatment Choice and Quality of Care for Men with Localized Prostate Cancer

Background:Variations in patterns of care and treatment outcomes suggest differences in the quality of care for men treated for localized prostate cancer. Objective:We sought to compare adherence with quality indicators for prostate cancer care among men treated with radical prostatectomy or external beam radiation therapy. Research Design and Subjects:We sampled 5230 men diagnosed in 2000 or 2001 with early-stage prostate cancer from 984 facilities reporting to the National Cancer Data Base. Our analytic cohort includes 2604 men (from 770 facilities) treated with radical prostatectomy or external beam radiation. Main Outcome Measure:Subject-level compliance with the RAND quality indicators for localized prostate cancer care, stratified by treatment. We applied sampling weights to obtain national estimates of quality indicator adherence. Results:The weighted samples represent 24,547 and 27,125 men treated with radical prostatectomy or external beam radiation therapy, respectively. Compliance with several quality indicators approached 100% in both treatment groups; however treatment-specific variations were noted. Men receiving radiation were less likely than those undergoing surgery to be treated in facilities with a board-certified urologist (odds ratio [OR] = 0.4, 95% confidence interval [95% CI] = 0.2–0.8). Adherence with process of care indicators was appreciably higher among radiation subjects, including documentation of clinical stage (OR = 7.5, 95% CI = 4.8–11.9), pretherapy assessment of urinary (OR = 2.8, 95% CI = 1.9–4.2) and sexual (OR = 1.6, 95% CI = 1.2–2.2) function, and discussion of treatment options (OR = 1.8, 95% CI = 1.1–2.9). Conclusions:Documented compliance with process of care quality indicators among men with localized prostate cancer appears superior for those treated with external beam radiation compared with those treated surgically.

Barriers and Facilitators to Digital Rectal Examination Screening Among African-American and African-Caribbean Men

OBJECTIVES To examine the effect of race/ethnicity and fear characteristics on the initiation and maintenance of digital rectal examination (DRE) screening. METHODS A total of 533 men from Brooklyn, New York, aged 45-70 years, were classified into 4 race/ethnic groups: U.S.-born whites, U.S.-born African-American, Jamaican, and Trinidadian/Tobagonian. The participants recorded the number of DREs in the past 10 years. The demographics and structural variables and prostate cancer worry and screening fear were measured using validated tools. RESULTS Overall, 30% of subjects reported never having a DRE, and 24% reported annual DREs. African-American, Jamaican, and Trinidadian/Tobagonian men had greater prostate cancer worry and screening fear scores than did the white men (all P < .05). African-American, Jamaican, and Trinidadian/Tobagonian men were less likely to maintain annual DREs than white men (odds ratio 0.17, 0.26, and 0.16, respectively, all P < .05). The men with low screening fear were more likely to have had an initial DRE (OR 2.3, P < .05 vs high screening fear) but were no more or less likely to undergo annual DREs. Having a regular physician, comprehensive physician discussion, and annual visits were also associated with undergoing DREs. CONCLUSIONS We identified several ethnically varying barriers and facilitators to DRE screening. African-American and African-Caribbean men undergo DRE less often and have greater prostate cancer worry and screening fear scores than did white men. Screening fear predicts the likelihood of undergoing an initial, but not annual, DRE screening. Access to a physician and annual visits facilitate DRE screening. Interventions that include both culturally sensitive education and patient navigation and considered whether patients should be initiating or maintaining screening might facilitate guideline-consistent screening.