Claude Messan Setodji

Use of Radical Cystectomy for Patients With Invasive Bladder Cancer

BACKGROUND Evidence-based guidelines recommend radical cystectomy for patients with muscle-invasive bladder cancer. However, many patients receive alternate therapies, such as chemotherapy or radiation. We examined factors that are associated with the use of radical cystectomy for invasive bladder cancer and compared the survival outcomes of patients with invasive bladder cancer by the treatment they received. METHODS From linked Surveillance, Epidemiology, and End Results-Medicare data, we identified a cohort of 3262 Medicare beneficiaries aged 66 years or older at diagnosis with stage II muscle-invasive bladder cancer from January 1, 1992, through December 31, 2002. We examined the use of radical cystectomy with multilevel multivariable models and survival after diagnosis with the use of instrumental variable analyses. All statistical tests were two-sided. RESULTS A total of 21% of the study subjects underwent radical cystectomy. Older age at diagnosis and higher comorbidity were associated with decreased odds of receiving cystectomy (for those > or = 80 vs 66-69 years old, odds ratio [OR] = 0.10, 95% confidence interval [CI] = 0.07 to 0.14; for Charlson comorbidity index of 3 vs 0-1, OR = 0.25, 95% CI = 0.14 to 0.45). Long travel distance to an available surgeon was associated with decreased odds of receiving cystectomy (for >50 vs 0-4 miles travel distance to an available surgeon, OR = 0.60, 95% CI = 0.37 to 0.98). Overall survival was better for those who underwent cystectomy compared with those who underwent alternative treatments (for chemotherapy and/or radiation vs cystectomy, hazard ratio of death = 1.5, 95% CI = 1.3 to 1.8; for surveillance vs cystectomy, hazard ratio of death = 1.9, 95% CI = 1.6 to 2.3; 5-year adjusted survival: 42.2% [95% CI = 39.1% to 45.4%] for cystectomy; 20.7% [95% CI = 18.7% to 22.8%] for chemotherapy and/or radiation; 14.5% [95% CI = 13.0% to 16.2%] for surveillance). CONCLUSIONS Guideline-recommended care with radical cystectomy is underused for patients with muscle-invasive bladder cancer. Many bladder cancer patients whose survival outcomes might benefit with surgery are receiving alternative less salubrious treatments.

Parks and physical activity: Why are some parks used more than others?

OBJECTIVE To assess how park characteristics and demographic factors are associated with park use. METHODS We studied a diverse sample of parks in a Southern California metropolitan area in 2006-2008 representing a variety of racial and ethnic communities of different socioeconomic strata. We surveyed 51 park directors, 4257 park users and local residents, and observed 30 parks. We explored relationships among the number of people observed, the number of park programs offered, number of organized activities observed, park size, existence of park advisory board, perceptions of safety, and population density and characteristics. RESULTS The strongest correlates of the number of people using the park were the park size and the number of organized activities observed. Neighborhood population density, neighborhood poverty levels, perceptions of park safety, and the presence of a park advisory board were not associated with park use. CONCLUSION While perceptions of low safety have been considered a barrier to park use, perceptions of high safety do not appear to facilitate park use. Having events at the park, including sports competitions and other attractions, appears to be the strongest correlate of park use and community-level physical activity.

Mortality increases when radical cystectomy is delayed more than 12 weeks

Single‐institution series have documented the adverse impact of a 12‐week delay between resection of muscle‐invasive bladder cancer and radical cystectomy. These data are derived from tertiary centers, in which referral populations may confound outcomes. The authors sought to examine the survival impact of a delay in radical cystectomy using nationally representative data.

Mortality Increases When Radical Cystectomy Is Delayed More Than 12 Weeks : Results From a Surveillance, Epidemiology, and End Results-Medicare Analysis

Single‐institution series have documented the adverse impact of a 12‐week delay between resection of muscle‐invasive bladder cancer and radical cystectomy. These data are derived from tertiary centers, in which referral populations may confound outcomes. The authors sought to examine the survival impact of a delay in radical cystectomy using nationally representative data.

Compliance with guidelines for patients with bladder cancer: variation in the delivery of care.

Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. In the current study, the authors sought to characterize practice patterns in patients with high‐grade non–muscle‐invasive bladder cancer in relation to established guidelines.

The quality of pharmacologic care for adults in the United States.

Background:Despite rising annual expenditures for prescription drugs, little systematic information is available concerning the quality of pharmacologic care for adults in the United States. We evaluated how frequently appropriate pharmacologic care is ordered in a national sample of U.S. residents. Methods:The RAND/UCLA Modified Delphi process was used to select quality-of-care indicators for adults across 30 chronic and acute conditions and preventive care. One hundred thirty-three pharmacologic quality-of-care indicators were identified. We interviewed a random sample of adults living in 12 metropolitan areas in the United States by telephone and received consent to obtain copies of their medical records for the most recent 2-year period. We abstracted patient medical records and evaluated 4 domains of the prescribing process that encompassed the entire pharmacologic care experience: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. A total of 3457 participants were eligible for at least 1 quality indicator, and 10,739 eligible events were evaluated. We constructed aggregate scores and studied whether patient, insurance, and community factors impact quality. Results:Participants received 61.9% of recommended pharmacologic care overall (95% confidence interval 60.3–63.5%). Performance was lowest in education and documentation (46.2%); medication monitoring (54.7%) and underuse of appropriate medications (62.6%) performance were higher. Performance was best for avoiding inappropriate medications (83.5%). Patient race and health services utilization were associated with modest quality differences, while insurance status was not. Conclusions:Significant deficits in the quality of pharmacologic care were seen for adults in the United States, with large shortfalls associated with underuse of appropriate medications. Strategies to measure and improve pharmacologic care quality ought to be considered, especially as we initiate a prescription drug benefit for seniors.

Urinary Diversion and Morbidity After Radical Cystectomy for Bladder Cancer

The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy.

Bayesian Methods for Scalable Multivariate Value-Added Assessment.

There is increased interest in value-added models relying on longitudinal student-level test score data to isolate teachers’ contributions to student achievement. The complex linkage of students to teachers as students progress through grades poses both substantive and computational challenges. This article introduces a multivariate Bayesian formulation of the longitudinal model developed by McCaffrey, Lockwood, Koretz, Louis, and Hamilton (2004) that explicitly parameterizes the long-term effects of past teachers on student outcomes in future years and shows how the Bayesian approach makes estimation feasible even for large data sets. The article presents empirical results using reading and mathematics achievement data from a large urban school district, providing estimates of teacher effect persistence and examining how different assumptions about persistence impact estimated teacher effects. It also examines the impacts of alternative methods of accounting for missing teacher links and of joint versus marginal modeling of reading and mathematics.

Overall Survival Advantage with Partial Nephrectomy: A Bias of Observational Data?

Partial nephrectomy (PN) and radical nephrectomy (RN) are standard treatments for a small renal mass. Retrospective studies suggest an overall survival (OS) advantage, however a randomized phase 3 trial suggests otherwise. The effects of both surgical modalities on OS were evaluated compared with controls.

Quality of Surveillance for Stage I Testis Cancer in the Community

PURPOSE Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community. METHODS We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network. RESULTS Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance. CONCLUSION Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.