Gregory B. Auffenberg

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 Roadmap for Improving the Management of Favorable Risk Prostate Cancer

A proposed solution to concerns about overpriorities. MUSIC is a consortium of more than 250 treatment of men with favorable risk, early stage prostate cancer is the unlinking of diagnosis from treatment through expanded use of active surveillance and selective delayed intervention. At a population level the safety and impact of surveillance as a strategy for reducing overtreatment depend on accurate initial identification of men with indolent tumors, followed by periodic monitoring for changes in either cancer severity or patient preferences which may prompt transition to definitive therapy while the cancer is still curable. Although recent reports indicate that a growing proportion of men with favorable risk prostate cancer are undergoing surveillance, rates of adoption in the United States often lag behind those reported internationally, and challenges to safe and successful implementation across large populations remain. The documented wide variation in adoption across physicians may indicate residual uncertainty regarding patient selection for surveillance. Furthermore, many men are entering surveillance after a single diagnostic biopsy and without an early reassessment aimed at confirming tumor severity (eg repeat biopsy or other testing). Finally, the surveillance process is predicated on adherence to a regular cadence of repeat clinical evaluations, prostate specific antigen (PSA) blood tests and prostate biopsy but, in reality, many men receive less frequent followup than recommended by current guidelines. This less active surveillance is concerning in light of recent data indicating that men infrequently monitored have an increased risk of cancer progression relative to those receiving definitive treatment with surgery or radiation. Accordingly, coordinated efforts aimed at refining patient selection, expanding the use of confirmatory tests of cancer severity and ensuring reliable followup are essential to increase the safety, sustainability and ultimate impact of surveillance as a strategy for reducing overtreatment. MUSIC (Michigan Urological Surgery Improvement Collaborative) is pursuing each of these

Practice- vs Physician-Level Variation in Use of Active Surveillance for Men With Low-Risk Prostate Cancer: Implications for Collaborative Quality Improvement

Practicevs Physician-Level Variation in Use of Active Surveillance for Men With Low-Risk Prostate Cancer: Implications for Collaborative Quality Improvement Owing to concerns about overtreatment, urologists are increasingly using active surveillance (AS) as the initial management for men with low-risk prostate cancer.1,2 Nonetheless, additional progress in this area requires a deeper understanding of the wellestablished and wide variation in use of AS.3,4 Of particular interest from a quality improvement perspective is whether practice patterns tend to vary widely even among urologists in the same practice and/or based on her or his panel size (ie, the volume of men with low-risk prostate cancer a given urologist manages). In the context of limited resources, the availability of such information may be used to develop efficient improvement interventionsaimedatoptimizingtheimplementationofASamong diverse urologists and practice settings.

Evaluation of Prostate Cancer Risk Calculators for Shared Decision Making Across Diverse Urology Practices in Michigan

OBJECTIVE To compare the predictive performance of a logistic regression model developed with contemporary data from a diverse group of urology practices to that of the Prostate Cancer Prevention Trial (PCPT) Risk Calculator version 2.0. MATERIALS AND METHODS With data from all first-time prostate biopsies performed between January 2012 and March 2015 across the Michigan Urological Surgery Improvement Collaborative (MUSIC), we developed a multinomial logistic regression model to predict the likelihood of finding high-grade cancer (Gleason score ≥7), low-grade cancer (Gleason score ≤6), or no cancer on prostate biopsy. The performance of the MUSIC model was evaluated in out-of-sample data using 10-fold cross-validation. Discrimination and calibration statistics were used to compare the performance of the MUSIC model to that of the PCPT risk calculator in the MUSIC cohort. RESULTS Of the 11,809 biopsies included, 4289 (36.3%) revealed high-grade cancer; 2027 (17.2%) revealed low-grade cancer; and the remaining 5493 (46.5%) were negative. In the MUSIC model, prostate-specific antigen level, rectal examination findings, age, race, and family history of prostate cancer were significant predictors of finding high-grade cancer on biopsy. The 2 models, based on similar predictors, had comparable discrimination (multiclass area under the curve = 0.63 for the MUSIC model and 0.62 for the PCPT calculator). Calibration analyses demonstrated that the MUSIC model more accurately predicted observed outcomes, whereas the PCPT risk calculator substantively overestimated the likelihood of finding no cancer while underestimating the risk of high-grade cancer in this population. CONCLUSION The PCPT risk calculator may not be a good predictor of individual biopsy outcomes for patients seen in contemporary urology practices.

Calculating life expectancy to inform prostate cancer screening and treatment decisions

cancer screening and treatment decisions Scott R. Hawken*, Gregory B. Auffenberg*, David C. Miller*, Brian R. Lane, Michael L. Cher, Firas Abdollah, Hyunsoon Cho and Khurshid R. Ghani* for the Michigan Urological Surgery Improvement Collaborative *Department of Urology, University of Michigan, Ann Arbor, Section of Urology, Spectrum Health Medical Group, College of Human Medicine, Michigan State University, Grand Rapids, Department of Urology, Wayne State University, VUI Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA, and Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea

Evaluation of a needle disinfectant technique to reduce infection-related hospitalisation after transrectal prostate biopsy

To determine whether a needle disinfectant step during transrectal ultrasonography (TRUS)‐guided prostate biopsy is associated with lower rates of infection‐related hospitalisation.

MP75-04 VARIATION IN NATIONAL OPIOID PRESCRIBING PATTERNS FOLLOWING OUTPATIENT NEPHROLITHIASIS PROCEDURES

have recently instituted several quality improvement initiatives, one of which includes decreased hospital reimbursement for re-admissions within 30 days. We attempted to identify trends surrounding outpatient ureteroscopy in hopes of decreasing future ED visits. METHODS: A retrospective chart review from 7/1/2015 to 12/ 31/2015 was performed to identify patients who returned to the ED within 30 days of elective ureteroscopy. CPT codes 52351-6 and 52344-6 were used as search parameters. Patient demographics, operative characteristics, and ED presentation data were collected and analyzed. RESULTS: A total of 330 ureteroscopies were performed, resulting in 47 ED visits (14.2%) occurring an average of 8.4 days [1e28] postoperatively. 29 were female and 18 male with an average age of 48.2 [16-86]. 27 (57.4%) were pre-stented an average of 11.5 days preoperatively. All patients were discharged with a stent in place, and 26 (55.3%) with a string attached with instructions to remove at home. 40 (85.1%) were discharged with either Tylenol#3 or Tramadol for pain control. The most common presenting complaint was flank pain (59.6%). Of these patients, 13 (46.4%) presented after the stent was self-pulled, 3 (10.7%) presented after the stent was inadvertently removed, 4 (14.3%) after it was removed via cystoscopy in clinic, and 8 (28.6%) with the stent in place. CONCLUSIONS: The rate of ED visits following ureteroscopy is estimated to be from 5% to 16%. Our results were in line with previous data demonstrating pain as the most common presenting complaint in the ED following ambulatory surgery. The cause of the pain may be due to issues with self-removal of stents and inadequate postoperative pain management. Some evidence exists that pre-stenting improves stone free rates, which intuitively would lead to decreased ED visits. However, this was not the case in our data as a majority of patients had been prestented. This hypothesis-generating study elicits the need to explore potential methods, including improved pain management and expectations, particularly with self-pulled stents, in order to possibly decrease ED visit rates.

Integration and Diagnostic Accuracy of 3T Nonendorectal coil Prostate Magnetic Resonance Imaging in the Context of Active Surveillance

OBJECTIVE To evaluate the integration of 3T nonendorectal coil multiparametric prostate magnetic resonance imaging (mpMRI) at 2 high-volume practices that routinely use mpMRI in the setting of active surveillance. MATERIALS AND METHODS This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, and dual-institution retrospective cohort study. Subjects undergoing 3T mpMRI without endorectal coil at either study institution over a 13-month period (August 1, 2015-August 31, 2016) were selected based on predefined criteria: clinical T1/T2 Gleason 6 prostate cancer, prostate-specific antigen <15 ng/mL, ≥40 years old, mpMRI within 2 years of prostate biopsy, and Prostate Imaging Reporting and Data System (PI-RADS) v2 score assigned. Subjects surveilled for Gleason ≥3 + 4 prostate cancer were excluded. The primary outcome was detection of Gleason ≥3 + 4 prostate cancer on magnetic resonance-ultrasound fusion biopsy, standard biopsy, or prostatectomy within 6 months following mpMRI. Positive predictive values (PPVs) were calculated. RESULTS A total of 286 subjects (N = 193 from institution 1, N = 93 from institution 2) met the criteria. Most (87% [90 of 104]) with maximum PI-RADS v2 scores of 1-2 did not receive immediate biopsy or treatment and remained on active surveillance. Incidence and PPVs for PI-RADS v2 scores of ≥3 were the following: PI-RADS 3 (n = 57 [20%], PPV 21% [6 of 29]), PI-RADS 4 (n = 96 [34%], PPV 51% [39 of 77]), and PI-RADS 5 (n = 29 [13%], PPV 71% [20 of 28]). No Gleason ≥4 + 3 prostate cancer was identified for PI-RADS v2 scores of 1-3 (0 of 43 with histology). Following mpMRI and subsequent biopsy, 21% (61 of 286) of subjects were removed from active surveillance and underwent definitive therapy. CONCLUSION The 3T nonendorectal coil mpMRI has been integrated into the care of patients on active surveillance and effectively stratifies risk of Gleason ≥3 + 4 prostate cancer in this population.