Jeremy Shelton

Androgen Deficiency in Aging and Metabolically Challenged Men

Androgen deficiency in aging men is common, and the potential sequelae are numerous. In addition to low libido, erectile dysfunction, decreased bone density, depressed mood, and decline in cognition, studies suggest strong correlations between low testosterone, obesity, and the metabolic syndrome. Because causation and its directionality remain uncertain, the functional and cardiovascular risks associated with androgen deficiency have led to intense investigation of testosterone replacement therapy in older men. Although promising, evidence for definitive benefit or detriment is not conclusive, and treatment of late-onset hypogonadism is complicated.

Quality of prostate cancer care among rural men in the Veterans Health Administration.

Patient travel distances, coupled with variation in facility‐level resources, create barriers for prostate cancer care in the Veterans Health Administration integrated delivery system. For these reasons, the authors investigated the degree to which these barriers impact the quality of prostate cancer care.

Telemedicine in Urology: State of the Art.

Whereas telemedicine is recognized as one of the fastest-growing components of the healthcare system, the status of telemedicine use in urology is largely unknown. In this narrative review, we detail studies that investigate the use of televisits and teleconsultations for urologic conditions. Moreover, we discuss current regulatory and reimbursement policies. Finally, we discuss the significant barriers to widespread dissemination and implementation of telemedicine and reasons why the field of urology may be positioned to become a leader in the provision of telemedicine services.

Expectant management of veterans with early-stage prostate cancer.

For certain men with low‐risk prostate cancer, aggressive treatment results in marginal survival benefits while exposing them to urinary and sexual side effects. Nevertheless, expectant management has been underused. In the current study, the authors evaluated the association between various factors and expectant management use among veterans diagnosed with prostate cancer.

Implementing risk-aligned bladder cancer surveillance care

Implementation science is a rapidly developing field dedicated to the scientific investigation of strategies to facilitate improvements in healthcare delivery. These strategies have been shown in several settings to lead to more complete and sustained change. In this essay, we discuss how refined surveillance recommendations for non-muscle-invasive bladder cancer, which involve a complex interplay between providers, healthcare facilities, and patients, could benefit from use of implementation strategies derived from the growing literature of implementation science. These surveillance recommendations are based on international consensus and indicate that the frequency of surveillance cystoscopy should be aligned with each patients risk for recurrence and progression of disease. Risk-aligned surveillance entails cystoscopy at 3 and 12 months followed by annual surveillance for low-risk cancers, with surveillance every 3 months reserved for high-risk cancers. However, risk-aligned care is not the norm. Implementing risk-aligned surveillance could curtail overuse among low-risk patients, while curbing underuse among high-risk patients. Despite clear direction from respected and readily available clinical guidelines, there are multiple challenges to implementing risk-aligned surveillance in a busy clinical setting. Here, we describe how implementation science methods can be systematically used to understand determinants of care and to develop strategies to improve care. We discuss how the tailored implementation for chronic diseases framework can facilitate systematic assessment and how intervention mapping can be used to develop implementation strategies to improve care. Taken together, these implementation science methods can help facilitate practice transformation to improve risk-aligned surveillance for bladder cancer.

The implications of baseline bone health assessment at initiation of androgen deprivation therapy for prostate cancer

To assess bone‐density testing (BDT) use amongst prostate cancer survivors receiving androgen‐deprivation therapy (ADT), and downstream implications for osteoporosis and fracture diagnoses, as well as pharmacological osteoporosis treatment in a national integrated delivery system.

Characterizing potential bone scan overuse among men treated with radical prostatectomy

To characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown.

Advance care planning and patient preferences in a feasibility pilot study to improve end-of-life communication among men with metastatic urological malignancies

Introduction: Rates of advance care planning for patients with cancer are poor despite efforts to enhance discussions regarding goals of care. Good patient‐physician communication is critical to providing quality end‐of‐life care and, thus, it is important to identify effective interventions to improve systems through which patient preferences are addressed. Methods: To improve rates of advance care planning as well as examine patient preferences regarding end‐of‐life care, we developed an integrated urology‐palliative care clinic. All patients with a new diagnosis of a metastatic urological malignancy or castration resistant prostate cancer seen in a urology clinic within the Veterans Affairs Greater Los Angeles Healthcare System were offered a palliative care referral to be performed immediately after their urology appointment. The primary outcome was completion of an advance directive or POLST (Physician Orders for Life‐Sustaining Treatment) form and the secondary outcome was patient preference regarding end‐of‐life care. Results: A total of 59 patients were enrolled in the study between February 2012 and October 2016, and no patients were lost or excluded. There were 25 eligible patients who declined enrollment. Overall 85% of patients completed an advance directive or POLST form, and 98% chose to withhold cardiopulmonary resuscitation, advanced cardiac life support and artificially administered nutrition. Conclusions: High levels of advance care planning are achievable in an integrated urology‐palliative care clinic and the majority of patients with a terminal illness are averse to aggressive end‐of‐life care.

PD47-10 THE RESEARCH IMPLICATIONS OF PSA REGISTRY ERRORS

RESULTS: In 825,707 men, utilization of radiation therapy declined and utilization of radical prostatectomy increased for all prostate cancer risk-groups between 2004-2013 (p<0.0001). Observation for low-risk prostate cancer increased from 16.3% in 2004-2005 to 32.0% in 2012-2013 (p<0.0001). Significant treatment variation was observed based on Commission on Cancer-facility type. For all riskgroups, rates of treatment according to facility type ranged from 28.4% to 76.9% for radical prostatectomy, 3.6% to 16.2% for brachytherapy, 13.7% to 28.1% for external beam radiation therapy, 1.3% to 7.3% for androgen deprivation therapy, 4.6% to 19.1% for observation, and 0% to 2.1% for cryotherapy. The highest rates of observation for low-risk disease were observed in academic centers. After adjusting for sociodemographic and facility factors, the highest proportions of treatment variation attributable to the single institution were observed for CT (59%, 95%CI 0.45-0.73) and BT (46%, 95%CI 38-53%), while the lowest proportion of treatment variation was observed for ADT (14%, 95%CI 12-15%), and Observation (15%, 95%CI 14-17%). The results were consistent in the sensitivity analysis and in all NCCN risk-groups. CONCLUSIONS: Regardless of tumor characteristics, significant variations in treatment modality exist among different facility types and institutions. The increased utilization of observation in low-risk prostate cancer is an encouraging finding, which appears to be mainly derived by a decrease in radiotherapy utilization in this risk group.

82 SPECIFICATION AND VALIDATION OF PROSTATE CANCER QUALITY OF CARE E-MEASURES IN THE VETERANS HEALTH ADMINISTRATION

INTRODUCTION AND OBJECTIVES: Quality measures based on chart abstraction are the “gold-standard,” but the costs of measurement limit widespread adoption. Electronically specified measures (e-measures) promise a way forward, however the fidelity of electronic abstraction compared to chart abstraction is unknown. We sought to validate e-measure versions of VHA-developed prostate cancer quality of care measures. METHODS: Quality measures were chart abstracted from the medical records of 11,263 men in the VHA with incident prostate cancer in 2008. We identified and linked VHA cancer registry and administrative data for the same cohort. E-measures were specified iteratively and validated by comparing the sensitivity, specificity and accuracy of measure denominators and numerators, and the overall pass rates to chart abstracted results. RESULTS: 2 of 6 quality measures were successfully specified and validated while a third measure was specified, but validation was limited by a high pass rate (Table 1). CONCLUSIONS: The VHA’s information technology infrastructure is sufficiently advanced to support valid e-measurement that is equivalent to that performed by chart abstraction, however data availability at this time limits the breadth of e-measurement as compared to chart abstraction.