Compliance with PCa quality measures not tied to outcomes


A study of patient outcomes 1 year after localized prostate cancer care seems to indicate that the answer is “no.”

New Orleans-Physician compliance with different quality indicators for localized prostate cancer care varies. However, while improving compliance may impact physician reimbursement in the recently established Merit-based Incentive Payment System, its relevance for ensuring delivery of quality care is unclear because increased compliance does not seem to influence patient-centered outcomes during the first 12 months after treatment.

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Dr. SohnThat is the conclusion of study co-authors William Sohn, MD, and Daniel Barocas, MD, urologic oncologists from Vanderbilt University Medical Center, Center for Surgical Quality and Outcomes Research, Nashville, TN

The research was presented at the AUA annual meeting in New Orleans.

“Quality indicators from national quality consortia were developed to be incorporated in the value calculation in medicine, which is the quotient of quality over cost. However, there are no studies validating that clinical outcomes are improved by complying with these measures for localized prostate cancer,” said Dr. Sohn, clinical instructor in urologic surgery at Vanderbilt.

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“We propose that as we go forward in this era of patient-centered medicine, national quality consortia should indicate the anticipated effect of adherence to quality measures so that the value of adherence can be ascertained objectively. And, we believe there should be a focus on developing quality measures that will translate into improvements that are important and meaningful to patients.”

NEXT: Compliance with six quality indicators assessed

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Compliance with six quality indicators assessed

The research analyzed data from 2,781 participants in the population-based, prospective Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study. Physician compliance with the following six quality indicators, which are endorsed by various national quality consortia, was assessed:

  • avoidance of bone scan in men with low-risk tumors

  • androgen deprivation therapy for high-risk patients undergoing radiation therapy

  • documentation of clinical T stage and biopsy Gleason score at new diagnosis

  • documentation of digital rectal examination, clinical T stage, and biopsy Gleason score prior to primary therapy

  • documentation of discussion of treatment options

  • documentation of pathologic T and N stage, Gleason score, and margin status on pathology report.

Multivariable regression analysis was performed with adjustment for treatment, sociodemographic, and clinical characteristics to investigate whether for each indicator, compliance was associated with patient-reported health-related quality of life (HRQoL) outcomes assessed using 6- and 12-month scores for the Expanded Prostate Cancer Index Composite-26 domains (sexual function, bowel function, urinary incontinence, urinary irritation); patient satisfaction with care based on the Service Satisfaction Scale for Cancer Care score at 1 year; and incidence of early and delayed treatment-related complications.

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The results showed the level of provider compliance with the different quality measures was variable, ranging from as low as 64% for documentation prior to primary therapy to 86% and 88% for documentation of discussion of treatment options and of pathologic data, respectively.

In the multivariable analyses, three of the six measures were weakly associated with 12-month sexual function and bowel function scores (β-4.6 and 1.69,2.93, respectively; p≤.05).

“However, the differences in scores are unlikely to be clinically meaningful,” Dr. Sohn said.

There were no other significant relationships between the quality measures and patient-reported HRQoL outcomes, nor were satisfaction scores and treatment-related complications associated with quality measure compliance.

NEXT: Limitations and future directions


Limitations and future directions

Dr. Sohn acknowledged that the study does not tell the whole story, since it assessed the impact of compliance with the indicators on patient-reported HRQoL outcomes. These nationally endorsed process measures may be associated with other desirable quality goals; namely, effective clinical care, cost-effectiveness, and efficiency, rather than improved patient-reported outcomes, he said.

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In addition, Dr. Sohn noted that compliance with the indicators might be relevant to outcomes in subgroups of vulnerable patients. The investigators did not identify any such effects based on age, race, or income level.

“Perhaps that is because of limited statistical power in these smaller subgroups. However, additional analyses could reveal certain high-risk sub-populations that may have improvements in HRQoL, satisfaction scores, and complications with quality measure compliance,” said Dr. Sohn.

“Our next steps are to try to figure out what influences quality measure compliance and if there are certain patient groups that benefit from improved compliance,” he told Urology Times.

“In addition, we will be looking at relationships between compliance and other outcomes, and ultimately see if we can develop other quality measures that are related to health-related quality of life.”

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