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Variation in the delivery of care
Article first published online: 11 JUL 2011
Copyright © 2011 American Cancer Society
Volume 117, Issue 23, pages 5392–5401, 1 December 2011
How to Cite
Chamie, K., Saigal, C. S., Lai, J., Hanley, J. M., Setodji, C. M., Konety, B. R., Litwin, M. S. and The Urologic Diseases in America Project (2011), Compliance with guidelines for patients with bladder cancer. Cancer, 117: 5392–5401. doi: 10.1002/cncr.26198
We acknowledge the efforts of the Applied Research Program at the National Cancer Institute; the Office of Research, Development, and Information at the Centers for Medicare and Medicaid Services; Information Management Services Inc; and the Surveillance, Epidemiology, and End Results (SEER) program tumor registries in the creation of the SEER-Medicare database.
This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. Dr. Chamie had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
- Issue published online: 18 NOV 2011
- Article first published online: 11 JUL 2011
- Manuscript Accepted: 24 MAR 2011
- Manuscript Revised: 22 MAR 2011
- Manuscript Received: 16 FEB 2011
- high grade non-muscle-invasive bladder cancer;
- guideline adherence;
- quality of care;
- variation in 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.
Surveillance, Epidemiology and End Results (SEER)-Medicare–linked data were used to identify subjects diagnosed with high-grade non–muscle-invasive bladder cancer between 1992 and 2002 who survived at least 2 years without undergoing definitive treatment (n = 4545). The authors used mixed-effects modeling to estimate the association and partitioned variation of patient sociodemographic, tumor, and provider characteristics with compliance measures.
Of the 4545 subjects analyzed, only 1 received all the recommended measures. Approximately 42% of physicians have not performed at least 1 cystoscopy, 1 cytology, and 1 instillation of immunotherapy for a single patient nested within their practice during the initial 2-year period after diagnosis. After 1997, only use of radiographic imaging (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.03-1.37) and instillation of immunotherapy (OR, 1.67; 95% CI, 1.39-2.01) were found to be significantly increased. Surgeon-attributable variation for individual guideline measures (cystoscopy, 25%; cytology, 59%; radiographic imaging, 10%; intravesical chemotherapy, 45%; and intravesical immunotherapy, 26%) contributes to this low compliance rate.
There is marked underuse of guideline-recommended care in this potentially curable cohort. Unexplained provider-level factors significantly contribute to this low compliance rate. Future studies that identify barriers and modulators of provider-level adoption of guidelines are critical to improving care for patients with bladder cancer. Cancer 2011;. © 2011 American Cancer Society.