Quality improvement opportunities in prostatectomy care in a regional hospital-based urologic quality collaborative.

Abstract

234 Background: Prostate cancer care is susceptible to regional variation in treatment and outcomes. Recent national recommendations have highlighted the harms of prostate cancer treatment including urinary incontinence and impotence. We prospectively evaluated radical prostatectomy (RP) outcomes at participating Washington-state hospitals to identify quality improvement opportunities in RP care. Methods: A local clinician advisory group developed a chart abstraction tool that captures potential quality concerns in RP care. The abstraction tool was implemented at nine regional hospitals with data consolidated for review quarterly. The research team and clinician advisory group were blinded to hospital identities in feedback reports. Data were analyzed as aggregate rates and hospital-specific rates without risk adjustment using descriptive statistics. Results: We identified 461 patients undergoing RP at nine area hospitals from 2011 to 2013. The majority (74%) were robot-assisted minimally invasive RPs, Participating hospitals report as many as 97% or as few as 12% robot-assisted procedures. 26.3% of cases were pathologic non-organ-confined prostate cancer (pT3 or higher); pathologic stage was not further classified beyond "T2" or "T3" in 31% of RPs. Surgical margins were positive in 18% of cases overall; hospital-specific positive margin rates ranged from 12 to 25% among organ-confined cases and 0 to 75% among stage pT3 or higher prostate cancer. Length of stay exceeded three days post-prostatectomy in more than 10% of cases at 4 hospitals including one hospital where 36% of cases had prolonged lengths of stay. Conclusions: We identified several quality improvement opportunities that may improve health outcomes among men undergoing RP for prostate cancer. Positive margin rates were excessive at some hospitals and may represent uncertainty in the surgical approach to higher risk cases. Variation in lengths of stay may represent provider variability in post-prostatectomy clinical care algorithms. Survey of provider practices may inform development of quality improvement initiatives such as clinical pathways that may address the variations in RP care identified.