Variation in the Diagnostic Evaluation among Persons with Hematuria: Influence of Gender, Race and Risk Factors for Bladder Cancer.

PURPOSE: We sought to determine whether race, gender and number of bladder cancer risk factors are significant predictors of hematuria evaluation. MATERIALS AND METHODS: We used self-reported data from SCCS (Southern Community Cohort Study) linked to Medicare claims data. Evaluation of subjects diagnosed with incident hematuria was considered complete if imaging and cystoscopy were performed within 180 days of diagnosis. Exposures of interest were race, gender and risk factors for bladder cancer. RESULTS: Of the 1,412 patients evaluation was complete in 261 (18%). On our adjusted analyses African American patients were less likely than Caucasian patients to undergo any aspect of evaluation, including urology referral (OR 0.72, 95% CI 0.56-0.93), cystoscopy (OR 0.67, 95% CI 0.50-0.89) and imaging (OR 0.75, 95% CI 0.59-0.95). Women were less likely than men to be referred to a urologist (OR 0.59, 95% CI 0.46-0.76). Also, although all patients with 2 or 3 risk factors had 31% higher odds of urology referral (OR 1.31, 95% CI 1.02-1.69), adjusted analyses indicated that this effect was only apparent among men. CONCLUSIONS: Only 18% of patients with an incident hematuria diagnosis underwent complete hematuria evaluation. Gender had a substantial effect on referral to urology when controlling for socioeconomic factors but otherwise it had an unclear role on the quality of evaluation. African American patients had markedly lower rates of thorough evaluation than Caucasian patients. Number of risk factors predicted referral to urology among men but it was otherwise a poor predictor of evaluation. There is opportunity for improvement by increasing the completion of hematuria evaluations, particularly in patients at high risk and those who are vulnerable.

Knowledge of diagnosis, treatment history, and risk of late effects among childhood cancer survivors and parents: The impact of a survivorship clinic.

BACKGROUND: Childhood cancer survivors are at risk for treatment-related adverse health outcomes, known as late effects. Through matched and longitudinal cohorts, we assessed the impact of survivorship care on patient and parent knowledge of treatment history and associated health risks. PROCEDURE: Childhood cancer survivors were recruited from a single-institution survivorship clinic and matched with survivors receiving routine follow-up care (controls) on diagnosis, age, and time off therapy. One hundred seventy-four participants completed telephone interviews assessing knowledge of diagnosis, treatment history, and risk of late effects. Additionally, 48 new survivorship patients were followed longitudinally with serial interviews for 18 months. RESULTS: In the case-control study, survivorship participants were more likely than controls to correctly report their diagnosis (98% vs. 90%, P = 0.039) and indicate a previous discussion of risk of late effects (99% vs. 62%, P<0.0001). Compared to controls, survivorship participants were 13% more sensitive reporting chemotherapeutics (95%CI 2.8-23.7%, P = 0.013) and 12% more sensitive reporting late effect risk (95%CI 7.3-16.6%, P<0.0001). In the longitudinal cohort, participants were 7% more sensitive reporting chemotherapeutics (95%CI 5.4-10.8%, P < 0.001) and 9% more sensitive reporting late effect risk (95%CI 5.6-23.8%, P<0.001) at 3 months compared to baseline. In regression analysis, baseline knowledge correlated with subsequent interview performance, and time since survivorship visit correlated with decreased knowledge of late effects, but not diagnosis or treatment history. CONCLUSIONS: Survivorship care was associated with increased knowledge of diagnosis, treatment history, and risk of late effects in both cohorts. Knowledge of late effects decreases with time, suggesting the need for additional educational strategies.

Gender, race, and variation in the evaluation of microscopic hematuria among Medicare beneficiaries.

BACKGROUND: Female gender and black race are associated with delayed diagnosis and inferior survival in patients with bladder cancer. OBJECTIVE: We aimed to determine the association between gender, race, and evaluation of microscopic hematuria (an early sign of bladder cancer). DESIGN AND PARTICIPANTS: This was a cohort study using a 5 % random sample of fee-for-service Medicare beneficiaries diagnosed with incident hematuria (International Classification of Diseases, Ninth Revision [ICD-9] code 599.7x) between January 2009 and June 2010 in a primary care setting. Beneficiaries with pre-existing explanatory diagnoses or genitourinary procedures were excluded. MAIN MEASURES: The main endpoint was completeness of the hematuria evaluation in the 180 days after diagnosis. Evaluations were categorized as complete, incomplete, or absent based on receipt of relevant diagnostic procedures and imaging studies. KEY RESULTS: In all, 9,211 beneficiaries met the study criteria. Hematuria evaluations were complete in 14 %, incomplete in 21 %, and absent in 65 % of subjects. Compared to males, females were less likely to have a procedure (26 vs. 12 %), imaging (41 vs. 30 %), and a complete evaluation (22 vs. 10 %) (p < 0.001 for each comparison). Receipt of a complete evaluation did not differ by race. Controlling for baseline characteristics, a complete evaluation was less likely in white women (OR, 0.40 [95 % CI, 0.35-0.46]) and black women (OR, 0.46 [95 % CI, 0.29-0.70]) compared to white men; no difference was found between black and white men. CONCLUSIONS: Women are less likely than men to undergo a complete and timely hematuria evaluation, a finding likely relevant to women's more advanced stage at bladder cancer diagnosis. System-level process improvement between providers of urologic and primary care in the evaluation of hematuria may benefit women harboring malignancy.

The Impact of Gender on Use of Pelvic Lymphadenectomy at the Time of Radical Cystectomy.

INTRODUCTION: Although women are less likely to be diagnosed with bladder cancer than men, they experience a disproportionally high rate of cancer specific mortality. Underuse of evidence-based processes of care may contribute to this mortality difference. We explored variation in the use of pelvic lymphadenectomy at the time of radical cystectomy between men and women, and determined if this was impacted by surgeon or hospital volume. METHODS: We identified all patients with bladder cancer who underwent radical cystectomy from 1996 to 2009 in the New York, Maryland and Florida State Inpatient Databases. The effect of gender on the use of pelvic lymphadenectomy was analyzed using multivariate logistic regression models. RESULTS: Approximately 25% of our cohort was female. Compared to men, women were less likely to be treated with pelvic lymphadenectomy (54% vs 60%, p <0.001), and tended to be treated by lower volume surgeons and at lower volume hospitals. Women had 21% lower odds (95% CI 5-35) of undergoing pelvic lymphadenectomy compared to men when adjusting for patient characteristics, even when treated by high volume surgeons and at high volume hospitals. CONCLUSIONS: At radical cystectomy women were less likely to undergo pelvic lymphadenectomy even when treated by high volume providers. Since pelvic lymphadenectomy is an evidence-based process of care that is associated with improved survival in patients with bladder cancer, lower use of pelvic lymphadenectomy may contribute to the lower bladder cancer survival rate observed in women. Our findings identify an opportunity to improve quality of care in women with bladder cancer.

Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: a cluster-randomized trial.

Posttraumatic stress disorder (PTSD) is one of the fastest growing compensated medical conditions. The present study compared usual disability examiner practices for PTSD with a standardized assessment that incorporates evidence-based assessments. The design was a multicenter, cluster randomized, parallel-group study involving 33 clinical examiners and 384 veterans at 6 Veterans Affairs medical centers. The standardized group incorporated the Clinician Administered PTSD Scale and the World Health Organization Disability Assessment Schedule-II into their assessment interview. The main outcome measures were completeness and accuracy of PTSD diagnosis and completeness of functional assessment. The standardized assessments were 85% complete for diagnosis compared to 30% for nonstandardized assessments (p < .001), and, for functional impairment, 76% versus 3% (p < .001). The findings demonstrate that the quality of PTSD disability examination would be improved by using evidence-based assessment.