Cost-Effectiveness Analysis of the Clear Cell Likelihood Score Against Renal Mass Biopsy for Evaluating Small Renal Masses.

OBJECTIVE: To examine the cost-effectiveness of the clear cell likelihood score compared to renal mass biopsy (RMB) alone. METHODS: The clear cell likelihood score, a new grading system based on multiparametric magnetic resonance imaging, has been proposed as a possible alternative to percutaneous RMB for identifying clear cell renal carcinoma in small renal masses and expediting treatment of high-risk patients. A decision analysis model was developed to compare a RMB strategy where all patients undergo biopsy and a clear cell likelihood score strategy where only patients that received an indeterminant score of 3 undergo biopsy. Effectiveness was assigned 1 for correct diagnoses and 0 for incorrect or indeterminant diagnoses. Costs were obtained from institutional fees and Medicare reimbursement rates. Probabilities were derived from literature estimates from radiologists trained in the clear cell likelihood score. RESULTS: In the base case model, the clear cell likelihood score was both more effective (0.77 vs 0.70) and less expensive than RMB ($1629 vs $1966). Sensitivity analysis found that the nondiagnostic rate of RMB and the sensitivity of the clear cell likelihood score had the greatest impact on the model. In threshold analyses, the clear cell likelihood score was the preferred strategy when its sensitivity was greater than 62.7% and when an MRI cost less than $5332. CONCLUSION: The clear cell likelihood score is a more cost-effective option than RMB alone for evaluating small renal masses for clear cell renal carcinoma.

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis.

BACKGROUND: Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. METHODS: An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan-Meier analysis of stricture by cancer type. RESULTS: 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). CONCLUSIONS: Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.

Hypofractionated Postprostatectomy Radiation Therapy for Prostate Cancer to Reduce Toxicity and Improve Patient Convenience: A Phase 1/2 Trial.

PURPOSE: The phase 1 portion of this multicenter, phase 1/2 study of hypofractionated (HypoFx) prostate bed radiation therapy (RT) as salvage or adjuvant therapy aimed to identify the shortest dose-fractionation schedule with acceptable toxicity. The phase 2 portion aimed to assess the health-related quality of life (QoL) of using this HypoFx regimen. METHODS AND MATERIALS: Eligibility included standard adjuvant or salvage prostate bed RT indications. Patients were assigned to receive 1 of 3 daily RT schedules: 56.6 Gy in 20 Fx, 50.4 Gy in 15 Fx, or 42.6 Gy in 10 Fx. Regional nodal irradiation and androgen deprivation therapy were not allowed. Participants were followed for 2 years after treatment with outcome measures based on prostate-specific antigen levels, toxicity assessments (Common Terminology Criteria for Adverse Events, v4.0), QoL measures (the Expanded Prostate Cancer Index Composite [EPIC] and EuroQol EQ-5D instruments), and out-of-pocket costs. RESULTS: There were 32 evaluable participants, and median follow-up was 3.53 years. The shortest dose-fractionation schedule with acceptable toxicity was determined to be 42.6 Gy in 10 Fx, with most patients (23) treated with this schedule. Grade 3 genitourinary (GU) and gastrointestinal (GI) toxicities occurred in 3 patients and 1 patient, respectively. There was 1 grade 4 sepsis event. Higher dose to the hottest 25% of the rectum was associated with increased risk of grade 2+ GI toxicity; no dosimetric factors were found to predict for GU toxicity. There was a significant decrease in the mean bowel, but not bladder, QoL score at 1 year compared with baseline. Prostate-specific antigen failure occurred in 34.3% of participants, using a definition of nadir plus 2 ng/mL. Metastases were more likely to occur in regional lymph nodes (5 of 7) than in bones (2 of 7). The mean out-of-pocket cost for patients during treatment was $223.90. CONCLUSIONS: We identified 42.6 Gy in 10 fractions as the shortest dose-fractionation schedule with acceptable toxicity in this phase 1/2 study. There was a higher than expected rate of grade 2 to 3 GU and GI toxicity and a decreased EPIC bowel QoL domain with this regimen. Future studies are needed to explore alternative adjuvant/salvage HypoFx RT schedules after radical prostatectomy.

Assigning value to preparation for prostate cancer decision making: a willingness to pay analysis.

BACKGROUND: The Personal Patient Profile-Prostate (P3P) is a web-based decision support system for men newly diagnosed with localized prostate cancer that has demonstrated efficacy in reducing decisional conflict. Our objective was to estimate willingness-to-pay (WTP) for men's decisional preparation activities. METHODS: In a multicenter, randomized trial of P3P, usual care group participants received typical preparation for decision making plus referral to publicly-available, educational websites. Intervention group participants received the same, plus online P3P educational media specific to the user's personal preferences and values, and a communication coaching component tailored to race\ethnicity, age and language. WTP data were collected one week after physician consultation. An iterative bidding direct contingent valuation survey format was used, randomly assigning participants to high or low starting values (SV). Tobit models were used to explore associations between SV-adjusted WTP and age, education, marital and work-status, insurance, decision-control preference and decision-making stage. RESULTS: Of 392 participants enrolled, 141 P3P and 107 usual care (UC) provided a WTP value. Men were willing to pay a median $25 (IQR $10-100) for P3P in addition to usual care preparation materials. In the final multivariable tobit regression model, SV, marital status, stage of decision making and income were significantly associated with WTP for P3P. Decision control preference was considered marginally significant (p = 0.11). Men were WTP a median $30 (IQR $10-$200) for usual care material alone. In the final multivariable model, SV, education, and stage of decision making were significantly associated with WTP in usual care. CONCLUSION: WTP was similar for UC and for the addition of P3P to UC decision preparation. The WTP values were associated with demographic and preference variables. Findings can help focus decision support on future patients who would benefit most: those without strong support systems, at earlier stages of decision making, and open to a shared-decision style. TRIAL REGISTRATION: NCT NCT01844999 . Registered May 3, 2013.

Robotic-Assisted Surgery for Upper Tract Urothelial Carcinoma: A Comparative Survival Analysis.

BACKGROUND: We performed a comparative survival analysis of patients undergoing robotic-assisted versus laparoscopic or open surgery for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Patients diagnosed with non-metastatic UTUC undergoing removal of the kidney and/or ureter were identified using Medicare-linked Surveillance, Epidemiology, and End Results Program data (2004-2013). Patients aged 65-85 years were categorized based on surgical approach (open, laparoscopic, or robotic-assisted). Kaplan-Meier methods were used to determine survival (overall and cancer-specific) and intravesical recurrence rates, the former using a propensity score-weighted model. Independent predictors of survival were determined using multivariable Cox proportional hazards regression analysis. RESULTS: We identified a total of 3801 patients meeting the final inclusion criteria: open (n = 1862), laparoscopic (n = 1624), and robotic (n = 315). Robotic surgery was associated with the shortest length of hospital stay (p < 0.001) but highest in-hospital charges (p < 0.001), with no difference in readmission rates (p = 0.964). No difference was found in overall or cancer-specific survival in the robotic cohort when compared with open or laparoscopic surgery. In addition, no difference in the rate of intravesical recurrence was noted in robotic-assisted laparoscopy compared with the other groups. The sole predictor of improved survival was extent of lymphadenectomy, which was highest in the robotic cohort. CONCLUSIONS: Using a large, population-based cancer database, there was no survival difference when a robotic-assisted approach was utilized in patients undergoing surgery for UTUC. These findings are important with the increased use of robotic surgery in the management of UTUC.

Management of Ureteroenteric Stricture: Predictive Modeling to Compare Cost.

BACKGROUND: Ureteroenteric stricture occurs in as many as 15% of patients after cystectomy with urinary diversion. First-line management is typically percutaneous nephrostomy (PCN) drainage. We sought to compare costs of a urologic approach of retrograde stenting through flexible endoscopy and an interventional radiology (IR) approach of PCN and antegrade stenting using predictive modeling. The purpose of this study is to inform best practice for initial stricture management based on existing literature regardless of the benign stricture rate following radical cystectomy. Our hypothesis is that initial management by a urologist may be superior to IR management. MATERIALS AND METHODS: The primary outcome measure was cost based on 2015 Medicare reimbursement rates by Current Procedural Technology codes with a secondary endpoint of number of procedures a patient undergoes. We developed a simulation model to replicate the experience of stricture patients. The model describes three arms: urologic management with retrograde stent placement, sequential management by IR, and single-stage IR management. We simulated 10,000 patients through the model with the percentage of patients pursuing each treatment arm and success rates chosen based on a review of relevant literature and clinic experience. RESULTS: The average cost of urologic management is $703.23 compared with the average cost of $838.09 for patients using radiologic management. Within radiologic management, the average cost is $862.98 for sequential IR management and $639.44 for single-stage IR management. Patients would undergo an average of 2.53 procedures for those patients initially sent to urology and 2.91 procedures for those sent to radiology. For sequential IR, the average is 3.02 procedures, and for single-stage IR, it is 2.03 procedures. From a cost perspective, the success rate at which retrograde stent placement becomes worth attempting is 35%. If radiologic management is attempted initially, sequential IR management represents a cost-conscious option that limits the total number of procedures. CONCLUSION: The disparity in cost between IR and urologic management of ureteral stricture provides a rationale for rural practices that may not have immediate access to IR to manage the patient.

Comparison of Renal Cell Carcinoma Surveillance Guidelines: Competing Trade-Offs.

PURPOSE: We estimated the differences in intensity, cost, radiation exposure and cancer control of published surveillance guidelines screening for secondary renal cell carcinoma in patients treated with partial nephrectomy. MATERIALS AND METHODS: We developed a Monte Carlo simulation model to contrast the existing guidelines in terms of cost, radiation exposure and cancer control. Model inputs were extrapolated from the existing literature. Surveillance guidelines were analyzed from the AUA, CUA, EAU and NCCN®. Risk stratification among patients treated with partial nephrectomy was based on tumor characteristics. RESULTS: Expected costs during the 5 years after partial nephrectomy were $587 (CUA), $1,076 (AUA), $1,705 (EAU) and $1,768 (NCCN) for low risk patients, and $903 (CUA), $2,525 (EAU) and $3,904 (AUA and NCCN) for high risk patients. Radiation exposure ranged from 31.41 mSv (CUA) to 104.34 mSv (NCCN) for low risk patients and 46.88 mSv (CUA) to 231.61 mSv (AUA and NCCN) for high risk patients. The EAU and CUA guidelines led to the diagnosis of the highest percentage of low risk patients (more than 95%) while all guidelines diagnosed more than 92% of high risk patients with recurrence. CONCLUSIONS: Renal cell carcinoma surveillance guidelines differ greatly in terms of intensity, cost and radiation exposure. It is important for clinicians to adopt standardized surveillance strategies that limit unnecessary cost and radiation exposure without compromising cancer control.

Optimizing and validating the technical infrastructure of a novel tele-cystoscopy system.

INTRODUCTION: Bladder cancer is the most costly malignancy to manage per capita due to the technical nature and intensity of follow-up. There are few urologists in rural areas, often necessitating that patients travel hours to receive follow-up care multiple times per year. We plan to train registered nurses and allied health professionals to perform cystoscopies which are monitored and interpreted in real-time by board-certified urologists. The key is to ensure optimal picture resolution to guarantee this technology is not inferior to traditional cystoscopy. Our objective was to develop the technical infrastructure needed for a tele-cystoscopy system through assessment of the transmitted video quality using expert reviewers and crowd-sourcing. METHODS: All combinations of the tele-cystoscopy system were systematically tested using a single Thiel cadaver. The videos were reviewed by expert urologists and general reviewers using a crowd-sourcing website. The video quality responses were assessed to determine concordance between each set of reviewers, and to determine the optimal equipment that should be selected for the tele-cystoscopy system. RESULTS: Of eight equipment combinations, only two were of high enough quality to be appropriate for medical use. We found there to be strong concordance of responses between the expert and crowd-sourced responses. The trade-offs between cost and tele-cystoscopy system component quality were compared with efficiency frontiers to elucidate the optimal system. DISCUSSION: We created and tested the feasibility of a tele-cystoscopy system that was deemed suitable for medical diagnosis by a group of experts. We further validated tele-cystoscopy video quality using both experts and recently validated crowd-sourcing.

Alvimopan: A cost-effective tool to decrease cystectomy length of stay.

INTRODUCTION: We sought to evaluate the cost effectiveness of perioperative use of alvimopan in cystectomy and urinary diversion. A recent randomized controlled trial demonstrated the efficacy of alvimopan in reducing postoperative ileus and length of stay in cystectomy; however, a major limitation was the exclusion of epidural analgesia. MATERIALS AND METHODS: Eighty-six cystectomy and urinary diversion procedures performed by seven surgeons were analyzed between January 2008 and April 2012. The first 50 patients did not receive alvimopan perioperatively, while the subsequent 36 received a single dose of 12 mg preoperatively and then 12 mg every 12 hours for 15 doses or until discharge. RESULTS: The groups were equal with respect to age, gender, indication, surgeon, and type of diversion. Patients who received alvimopan experienced a shorter length of stay (LOS) versus those in who did not receive alvimopan (10.5 vs. 8.6 days, p = 0.005, 95% CI 0.6-3.3). Readmission for ileus was low in both alvimopan and control groups (0% and 4.4%, respectively). Costs were significantly lower in the alvimopan group than the control groups (2012 USD 32,443 vs. 40,604 p <0.001). This difference stood up to multivariate analysis with a $7,062 difference in hospital stay. CONCLUSIONS: Use of alvimopan in the routine perioperative care of our cystectomy and urinary diversion patients has decreased LOS by 1.9 days. Additionally, institution of routine perioperative alvimopan has reduced costs by $7,062 per admission (20% reduction). This demonstrates a real world application of alvimopan at a moderate volume center.

Levels of evidence ratings in the urological literature: an assessment of interobserver agreement.

OBJECTIVE: To determine to what extent urologists with no specific training agree upon level of evidence (LoE) ratings of studies published in the urological literature, as LoE are commonly referenced as a measure of evidence quality. MATERIALS AND METHODS: In all, 86 clinical research studies published in four major urology journals were reviewed. Each article was independently reviewed by eight reviewers using a standardized data abstraction form. Articles were assessed for type of study (therapy, prognosis, diagnosis or economic) and LoE (I, II, III or IV). Reviewers received only written instructions and no formal training in the application of this classification system. RESULTS: Of the 86 articles, 69% related to therapy, 16% to prognosis, and 15% to diagnosis. Eight studies (9%) provided Level I evidence, 18 studies (21%) Level II, 14 studies (16%) Level III and 46 studies (54%) Level IV evidence. The intraclass correlation coefficient (95% confidence interval) based on all reviewers (eight reviewers) was 0.67 (0.59-0.74; P= 0.001) for the type of study and 0.55 (0.48-0.64; P= 0.001) for the LoE. In an analysis limited to a subset of studies in which all reviewers agreed upon the type of study question (n= 40) the intraclass correlation coefficient was 0.79 (0.70-0.86; P= 0.001). CONCLUSION: In the present study there was a low interobserver agreement for LoE ratings by urologists with no specific training. These findings suggest caution in the interpretation of LoE ratings and emphasize the importance of specific training for individuals that are charged with quality of evidence determinations.

Economic costs of overactive bladder in the United States.

OBJECTIVES: To calculate, from a societal perspective, current direct (medical and nonmedical) and indirect costs of overactive bladder (OAB) in the United States and project them to future years. Existing cost assessments of OAB in the United States are incomplete and outdated. METHODS: A prevalence-based model was developed incorporating age- and sex-specific OAB prevalence rates, usage data, and productivity data. On the basis of the information gathered from the recent 5 years of the medical literature, practice guidelines, Medicare and managed care fee schedules, and expert panel input, the annual per capita and total US costs were calculated for 2007. US census population forecasts were used to project the costs of OAB to 2015 and 2020. RESULTS: In 2007, average annual per capita costs of OAB were $1925 ($1433 in direct medical, $66 in direct nonmedical, and $426 in indirect costs). Applying these costs to the 34 million people in the United States with OAB results in total national costs of $65.9 billion (billion = 1000 million), ($49.1 billion direct medical, $2.3 billion direct nonmedical, and $14.6 billion indirect). Average annual per capita costs in 2015 and 2020 would be $1944 and $1969 and total national costs would be $76.2 billion and $82.6 billion, respectively. CONCLUSIONS: These data suggest that the economic burden of OAB is about 5-fold higher than older, noncomprehensive estimates. These costs are higher than previously published data for the United States and Europe because this analysis relies on more current data, real world age- and sex-specific treatment patterns and costs, and includes a more complete set of cost components.

Determinants of treatment regret in low-income, uninsured men with prostate cancer.

OBJECTIVES: The regret of a prostate cancer treatment choice, a significant dimension of health-related quality of life, has not been well-characterized. Little is known about its association with the fear of cancer recurrence or spirituality. METHODS: We drew subjects from a men's health study composed of a clinically heterogeneous sample of subjects enrolled from a statewide, publicly funded assistance program that provided free prostate cancer treatment for uninsured, low-income men in California. We included men who completed a telephone interviews and self-administered questionnaires at study enrollment and at 6 months of follow-up. Using validated instruments, we measured regret, health-related quality of life, fear of cancer recurrence, and spirituality through telephone interviews and self-administered questionnaires. RESULTS: Of the 195 men, 90 underwent radical prostatectomy (46%), 50 underwent external beam radiotherapy (28%), and 51 underwent hormonal therapy (26%). Of these 195 men, 36 (18%) regretted their treatment choice. Multivariate analyses revealed that nonwhite men were more likely than white men to experience decisional regret (odds ratio [OR] range 7.27 to 12.26). Conversely, men confident of cancer cure (OR 0.19, 95% confident interval 0.04 to 0.86), men with greater spirituality (OR 0.91, 95% confidence interval 0.87 to 0.96), and men with acute treatment effects (OR 0.34, 95% confidence interval 0.12 to 0.93) were less likely to regret their treatment decisions. CONCLUSIONS: In our study, a fear of cancer recurrence, less spirituality, a longer interval since treatment, and nonwhite race were associated with treatment regret in low-income, underserved men with prostate cancer. Attempts to decrease anxiety and enhance spirituality in men treated for prostate cancer might diminish treatment regret. Additional studies in racially diverse cohorts are needed to examine the association of regret with race.

Health care cost associated with prostate cancer, androgen deprivation therapy and bone complications.

PURPOSE: We ascertained the health care costs of androgen deprivation therapy and related skeletal events. MATERIALS AND METHODS: Using data from the MarketScan Medicare Supplemental and Coordination of Benefits Database, we identified cases with International Classification of Disease, 9th Revision codes indicating a diagnosis of prostate cancer who initiated androgen deprivation therapy between 1999 and 2002. The control group consisted of patients with prostate cancer with no androgen deprivation therapy use, matched by age, geographic region, insurance plan and index year. All had followup data for at least 36 months. The occurrence and cost of osteoporosis and any bone fracture were assessed using a propensity score matched sample. RESULTS: Of the 8,577 eligible men with prostate cancer, 3,055 initiated androgen deprivation therapy and 5,522 did not. At the time of androgen deprivation therapy initiation those on androgen deprivation therapy had more severe comorbidity (3.1 vs 2.6, p <0.001) and proportionally more bone metastases (2.8% vs less than 0.6%, p <0.001) but no difference in fracture rate. After 3 years of followup the androgen deprivation therapy group experienced significantly more fractures (18.7% vs 14.6%, p <0.001). The mean unadjusted total cost of health care during the 36-month period was $48,350 per person for cases and $26,097 for controls. CONCLUSIONS: Among men with prostate cancer, those on androgen deprivation therapy cost the health care system almost twice as much as those not on androgen deprivation therapy. After controlling for differences in health status, the majority of the excess cost is attributable to androgen deprivation therapy and then to a lesser extent, the fractures. These results suggest that the bone complications of osteoporosis and fractures in men on androgen deprivation therapy have important economic consequences.

Androgen deprivation therapy increases cardiovascular morbidity in men with prostate cancer.

BACKGROUND: The use of androgen deprivation therapy (ADT) in the treatment of men with prostate cancer has risen sharply. Although cardiovascular disease is the most common reason for death among men with prostate cancer who do not die of the disease itself, data regarding the effect of ADT on cardiovascular morbidity and mortality in men with prostate cancer are limited. In the current study, the authors attempted to measure the risk for subsequent cardiovascular morbidity in men with prostate cancer who received ADT. METHODS: A cohort of newly diagnosed men in a population-based registry who were diagnosed between 1992 and 1996 were identified retrospectively. A total of 22,816 subjects were identified after exclusion criteria were applied. Using a multivariate model, the authors calculated the risk of subsequent cardiovascular morbidity in men with prostate cancer who were treated with ADT, as defined using Medicare claims. RESULTS: Newly diagnosed prostate cancer patients who received ADT for at least 1 year were found to have a 20% higher risk of serious cardiovascular morbidity compared with similar men who did not receive ADT. Subjects began incurring this higher risk within 12 months of treatment. However, Hispanic men were found to have a lowered risk for cardiovascular morbidity. CONCLUSIONS: ADT is associated with significantly increased cardiovascular morbidity in men with prostate cancer and may lower overall survival in men with low-risk disease. These data have particular relevance to decisions regarding the use of ADT in men with prostate cancer in settings in which the benefit has not been clearly established. For men with metastatic disease, focused efforts to reduce cardiac risk factors through diet, exercise, or the use of lipid-lowering agents may mitigate some of the risks of ADT.

Outcomes in men denied access to a California public assistance program for prostate cancer.

OBJECTIVES: To improve access to prostate cancer treatment for low income uninsured men, California initiated a program called IMPACT: Improving Access, Counseling and Treatment for Californians with Prostate Cancer. The program administered free treatment, case management, counseling, and educational materials to all eligible men until budget cuts led to a state-mandated suspension of enrollment and the establishment of a temporary waitlist in February 2005. To assess the effect of suspension of enrollment on patient outcomes, the authors compared health-related quality of life (HRQOL) in waitlisted and enrolled men. METHODS: Eighty-three men in each group were matched on disease stage, age, and race. HRQOL was captured with the UCLA Prostate Cancer Index short form (PCI-SF), the Medical Outcomes Study Short Form-12 (SF-12), and McCorkle and Young's Symptoms and Degrees of Distress in Patients with Cancer Scale (SDS). Self-efficacy was measured with the Perceived Efficacy in Patient-Physician Interactions (PEPPI) Questionnaire. RESULTS: At intake, waitlisted men demonstrated significantly more symptom-related distress (2.9; p=0.04) and less perceived self-efficacy (2.5; p=0.005) compared to enrollees. Waitlisted men were significantly less likely to have access to a doctor or nurse case manager, treatment medications, nutrition information, or counseling services (p<0.0001). CONCLUSIONS: Men denied enrollment into the IMPACT program exhibited significantly worse symptom distress and self-efficacy compared to enrolled men at initial assessment. The multivariate model suggests that HRQOL in the waitlisted men may be related to their lack of access to medical services. This data illustrates the importance of ongoing public assistance for low income men with prostate cancer.

Quality of prostate carcinoma care in a statewide public assistance program.

BACKGROUND: The authors evaluated the feasibility of measuring quality of care in a statewide public assistance program for men with prostate carcinoma. METHODS: The sample consisted of 84 men who were followed for > or = 6 months after receiving primary treatment for early-stage prostate carcinoma (55 received radical prostatectomy and 29 received radiotherapy) through a free public program for low-income, uninsured men. Quality was assessed by chart review with 16 indicators previously developed and validated at the RAND Corporation, as well as by telephone and mail surveys that included the University of California at Los Angeles Prostate Cancer Index short form. RESULTS: Quality of care measurement was feasible for 13 (81%) indicators from electronic chart abstraction, administrative documents, and patient questionnaires. Communication between specialist and primary physician was better for men treated with radiotherapy than with surgery (84% vs. 45%, P = 0.004). Subjects treated in private institutions were more likely than those treated in public institutions to have > or = 2 follow-up visits with the treating physician or institution within 1 year of treatment (93% vs. 63%, P = 0.003) and to have documentation of communication with the primary care physician (90% vs. 40%, P << 0.0001). Disease-specific, health-related quality of life 6 months after treatment did not appear to differ between public and private facilities. CONCLUSIONS: The authors found the application of quality of care indicators to be feasible in a statewide public assistance program, but with some differences between public and private providers. These quality of care indicators identified target areas for improvement.