A Statewide Intervention Improves Appropriate Imaging in Localized Prostate Cancer.

PURPOSE: We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer. MATERIALS AND METHODS: MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns. RESULTS: A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p <0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p <0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods. CONCLUSIONS: An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.

Impact of Gene Expression Classifier Testing on Adjuvant Treatment Following Radical Prostatectomy: The G-MINOR Prospective Randomized Cluster-crossover Trial.

BACKGROUND AND OBJECTIVE: Decipher is a tissue-based genomic classifier (GC) developed and validated in the post-radical prostatectomy (RP) setting as a predictor of metastasis. We conducted a prospective randomized controlled cluster-crossover trial assessing the use of Decipher to determine its impact on adjuvant treatment after RP. METHODS: Eligible patients had undergone RP within 9 mo of enrollment, had pT3-4 disease and/or positive surgical margins, and prostate-specific antigen <0.1 ng/ml. Centers were randomized to a sequence of 3-mo periods of either GC-informed care or usual care (UC). Cancer of the Prostate Risk Assessment Postsurgical (CAPRA-S) recurrence risk scores were provided to treating physicians and patients in all periods. KEY FINDINGS AND LIMITATIONS: Impact of GC test results on adjuvant treatment were compared with UC alone. Longitudinal patient-reported urinary and sexual function was assessed. A total of 175 patients were enrolled in 27 periods with GC and 163 in 28 periods with UC. At 18 mo after RP, an average patient in the GC arm received adjuvant treatment 9.7% of the time compared with 8.7% for an average individual in the UC arm (0.99% mean difference, 95% confidence interval [CI] -7.6%, 9.6%, p = 0.8). While controlling for CAPRA-S score, higher GC scores tended to result in an increased likelihood of adjuvant treatment that was not statistically significant (odds ratio [OR] = 1.35 per 0.1 increase in GC score, 95% CI 0.98-1.85, p = 0.066). Using the GC risk groups, reflecting clinical use, a high GC risk was associated with significantly higher odds of receiving adjuvant treatment (OR = 6.9, 95% CI 1.8, 26, p = 0.005) compared with a low GC score, adjusted for CAPRA-S score. There were no differences in patient-reported urinary and sexual function between the study arms. As oncologic outcomes are immature, the present data cannot address whether GC testing provides any cancer control benefit. CONCLUSIONS AND CLINICAL IMPLICATIONS: GC testing impacts adjuvant therapy administration when viewed through the risk categories presented in the patient report; however, these data do not provide specific support for GC testing in the adjuvant treatment setting.

Improvement in clinical TNM staging documentation within a prostate cancer quality improvement collaborative.

OBJECTIVE: To assess the effectiveness of a feedback and educational intervention to increase documentation of clinical tumor-node-metastasis (TNM) stage among urologists in a statewide quality improvement collaborative. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a consortium of urology practices that aims to improve the quality and cost-efficiency of prostate cancer care. In pilot data collection activities, trained abstractors recorded medical record documentation of clinical TNM stage by participating urologists. We compared levels of TNM stage documentation in 12 MUSIC practices at baseline and after performance feedback and a collaborative-wide educational intervention. We examined patient and practice characteristics associated with documentation of TNM stage. RESULTS: We accrued 491 and 581 men with newly diagnosed prostate cancer during the baseline and postfeedback phases of data collection, respectively. At baseline, 58% of patients had clinical TNM staging in the medical record, ranging from 19% to 96% across 12 practices (P <.05). After the intervention, documentation improved to 79% of patients overall, with 7 individual practices achieving significant improvements (all P <.05). The greatest improvements in documentation occurred among patients treated in smaller practices (ie, 1-4 urologists). CONCLUSION: After collaborative review of staging criteria and feedback of baseline performance, urologists in MUSIC practices dramatically improved documentation of clinical TNM stage. This finding underscores the behavioral change possible with the collaborative quality improvement model and ensures the necessary risk stratification data for our ongoing efforts to improve care.