Understanding the Barriers to Neoadjuvant Chemotherapy in Patients with Muscle Invasive Bladder Cancer: A Quality Improvement Initiative.

PURPOSE: Utilization of neoadjuvant chemotherapy (NAC) for the management of muscle-invasive bladder cancer remains low. We sought to understand our practice of NAC use in order to design a quality improvement initiative geared towards optimizing medical oncology referral. MATERIALS AND METHODS: We identified 339 patients with ≥cT2 bladder cancer treated with radical cystectomy between 2012-2017 at our institution. We assessed the rate of referral to medical oncology, rate of NAC administration, as well as medical, patient and provider variables associated with NAC use. Bayesian logistic regression modeling identified variables associated with NAC use and chart review provided granular patient-level data. RESULTS: 85% (n=289) of patients were referred to medical oncology and 62.5% (n=212) received NAC. Renal insufficiency, hearing loss, and treating urologist were conclusively associated with lower odds of NAC use. 46 patients were not referred to medical oncology and 50% of these had medical contraindications to cisplatin cited as the reason for no referral. 38 patients met with medical oncology but did not receive NAC. 30 (79%) had comorbidities that impacted this decision with 15 (39%) ineligible based on impaired renal function. CONCLUSIONS: Despite the relatively high rates of medical oncology referral and NAC use in this cohort, there are still opportunities to improve the efficiency of this practice. Quality improvement initiatives could optimize the referral of patients with ≥T2 bladder cancer for consideration of cisplatin-based NAC and establish an important quality metric in the management of these patients.

The Intentions of Letter Writers for Applicants to a Baccalaureate-M.D. Program: Self-Report and Content Analyses of Letters of Reference.

BACKGROUND: The purpose of this study was to determine how individuals providing reference letters framed the task and the specific attributes used to describe applicants. METHODS: Participants were letter writers (N=106) for accepted or alternate applicants. Participants received a brief anonymous survey and a return postcard to release their past letter for content analysis. RESULTS: Seventy-six percent of letter writers (N=81) returned a survey. Most (64%) intended to describe applicants' positive accomplishments. According to respondents' they were most likely to write about academic accomplishments (85%), work ethic (78%), dependability (70%) and motivation (70%). Seventy-four respondents (70%) released their letter for content analysis. Academic accomplishments (77%), motivation (41%) and leadership (41%) were the attributes most frequently mentioned in the letters. CONCLUSIONS: Most letter writers see their role as supportive rather than evaluative. Academic accomplishments, though often mentioned, are available from other sources. Many non-cognitive attributes of most interest to admissions committees are least likely to appear in reference letters.