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Variations in Quality of Care for Men With Early-Stage Prostate Cancer

Benjamin A. Spencer, David C. Miller, Mark S. Litwin, Jamie D. Ritchey, Andrew K. Stewart, Rodney L. Dunn, E. Greer Gay, Howard M. Sandler, John T. Wei

From the Departments of Urology and Epidemiology, College of Physicians and Surgeons, Columbia University, New York, NY; Departments of Urology and Radiation Oncology, University of Michigan, Ann Arbor, MI; Departments of Urology and Health Services, David Geffen School of Medicine, School of Public Health, and Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC; and American College of Surgeons Commission on Cancer, Chicago, IL

Corresponding author: John T. Wei, MD, MS, Department of Urology, University of Michigan, 1500 E Medical Center Dr, Women's Trailer Rm 1013, Ann Arbor, MI 48109-0759; e-mail: jtwei{at}umich.edu

Purpose The commencement of quality-improvement initiatives such as Pay for Performance and the Physician Consortium for Performance Improvement has underscored calls to evaluate the quality of cancer care on a patient level for nationally representative samples.

Methods We sampled early-stage prostate cancer cases diagnosed in 2000 through 2001 from the American College of Surgeons National Cancer Data Base and explicitly reviewed medical records from 2,775 men (weighted total = 55,160 cases) treated with radical prostatectomy or external-beam radiation therapy. We determined compliance with 29 quality-of-care disease-specific structure and process indicators developed by RAND, stratified by race, geographic region, and hospital type.

Results Overall compliance exceeded 70% for structural and pretherapy disease assessment indicators but was lower for documentation of pretreatment functioning (46.4% to 78.4%), surgical pathology (37.1% to 86.3%), radiation technique (62.6% to 88.3%), and follow-up (55%). Geographic variations were observed as higher compliance in the South Atlantic division than the New England division for having at least one board-certified urologist (odds ratio [OR], 9.2; 95% CI, 1.9 to 45.0), at least one board-certified radiation oncologist (OR, 3.3; 95% CI, 1.2 to 9.0), use of Gleason grading (OR, 4.1; 95% CI, 1.2 to 13.8), and administering total radiation dose 70 Gy (OR, 3.1; 95% CI, 1.6 to 6.1). Teaching/research hospitals and Comprehensive Cancer Centers had higher compliance than Community Cancer Centers, whereas racial differences were not observed for any indicator.

Conclusion The significant and unwarranted variations observed for these quality indicators by census division and hospital type illustrate the inconsistencies in prostate cancer care and represent potential targets for quality improvement. The lack of racial disparities suggests equity in care once a patient initiates treatment.

Supported by a Department of Defense Prostate Cancer Research Program Physician Research Training Award (Grant No. PC040167 to B.A.S.) and Grant No. NIH-1-T-32 DKO7782 from the National Institute of Diabetes and Digestive and Kidney Diseases (D.C.M.). The American College of Surgeons has supported this work through its Special Study program.

Presented in part at the 2006 American Society of Clinical Oncology Prostate Cancer Symposium, February 24-26, 2006, San Francisco, CA; the 34th Annual Spring Meeting of the American College of Surgeons, April 23-26, 2006, Dallas, TX; and the Annual Meeting of the American Urological Association, May 20-25, 2006, Atlanta, GA.

J.T.W. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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