Studies addressing adherence rates
There are few well-performed studies that specifically address adherence to recent bladder cancer guidelines. Schrag et al. evaluated adherence to cystoscopic surveillance following the diagnosis of NMIBC and found that only 40% underwent appropriate cystoscopic surveillance.28
More recently, Chamie et al. evaluated adherence to published guidelines using SEER-Medicare data, specifically studying the use of surveillance cystoscopy, upper tract imaging, intravesical BCG, and perioperative mitomycin-C within the first 2-years of diagnosis. Of the 4,545 patients in the study cohort, only one patient (0.02%) received appropriate guideline-based therapy, including eight cystoscopic examinations, eight urine cytologies, an induction course of BCG, two upper tract studies, and a single dose of perioperative mitomycin-C.29 Relaxing their definition to exclude perioperative mitomycin and upper tract imaging resulted in 19 patients (0.4%) having received care adherent to published guidelines.
Indeed, nearly two-thirds of patients in the study cohort did not receive one or more cystoscopy, one or more cytology, and one or more BCG instillation. The investigators also evaluated provider-level guideline adherence and documented equally sobering results, finding that 99% of treating physicians failed to provide eight or more cystoscopies, eight or more cytologies, and six or more BCG instillations within two years following diagnosis to a single patient captured by the study within their practice.
Furthermore, 42% of providers failed to provide one or more cystoscopy, one or more cytology, and one or more BCG instillation to a single patient. Interestingly, the only parameter that demonstrated improvement in adherence after the publication of clinical practice guidelines was the administration of an induction course of BCG. Unexplained provider-level variation largely contributed to the low compliance rates for cystoscopy, cytology, perioperative chemotherapy, and postoperative BCG.29
In addition to the aforementioned population-based studies, Bolenz et al. recently reported data surrounding adherence to EAU guidelines among a cohort of 206 elderly bladder cancer patients treated at a single tertiary care institution.
This study revealed appropriate initial surgical management including re-resection and the administration of a single dose of intravesical chemotherapy in 71.4% of patients. Of the 43 conservatively-treated patients with an indication for BCG, 28 patients (65.1%) received an induction course of BCG and 11 patients (25.6%) received maintenance BCG.30 These data closely resemble those published by Gontero et al., who evaluated adherence to EAU guidelines in 306 patients treated at eight Italian referral centers. Of the 124 patients with high-risk disease, 61 patients (49.2%) underwent re-resection, and 96 patients (77.4%) received either induction BCG or induction intravesical chemotherapy.
Clearly, there are profound differences in rates of guideline adherence between published studies. Many of these differences may be attributed to the definition of adherence, the parameter studied, the site of care delivery, and the specific dataset evaluated. Furthermore, one must take into account the considerable degree of publication bias that is likely associated with reporting adherence to published clinical practice guidelines.
Variations in practice: the initial evaluation of hematuria
While there are ample data demonstrating considerable variation in practice patterns following the diagnosis of bladder cancer, there is also a great deal of variation in care with regard to the initial evaluation of hematuria. Elias et al. recently studied patterns of care in a nested cohort of high-risk patients with microscopic hematuria.
This study found that 42.1% of men with one episode of microscopic hematuria never received any further evaluation. Within this cohort, 36% underwent repeat urinalysis, 15.2% had a urine culture, 10.4% underwent urine cytology, 22.6% received some form of imaging, and 12.8% underwent cystoscopy. A multivariate analysis revealed that tobacco use was the only predictive factor for referral and urologic evaluation.
Toward improving guideline adherence
While selected series reveal acceptable rates of guideline adherence, it is clear from population-based data that adherence to published guidelines remains poor. Therefore, two questions must be answered here: a) what are the barriers to guideline implementation; and b) How can we overcome these barriers?
As part of a recent study evaluating regional collaboration to improve guideline adherence, Miller et al. further defined the barriers to implementation as follows: a) clinicians have little empirical data regarding their own practice patterns; and b) there is significant uncertainty amongst clinicians regarding the means to implement quality improvement initiatives.32
Members of the collaborative, which included both academic and private urology practices, implemented a system of data collection, education, and feedback that resulted in significant improvements in guideline-adherent practices.31
The clinical management of NMIBC continues to evolve, and the incorporation of clinical guidelines provides a framework to assist practitioners in providing the highest quality care for their patients. There are a variety of resources available to assist the clinician in the diagnosis, treatment, and follow-up of patients with NMIBC. Like any guideline, each of these documents has at its core the goal of improving the quality of healthcare delivery—and each has inherent strengths and weaknesses.
Future improvements in guideline development include the continuous surveillance of published data and the timely incorporation of significant results to ensure that we are utilizing the most contemporary information. Finally, incentivizing healthcare providers with programs and tools that encompass education, feedback, and implementation will improve adherence to guidelines and ultimately improve the quality of care that we deliver to our patients.
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