“Best care” doesn’t equate to better outcomes! That’s not good!

A poster by Schroeck et al. — to be presented on May 20 at the upcoming annual meeting of the American Urological Association (AUA) — presents the latest set of data suggesting that “best care” does not lead to appropriate outcomes quality for men receiving standard forms of treatment for localized prostate cancer.

It has become increasingly clear over recent years that — despite the fact that quality of care measures for prostate cancer were initially introduced in 2000; are generally accepted by all relevant organizations; and were subsequently endorsed by the National Quality Forum and by the Physician Consortium for Performance Improvement — quality measures are not consistently adhered to and may be having little or no actual impact on patient outcomes.

A paper published on line by Schroeck et al. in the Journal of Urology just this month has already documented low adherence rates for most established prostate cancer quality of care measures among Medicare patients, and regional variation in adherence to quality measures appears to be pronounced.

In their poster to be presented in the “Outstanding Posters: Oncology” session at the AUA’s annual meeting on Tuesday, May 20, Schroeck et al. (abstract no. OP3-02) feature a further analysis of data extracted from the Surveillance Epidemiology and End Results (SEER)–Medicare database.

The authors used these data to identify 42,658 men treated for localized prostate cancer between 2004 and 2010. For every one of these patients, the authors determined whether he received “best care”, which was defined as care that met all of a set of five nationally endorsed, applicable measures. They also measured associations between application of “best care” and the need for such follow-up care as secondary cancer therapy and the need for procedures addressing urinary or sexual side effects.

Here are their key findings:

  • Just 3,826/42,658 men (9.0 percent) received “best care”.
  • At 5 years post-treatment, compared to the men who did not receive “best care”, the men who did receive “best care
    • Had a similar likelihood of secondary cancer therapy (e.g., 40.9 vs. 37.3 percent, p = 0.522, for men given radical prostatectomy for high-risk prostate cancer)
    • Had a similar likelihood of procedures for urinary side effects (e.g., 10.7 vs. 12.9 percent, p = 0.338, for men given radical prostatectomy).
    • Were more likely to have a procedure for sexual side effects (e.g., 17.3 vs. 10.8 percent, p < 0.001, for men given radical prostatectomy).
  • Similar trends were apparent among men treated with radiotherapy.

Schroeck et al. conclude that

Overall, men receiving best care did not fare better with regards to cancer control and treatment related morbidity. Collectively, our findings suggest that the current process of care measures are not tightly linked to outcomes and that more patient-centered quality of prostate cancer care measures are needed.

These findings should be hard for any clinician to justify to him- or herself. Its bad enough that only 9 percent of Medicare patients were receiving “best care” as defined by national quality standards. If there is also no evidence that supposedly high quality care is closely linked to better quality outcomes, then there is clearly something really badly wrong.

One possible conclusion is certainly the one drawn by the authors. However, another possible conclusion is that the overall quality of care available to Medicare patients diagnosed with localized prostate cancer is so poor that even the physicians who are making every effort to provide good care to these patients are failing disasterously!

Now we should be clear that the SEER-Medicare database is not a clinical database, and that can lead to significant difficulties in accurate interpretation of findings based on this database. However, if nothing else, findings like this should make it very clear to leaders in the prostate cancer management community that they are failing their patients in some very significant ways. Either the forms of treatment being offered to patients today for the management of localized prostate cancer are even less effective and less safe than many patients already consider them to be … or there is an utter lack of true enforcement of quality standards that really ought to be applied … or, worst of all, both!

7 Responses

  1. In regards to the criteria “treated at a high volume treatment center”, is that a matter of patient education through organizations like PCI, or is that an expectation that primary care doctors and urologists are going to refer patients to these treatment centers? My own experience with my primary care doctor is that he is an employee of a large “health system” which includes hospitals and a large network of specialists. He is always going to recommend (I’m in a PPO, so an actual referral is not necessary) a specialist in his organization. (As a patient, I know that if anything is ever seriously wrong with me, I will seek out a top high volume center that specializes in whatever my problem is). For urologists not associated with a high volume treatment center, this would seem like we are expecting them to send a big chunk of business elsewhere.

  2. Dear Doug:

    Actually you might be quite surprised how many urologists do refer patients to prostate cancer specialists today (within and outside networks depending on the patients’ insurance coverage and wishes).

    Clearly there are elements of physician education and patient education associated with these issues.

  3. My first response is perhaps the problem lies with the definitions for “quality of care” management — what you Sitemaster call “best care”.

    I am not familiar with them, and they are not outlined in the abstract, but perhaps they need tightening or relating to some post-treatment follow-up.

  4. Rick:

    I spent an hour yesterday trying to find a good, straightforward link to the guidelines specified by Schroeck et al. So far I have not been able to find one. I intend to look some more today.

  5. Rick:

    In the full text of their paper in the Journal of Urology, Schroeck et al. state that the five nationally endorsed RAND and PCPI measures that could be assessed in Medicare claims to ensure a broad view of quality of care are:

    (1) The proportion of patients seen by a urologist and a radiation oncologist between diagnosis and start of treatment (RAND process measure)
    (2) The proportion of patients with low-risk cancer avoiding receipt of a non-indicated bone scan (PCPI process measure endorsed by NQF)
    (3) The proportion of patients with high-risk cancer receiving adjuvant ADT while undergoing radiotherapy (PCPI process measure endorsed by NQF)
    (4) The proportion of patients treated by a high volume provider (RAND structure measure)
    (5) The proportion of patients having at least two follow-up visits with a treating radiation oncologist or urologist (RAND process measure)

  6. Thanks for doing the additional research. I’m trying to get my head around how these “standards” relate to their measures of outcome.

    Couple of thoughts:

    (1) I’m not sure the standards and the outcomes are totally independent — e.g., while more ADT for high-risk men constitutes “best care,” ADT can exacerbate ED.
    (2) Their results are not that different from the accepted 35% overall rate of recurrence — best care, no best care, type of treatment, etc., etc.
    (3) Procedures for both incontinence and ED are a pretty extreme outcome to measure by.

    Overall, the hypothesis is a good one to test — just not sure how good a protocol this was to test it!

  7. Rick:

    I think that one of the points that Dr. Schroeck and his colleagues are trying to make is that the “standards” for “best care” defined to date have, in fact, very little to do with whether “best care” is actually being delivered. This leads to the very reasonable question of how “best care” should really be defined — with a strong emphasis on what that should mean for the patients.

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