Presentation Authors: Daniel D Joyce*, Nashville, TN, Daniel J Lee, Philadelphia, PA, Cetin Demirdag, Kirk A Keegan, Daniel A Barocas, Nashville, TN
Introduction: In an effort to assess and improve quality of care, the Commission on Cancer (CoC) developed three evidence-based quality measures (QMs) for the treatment of muscle invasive bladder cancer (MIBC). These measures include timely administration of treatment; receipt of neoadjuvant or adjuvant chemotherapy; and lymphadenectomy at the time of cystectomy. In this study we assessed performance of these QMs prior to their CoC implementation, whether QMs were associated with overall survival (OS), and whether patient factors influenced the receipt of these QMs.
Methods: Using the National Cancer Database (NCDB) we identified all patients age 18-90 years old with MIBC (cT2-4N0M0) from 2004 to 2015. Compliance with QMs was recorded. Both univariate and multivariate analyses were utilized to assess the effect of QM compliance on OS as well as patient level predictors of compliance.
Results: A total of 46,502 patients were identified for analysis. Of these, 22,218 (47.8%) underwent radical or partial cystectomy, 5,282 (11.4%) received trimodal therapy, and 19,002 (40.9%) received no treatment. All three QMs were achieved in 44.9% of the surgical cohort and compliance was associated with improved 30-day (HR 0.32, p < 0.01), 90-day (HR 0.40, p < 0.01), and all-cause mortality (HR 0.82, p < 0.01) via univariate and multivariate analyses. Time < 90 days to trimodal therapy was achieved in 35.0% of patients and did not improve all-cause mortality (HR 0.93, p=0.07). In the surgical cohort, predictors of compliance with all 3 metrics included Medicaid (OR 1.26, p=0.05) or other governmental insurance (OR 1.61, p < 0.01), higher income (OR 1.27, p < 0.01), and living in a low-education zip code area (OR 1.15, p=0.02) >10 miles from the place of treatment (OR 1.38, p < 0.01). In the trimodal therapy cohort, age >74 years (OR 0.52, p < 0.01), rural residence (OR 0.81, p=0.01), and living in a low-education zip code area (OR 0.74, p=0.02) predicted lower likelihood of treatment within 90 days of diagnosis.
Conclusions: Compliance with the CoC QMs is associated with improved survival in patients with MIBC undergoing surgical management. Despite this benefit, achievement of all 3 metrics was observed in less than half of patients prior to QM implementation. By design, measurement of these QMs and subsequent implementation feedback to CoC member hospitals is expected to improve compliance and patient outcomes.