Introduction:

The diagnosis and management of non-muscle invasive (NMIBC) bladder cancer relies heavily upon high quality transurethral resection, re-resection when indicated, and appropriate use of intravesical therapy; however, there are known issues in achieving excellence across these domains that may impact patient outcomes. We sought to characterize baseline performance across various bladder cancer quality measures and to evaluate predictors of variation in performance as a basis for future quality improvement interventions.  

Methods:

With electronic medical record data from across our health system comprised of over 70 credentialed urologists and 9 acute care hospitals, we identified all transurethral resection of bladder tumor procedures (TURBT) performed from 9/2018 – 9/2019. Manual chart abstraction was used to create a clinicopathologic database of procedural findings and outcomes. We evaluated surgeon-specific performance across three NMIBC quality measures (detrusor sampling on TURBT, re-resection for high-grade (HG) Ta/T1 disease within 8 weeks, and post-operative intravesical chemotherapy use). Multivariable logistic regression models were fit to evaluate the relationship between detrusor sampling, clinicopathologic features, and surgeon. 

Results:

During the study period, 343 TURBTs were performed in 295 patients for urothelial carcinoma by 21 surgeons.Among these procedures, detrusor muscle was sampled in 71.1% (244/343). Figure 1a displays regression results evaluating the relationship between clinicopathologic parameters and detrusor muscle sampling. After adjusting for these factors significant variation in surgeon-specific rates of sampling detrusor muscle remained (Figure 1b). Of these TURBTs, the highest stage present was 7% (24/343) CIS only, 49.9% (171/343) Ta, 32.4% (111/343) T1, and 10.8% (37/343) T2 or higher with 32.4% being low grade and 67.6% high grade. Re-resection was performed for 44.8% (64/143) with HG Ta or T1 disease. By stage, re-resection occurred 30.3% (17/56) in HG Ta, and 54% (47/87) in HG T1. The surgeon-specific rate of re-resection for HG Ta/T1 patients varied from 0 to 100%, p=0.04. Post-operative intravesical chemotherapy was used for 19.5% (67/343) of resections. 

Conclusion:

We demonstrate significant surgeon-specific variability in three TURBT quality measures across a large integrated health system. This presents an opportunity for quality improvement to reduce surgeon-specific variation and improve outcomes for patients with NMIBC. 

Funding: N/A