title: Compliance with guidelines for patients with bladder cancer: variation in the delivery of care.
abstract: BACKGROUND
  Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. In the current study, the authors sought to characterize practice patterns in patients with high-grade non-muscle-invasive bladder cancer in relation to established guidelines.
  
  
  METHODS
  Surveillance, Epidemiology and End Results (SEER)-Medicare-linked data were used to identify subjects diagnosed with high-grade non-muscle-invasive bladder cancer between 1992 and 2002 who survived at least 2 years without undergoing definitive treatment (n = 4545). The authors used mixed-effects modeling to estimate the association and partitioned variation of patient sociodemographic, tumor, and provider characteristics with compliance measures.
  
  
  RESULTS
  Of the 4545 subjects analyzed, only 1 received all the recommended measures. Approximately 42% of physicians have not performed at least 1 cystoscopy, 1 cytology, and 1 instillation of immunotherapy for a single patient nested within their practice during the initial 2-year period after diagnosis. After 1997, only use of radiographic imaging (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.03-1.37) and instillation of immunotherapy (OR, 1.67; 95% CI, 1.39-2.01) were found to be significantly increased. Surgeon-attributable variation for individual guideline measures (cystoscopy, 25%; cytology, 59%; radiographic imaging, 10%; intravesical chemotherapy, 45%; and intravesical immunotherapy, 26%) contributes to this low compliance rate.
  
  
  CONCLUSIONS
  There is marked underuse of guideline-recommended care in this potentially curable cohort. Unexplained provider-level factors significantly contribute to this low compliance rate. Future studies that identify barriers and modulators of provider-level adoption of guidelines are critical to improving care for patients with bladder cancer.
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA. kchamie@mednet.ucla.edu
authors.forename: Karim
authors.initials: K
authors.lastname: Chamie
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Saigal
authors.forename: Julie
authors.initials: J
authors.lastname: Lai
authors.forename: Jan M
authors.initials: JM
authors.lastname: Hanley
authors.forename: Claude M
authors.initials: CM
authors.lastname: Setodji
authors.forename: Badrinath R
authors.initials: BR
authors.lastname: Konety
authors.forename: Mark S
authors.initials: MS
authors.lastname: Litwin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008297:Male; D001749:Urinary Bladder Neoplasms / Q000628:therapy*