title: Quality of care in patients with bladder cancer: a case report?
abstract: BACKGROUND
  Although there is level I evidence demonstrating the superiority of intravesical therapy in patients with bladder cancer, surveillance strategies are primarily founded on expert opinion. The authors examined compliance with surveillance and treatment strategies and the pursuant impact on survival in patients with high-grade disease.
  
  
  METHODS
  Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors identified subjects with a diagnosis of high-grade, non-muscle-invasive disease between 1992 and 2002 who survived 2 years and did not undergo definitive treatment during that time. Nonlinear mixed-effects regression analyses was used to examine compliance with surveillance and treatment strategies. After adjusting for confounders using a propensity score-weighted approach, the authors determined whether individual and comprehensive strategies during the initial 2 years after diagnosis were associated with survival after 2 years.
  
  
  RESULTS
  Of 4790 subjects, only 1 received all the recommended measures. Although mean utilization for most measures significantly increased after 1997, only compliance with an induction course of bacillus Calmette-Guerin (BCG) increased (13% to 20%; P < .001). On multivariate analysis, compliance with ≥ 4 cystoscopies, ≥ 4 cytologies, and BCG instillation was found to be lower among octogenarians and higher among those with undifferentiated, Tis, and T1 tumors, and among those individuals diagnosed after 1997. Subjects compliant with these measures had a lower hazard of mortality (hazard ratio, 0.41; 95% confidence interval, 0.18-0.93) than those who received < 4 cystoscopies, < 4 cytologies, and no BCG.
  
  
  CONCLUSIONS
  There was a statistically significant survival advantage found among those who received at least half of the recommended care. Improving compliance with these process-of-care measures via systematic quality improvement initiatives serves as the primary target to meliorate bladder cancer care.
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California 90024, 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; D001500:BCG Vaccine / Q000008:administration & dosage; D002295:Carcinoma, Transitional Cell / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D015331:Cohort Studies; D003558:Cystoscopy / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data; D018426:SEER Program; D001749:Urinary Bladder Neoplasms / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*
chemical_list: D001500:BCG Vaccine