title: Identifying better practices for early-stage bladder cancer.
abstract: BACKGROUND
  Practice guidelines for nonmuscle invasive (ie, early stage) bladder cancer are ambiguous, resulting in substantial practice variation without a clear patient benefit.
  
  
  OBJECTIVE
  To profile urologist practice styles and empirically derive better patterns of use for common bladder cancer services.
  
  
  METHODS
  Retrospective cohort.
  
  
  METHODS
  Elderly patients diagnosed with early-stage bladder cancer between January 1, 1992 and December 31, 2005 in Surveillance, Epidemiology, and End Results-Medicare linked data.
  
  
  METHODS
  After identifying each patient's treating urologist, we fit multilevel models to obtain reliability-adjusted measures of the urologist's use of surveillance-associated (cytoscopy and urine cytology) and treatment-associated (intravesical therapy) services during the 2 years after diagnosis. We then used the Cox proportional hazards regression to evaluate the association between a patient's risk of bladder cancer death and his urologist's frequency of service use.
  
  
  RESULTS
  Regardless of disease severity, no measurable patient benefit was associated with care delivery by a urologist residing in the highest quartile for cystoscopy or intravescial therapy use. However, maximal intensity of cytology use was associated with a lower risk of bladder cancer death for patients with high-grade stage Ta/Tis (highest vs. lowest intensity quartiles: hazard ratio, 0.73; 95% confidence interval, 0.56-0.95) and stage T1 disease (hazard ratio, 0.59; 95% confidence interval, 0.49-0.72).
  
  
  CONCLUSIONS
  Our analysis supports a more tailored approach to patients with early-stage bladder cancer. Further, it serves as an example for applying observational data to characterize better clinical practices in the absence of experimental studies.
authors: Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.
authors: John Malcolm
authors: JM
authors: Hollingsworth
authors: Yun S
authors: YS
authors: Zhang
authors: David C
authors: DC
authors: Miller
authors: Ted A
authors: TA
authors: Skolarus
authors: David P
authors: DP
authors: Wood
authors: Cheryl T
authors: CT
authors: Lee
authors: James E
authors: JE
authors: Montie
authors: Brent K
authors: BK
authors: Hollenbeck
mesh_terms: D000283:Administration, Intravesical; D000368:Aged; D000369:Aged, 80 and over; D003558:Cystoscopy; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D012720:Severity of Illness Index; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000628:therapy*