title: Practice based collaboration to improve the use of immediate intravesical therapy after resection of nonmuscle invasive bladder cancer.
abstract: OBJECTIVE
  Perioperative instillation of intravesical chemotherapy after bladder tumor resection is supported by level I evidence showing a 30% decrease in tumor recurrence. However, studies of administrative data sets show poor use in practice.
  
  
  METHODS
  We prospectively evaluated the use of perioperative intravesical chemotherapy in a multipractice quality improvement collaborative. Cases were categorized as ideal for intravesical chemotherapy (1 or 2 papillary tumors, cTa/cT1 and completely resected) and nonideal. The reasons for not administering intravesical chemotherapy in ideal cases were classified as appropriate or modifiable. Before and after comparative feedback and educational interventions we calculated judicious use of intravesical chemotherapy (nonuse in nonideal cases plus use in ideal cases plus appropriate nonuse in ideal cases) and quality improvement potential (use in nonideal cases plus nonuse in ideal cases attributable to modifiable factors).
  
  
  RESULTS
  We accrued a total of 2,794 cases at the 5 sites in 22 months. The rate of use in ideal cases was 38% before and 34.8% after intervention (p=0.36), while use in nonideal cases decreased from 15% to 12% (p=0.08). Overall, intravesical chemotherapy was used judiciously in 83.0% to 85.7% of cases, while the remaining 14.3% to 17.0% represented quality improvement potential.
  
  
  CONCLUSIONS
  Judicious use of perioperative intravesical chemotherapy is relatively high in routine practice. Most instances of nonuse represent appropriate clinical judgment. Utilization did not change after quality improvement interventions, suggesting that there may a ceiling effect that makes it difficult to improve care that is high quality at baseline. Moreover, decreasing unnecessary use of an intervention may be easier than encouraging appropriate use of potentially toxic therapy.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee. Electronic address: dan.barocas@vanderbilt.edu.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Barocas
authors.forename: Alice
authors.initials: A
authors.lastname: Liu
authors.forename: Frank N
authors.initials: FN
authors.lastname: Burks
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Suh
authors.forename: Timothy G
authors.initials: TG
authors.lastname: Schuster
authors.forename: Timothy
authors.initials: T
authors.lastname: Bradford
authors.forename: Don A
authors.initials: DA
authors.lastname: Moylan
authors.forename: Peter M
authors.initials: PM
authors.lastname: Knapp
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Murtagh
authors.forename: David
authors.initials: D
authors.lastname: Morris
authors.forename: Rodney L
authors.initials: RL
authors.lastname: Dunn
authors.forename: James E
authors.initials: JE
authors.lastname: Montie
authors.forename: David C
authors.initials: DC
authors.lastname: Miller
mesh_terms: D000283:Administration, Intravesical; D003131:Combined Modality Therapy; D006801:Humans; D009361:Neoplasm Invasiveness; D011446:Prospective Studies; D058996:Quality Improvement; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery
keywords: BC; IVC; MMC; NMIBC; QI; QI potential; QIP; TURBT; administration; bladder cancer; drug therapy; intravesical; intravesical chemotherapy; mitomycin C; nonmuscle invasive BC; quality improvement; transurethral bladder tumor resection; urinary bladder; urinary bladder neoplasms