title: Defining the potential of neoadjuvant chemotherapy use as a quality indicator for bladder cancer care.
abstract: OBJECTIVE
  Despite known survival benefits, overall use of neoadjuvant chemotherapy before cystectomy is low, raising concerns about quality of care. However, not all patients undergoing cystectomy are eligible for this therapy. We establish the maximum proportion of patients expected to receive neoadjuvant chemotherapy if all those eligible had a consultation with medical oncology.
  
  
  METHODS
  From institutional data (January 2010 through December 2012) we identified 215 patients treated with radical cystectomy for bladder cancer. After excluding patients not eligible for neoadjuvant chemotherapy, we fit models assessing patient disease and health factors affecting referral to medical oncology and receipt of neoadjuvant chemotherapy. Expected use of chemotherapy was then determined for increasingly broad groups of patients treated with cystectomy after controlling for factors precluding the use of neoadjuvant chemotherapy.
  
  
  RESULTS
  Of the 215 patients identified 127 (59%) were eligible for neoadjuvant chemotherapy. After additional consideration of patient factors (patient refusal, health status and poor renal function), maximum receipt of neoadjuvant chemotherapy increased from 42% to 71% as more restrictive definitions for the eligible patient cohort were used.
  
  
  CONCLUSIONS
  Substantial variability exists in the proportion of patients eligible for neoadjuvant chemotherapy based on the population identified. While there is substantial underuse of neoadjuvant chemotherapy, the development of quality metrics for this essential therapy depends on correct identification of the cystectomy population being assessed. Even with referral of all appropriate patients for medical oncology evaluation, use of chemotherapy would likely not exceed 50% of patients in nationally representative cystectomy data.
authors: Division of Urology, Barnes Jewish Hospital/Washington University in St. Louis, School of Medicine, St. Louis, Missouri. Electronic address: vemanag@wudosis.wustl.edu.
authors: Goutham
authors: G
authors: Vemana
authors: Department of Urology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
authors: Kenneth G
authors: KG
authors: Nepple
authors: Division of Urology, Barnes Jewish Hospital/Washington University in St. Louis, School of Medicine, St. Louis, Missouri.
authors: Joel
authors: J
authors: Vetter
authors: Division of Urology, Barnes Jewish Hospital/Washington University in St. Louis, School of Medicine, St. Louis, Missouri.
authors: Gurdarshan
authors: G
authors: Sandhu
authors: Division of Urology, Barnes Jewish Hospital/Washington University in St. Louis, School of Medicine, St. Louis, Missouri.
authors: Seth A
authors: SA
authors: Strope
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D018579:Patient Selection; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy*
keywords: drug therapy; eligibility determination; health care; neoadjuvant therapy; quality indicators; urinary bladder neoplasms