AUA QI Summit 2017: Urologist-Led Success Stories in Stewardship of Imaging for Prostate Cancer

Linthicum, Maryland ( Dr. Jim Montie from the University of Michigan provided an excellent summary of the Michigan Urological Surgery Improvement Collaborative (MUSIC) initiative for imaging stewardship for prostate cancer. MUSIC is collaborative across the state of Michigan that aims to improve the quality and cost-efficiency of care for men with prostate cancer, with recent initiatives directed at patients with kidney stones and small renal masses. One of the key principles of the collaborative is a non-competitive platform, without individual practices using data to demonstrate improved outcomes by comparison to other practices in the state. The MUSIC prostate cancer initiative collects ~150 variables for each patient, with trained data abstracters at each practice site and the headquarters at the University of Michigan. There are currently 261 urologists (among 44 practices) participating in the collaborative, representing 90% of urologists in the state – 42,000 patients are currently listed in the registry.

One of the first projects for the MUSIC registry was appropriate imaging, specifically bone and CT imaging in low-risk prostate cancer patients (also an AUA Choosing Wisely campaign initiative). Encouragingly, they found that there was in fact appropriately little use of these diagnostic studies in low-risk patients [1], allowing the collaborative to report these findings to their practices and at meetings. However, in the intermediate-risk group, there were very few positive imaging studies according to Dr. Montie. Based on review of their cases in the registry, as well as the literature, the MUSIC Imaging Appropriateness criteria for prostate cancer was developed:

• Order a bone scan if: (i) PSA >20 ng/mL, OR (ii) Gleason score ≥8 disease
• Order a CT scan if: (i) PSA > 20 ng/mL, OR (ii) Gleason score ≥8 disease, OR (iii) ≥cT3 disease

The goals of this initiative were to perform imaging in ≥95% of patients meeting criteria, while not performing imaging in <10% of patients not fitting the appropriate criteria. To assess this initiative, baseline rates of radiographic staging were established in 2012-2013, interventions were employed in 2014 (highlighting Choosing Wisely initiatives, clinical slide presentations/videos, site visits, repetitive feedback, etc), and imaging utilization was remeasured in 2015. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after intervention, as did the use of CT scan imaging (14.7% at baseline to 7.7% after intervention) [2]. According to Dr. Montie, changing imaging behavior is likely “low hanging fruit” and easier than other topics such as surgical technique, treatment appropriateness, etc, but even these initiatives require more than just data feedback to obtain optimal results.

A subsequent initiative of the MUSIC collaborative was to assess appropriateness of prostate MRI. Dr. Montie highlights that there is great potential based on results of centers of excellence, however there is uncertainty with regards to how these results can be translated to a population-level. In the MUSIC registry, they noticed a dramatic increase in the use of MRI in 2016, however the data collection was severely lacking and urologists knew they often could not trust the quality of the MRI they were receiving. The prostate MRI goals in MUSIC are to provide an infrastructure for ensuring and demonstrating high quality prostate MRI and fusion biopsy by:

(i) Validating the registry to provide reliable data
    a. Right equipment – 1.5 of 3T body coil or 1.5T endorectal coil
    b. Optimal technique – mpMRI images
    c. Consistent interpretation – PI-RADS v2
    d. High quality care – distribution of PI-RADS scores

(ii) Evaluating MRI technical aspects and radiology/pathology agreement

(iii) Provide feedback and reporting mechanisms
     a. MRI fusion biopsy scorecard

(iv) Implement quality assurance activities

Dr. Montie concluded by remarking that imaging in the MUSIC collaborative has had one success with evaluating appropriate use of bone scan and CT imaging in prostate cancer, and he notes that the jury is still out on assessing/improving prostate MRI within the collaborative.

Speaker: Jim Montie, University of Michigan, Ann Arbor, MI, USA

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the AUA Quality Improvement Summit - October 21, 2017- Linthicum, Maryland

1. Ross I, et al. MUSIC: Patterns of care in the radiographic staging of men with newly diagnosed low risk prostate cancer. J Urol 2015;193(4):1159-1162.
2. Hurley P, et al. A Statewide Intervention improves appropriate imaging in localized prostate cancer. J Urol 2017;197(5):1222-1228.