AUA 2017: Building an active surveillance program for community practice 

Boston, MA (UroToday.com) This session discussed growing an active surveillance program in a large, community-based practice. Dr. Benjamin Lowentritt of Chesapeake Urology provided an overview of some of the challenges inherent to rolling out active surveillance protocols in this setting. The rationale for active surveillance is strong and based on level 1 evidence from recently published trials (e.g. ProtecT). Moreover, guideline statements from multiple organizations now preferentially recommend active surveillance in the setting of low risk prostate cancer. However, most active surveillance programs occur in the context of the academic medical center. While the concept doesn’t necessarily differ in the community, there are some gray areas which remain challenging to define. These are related to patient selection, patient adherence, variation in adoptions by physicians, risk management (i.e. is there exposure to litigation by not treating, and value-based care.

The goal of active surveillance programs in the community setting represents more than simply creating a pathway. Instead, it involves taking care of the patient, knowing one’s own data, implementing quality control, providing guidance for doctors adjusting to new paradigms, and giving patients an idea of what to expect. Compiling patient data is challenging. Active surveillance does not have a searchable diagnosis code and many community practices have multiple offices making the creating of a single database difficult. Finally, although active surveillance affords opportunities to show value, there is no alternative payment model or established PQRS/MIPS measures.

At this point, Dr. Shore offered his thoughts on current efforts by the large urology group practice association (LUGPA) relating to alternative payment models (APMs). CMS estimates that only 88 urologists would be qualified participants in advanced APMs in 2017 and only 5 urology practices will participate in the Oncology Care model. LUGPA is collaborating with various stakeholders to develop urology-specific APMs for localized prostate cancer and prostate biopsy. He made the point that CMS is interested in models that address appropriateness of treatments, not simply the costs of treatments

To gather data, Dr. Lowentritt noted that there is no single method. His group has created code, used a navigator, and engaged in third party search and occasional manual chart review. The overarching goal should be to understand all treatment trends. These data can be used to drive education. Specific attention should be paid to who qualifies for active surveillance and how are they monitored. Most guidelines offer minimal acceptable time intervals for PSA and biopsy; however gray areas remain and often one size does not fit all.

Currently the Chesapeake urology stratifies risk groups based largely on NCCN guidelines modified by patient factors. The monitoring plan is based on risk-stratification. Other components of the program include patient information packets, consent forms, guidance for when to come off active surveillance (PSAdt < 3 years, presence of primary Gleason pattern 4, increase volume of disease, and patient anxiety). Follow-up questionnaires seek to understand adherence and patient satisfaction.

Presented by: Neal Shore, MD and Benjamin Lowentritt, MD

Written By: Benjamin T. Ristau, MD, Fox Chase Cancer Center, Philadelphia, PA

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA
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