To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA).
Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (i. e. low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or two years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression.
Overuse occurred in 75% of patients (852/1,135) - with an excess of 1,846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (OR 0.49, 95% CI: 0.28, 0.85 unlisted race vs. White), having two comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs. no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs. 2011 and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs. 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (i.e. intermediate-risk), overuse would have still occurred in 45% of patients.
Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data.
Urology. 2019 May 27 [Epub ahead of print]
David S Han, Kristine E Lynch, Ji Won Chang, Brenda Sirovich, Douglas J Robertson, Amanda R Swanton, John D Seigne, Philip P Goodney, Florian R Schroeck
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH. Electronic address: ., VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT. Electronic address: ., VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT. Electronic address: ., The White River Junction VA Medical Center, White River Junction, VT. Electronic address: ., The White River Junction VA Medical Center, White River Junction, VT. Electronic address: ., Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: ., Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: ., The White River Junction VA Medical Center, White River Junction, VT. Electronic address: ., The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH; The White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: .