Quality indicators in the management of bladder cancer: A modified Delphi study

doi:10.1016/j.urolonc.2016.12.003

Urologic Oncology: Seminars and Original Investigations

Volume 35, Issue 6, June 2017, Pages 328-334

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https://doi.org/10.1016/j.urolonc.2016.12.003 Get rights and content

Highlights

•
Nonadherence to best practices leads to marked variations in bladder cancer care.
•
We present 60 quality indicators that can quantify adherence to best practices.
•
Structure and process indicators that predict for quality outcomes are presented.
•
Indicators span several disciplines and phases of the cancer care continuum.

Abstract

Background

Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement.

Objective

To produce an evidence- and consensus-based list of QIs for the management of bladder cancer.

Methods

A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed.

Results

A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed.

Conclusions

This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.

Introduction

Bladder cancer is the ninth most common cancer worldwide [1], and the fifth most common cancer in Canada [2]. It includes a wide spectrum of disease from low-risk non–muscle-invasive tumors to highly aggressive, and often lethal, muscle-invasive tumors. Accordingly, the management of bladder cancer is complex and covers a broad range of interventions.

Despite advances in diagnosis and treatment modalities, only a moderate improvement in cancer-specific survival has been observed over the past 2 decades [3]. Furthermore, population-based data have shown lower patient survival than that of clinical trials or academic centers [4]. The reason for this survival discrepancy is multifactorial ranging from a lack of proper health care facilities to nonadherence to urological guidelines [5], [6]. Nonadherence leads to marked variations in care with several studies showing a link to poorer outcomes [5], [7].

In countries where care facilities and availability of treatment are less likely contributors to poor patient outcomes, standardized quality-of-care assessment can serve to track performance and subsequent effect on clinical outcomes across the health care system [8]. To that end, the objective of this study was to produce an evidence- and consensus-based list of quality indicators (QIs) spanning the bladder cancer care continuum with input from a multidisciplinary expert panel. The QIs can be used to quantify adherence to best practices and provide data for benchmarking and quality improvement. It is our hope that performance measurement against common QIs will encourage the advancement of practice standards, promote performance comparison across jurisdictions in efforts to improve care, and stimulate sharing of best practices. The ultimate goal is to improve clinical outcomes of patients with bladder cancer.

Section snippets

Material and methods

QIs were developed using a modified Delphi approach. The Delphi method has been used in similar studies and involves iterative rounds with controlled feedback to gain consensus from a group of experts in a systematic manner [9], [10]. The modification involves an in-person meeting during the consensus process; however, owing to logistical reasons, a video-conference was held instead. In short, a literature review resulted in a list of evidence-based QIs that were compiled into a candidate

Results

The expert panel was composed of 27 members: 4 medical oncologists, 2 radiation oncologists, 1 genitourinary pathologist, and 20 urologic oncologists. All nominated members participated in the study.

A total of 42 relevant records were retrieved from the literature search. From review of these records, 52 candidate indicators were extracted and organized as follows: 5 for diagnosis, 8 for staging, 19 for treatment, 4 for prophylactic measures, 2 for organizational process, 6 for outcomes, 2 for

Discussion

Bladder cancer is a heterogeneous disease that requires care across many disciplines along the care continuum from diagnosis to palliation. Despite progress in treatment, survival in patients with bladder cancer has only moderately improved. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care and a possible link to inferior outcomes. In this study, an evidence- and consensus-based list of QIs for the management of bladder

Conclusions

Discrepancies in survival outcomes have been observed in bladder cancer and may be owing to nonadherence to best practices. Given the need for standard QIs to assess adherence to best practice, this is the first study to comprehensively produce a list of QIs using a modified Delphi method that incorporated evidence from existing literature as well as consensus among an expert group of clinicians. A total of 60 QIs representing structure, process, and outcome measures in bladder cancer

Acknowledgments

We would like to thank Bladder Cancer Canada for funding this work. The funding organization had no involvement in the study design, implementation, or writing of the manuscript.

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Cited by (22)

Quality Indicators in the Clinical Specialty of Urology: A Systematic Review
2023, European Urology Focus
Citation Excerpt :
Regarding domain II (stakeholder involvement), most QI sets did not meet the requirements for participation by having all relevant health care professionals: only 22% (13/57) met the requirements [16,25,32,36,38,40,46,52,54,58,61,63,67] and only 33% (19/57) had clear statements that participants were involved in all rounds of the development process [23,25,27,32,36,38–40,46,47,52,54,57,58,61–63,66,67]. Regarding domain III, 67% (38/57) of the QI sets scored highly on the use of evidence–based guidelines and articles published in peer-reviewed scientific journals when developing QIs [16,18–20,25–32,34,35,38–41,45–47,49–54,56–58,60–64,66,67,69], but most QI sets did not score highly on the use of systematic methods for searching for scientific evidence or on critical appraisal of scientific evidence, with only 28% (16/57) [19,27,29,32,39,40,49,52,54,57,58,61,63,66,67,69] and 25% (14/57) [16,19,27,29,32,46,52,54,58,61–63,66,67] of the QI sets, respectively, fulfilling these criteria. Finally, regarding domain IV, most QI sets clearly defined the target populations, with 95% (54/57) fulfilling this criterion [16,17,19–32,34–54,56–72].
In health care, monitoring of quality indicators (QIs) in general urology remains underdeveloped in comparison to other clinical specialties.
To identify, synthesise, and appraise QIs that monitor in-hospital care for urology patients.
This systematic review included peer-reviewed articles identified via Embase, MEDLINE, Web of Science, CINAHL, Global Health, Google Scholar, and grey literature from 2000 to February 19, 2021. The review was carried out under the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used the Appraisal of Indicators through Research and Evaluation (AIRE) tool for quality assessment.
A total of 5111 articles and 62 government agencies were screened for QI sets. There were a total of 57 QI sets included for analysis. Most QIs focused on uro-oncology, with prostate, bladder, and testicular cancers the most represented. The most common QIs were surgical QIs in uro-oncology (positive surgical margin, surgical volume), whereas in non-oncology the QIs most frequently reported were for treatment and diagnosis. Out of 61 articles, only four scored a total of ≥50% on the AIRE tool across four domains. Aside from QIs developed in uro-oncology, general urological QIs are underdeveloped and of poor methodological quality and most lack testing for both content validity and reliability.
There is an urgent need for the development of methodologically robust QIs in the clinical specialty of general urology for patients to enable standardised quality of care monitoring and to improve patient outcomes.
We investigated a range of quality indicators (QIs) that provide health care professionals with feedback on the quality of their care for patients with general urological diseases. We found that aside from urological cancers, there is a lack of QIs for general urology. Hence, there is an urgent need for the development of robust and disease-specific QIs in general urology.
Public reporting of outcomes in radiation oncology: the National Prostate Cancer Audit
2021, The Lancet Oncology
Citation Excerpt :
Globally, there has been sparse public reporting of outcomes of either efficacy (eg, local control and survival) or toxicity following radiotherapy, and if outcomes reporting is available it almost exclusively considers structural or process indicators (eg, the availability of intensity-modulated radiotherapy and the use of particular dose fractionation radiotherapy regimens).13,14 Benchmarking activities against fractionation radiotherapy process measures—such as, adherence to dosimetric criteria, use of image guided radiotherapy (IGRT), and treatment margins—have been done with surveys and national quality improvement initiatives (eg, quality research in radiation oncology).15–32 However, these measures do not necessarily reflect the actual quality of care delivered.33
The public reporting of patient outcomes is crucial for quality improvement and informing patient choice. However, outcome reporting in radiotherapy, despite being a major component of cancer control, is extremely sparse globally. Public reporting has many challenges, including difficulties in defining meaningful measures of treatment quality, limitations in data infrastructure, and fragmented health insurance schemes. The National Prostate Cancer Audit (NPCA), done in the England and Wales National Health Service (NHS), shows that it is feasible to develop outcome indicators for radiotherapy treatment, including patient-reported outcomes. The NPCA provides a transparent mechanism for comparing the performance of all NHS providers, with results accessible to patients, providers, and policy makers. Using the NPCA as a case study, we discuss the development of a radiotherapy-outcomes reporting programme, its impact and future potential, and the challenges and opportunities to develop this approach across other tumour types and in different health systems.
Enhanced Quality and Effectiveness of Transurethral Resection of Bladder Tumour in Non–muscle-invasive Bladder Cancer: A Multicentre Real-world Experience from Scotland's Quality Performance Indicators Programme[Formula presented]
2020, European Urology
Clinical outcomes from non–muscle-invasive bladder cancer (NMIBC) are partly determined by the quality of initial interventions. To improve and standardise treatment for cancer, Scotland implemented a national Quality Performance Indicator (QPI) programme for bladder cancer (BC).
To evaluate compliance with specific quality indicators (QIs) related to transurethral resection of bladder tumour (TURBT) and to understand clinical outcomes from NMIBC following the introduction of the QPI programme.
Within a robust governance framework, 12 mandatory evidence-based QPIs were implemented nationally in April 2014. We report prospectively collected data for all new BC patients (between April 2014 and March 2017). We include follow-up data for 2689 patients.
The TURBT-related QPIs were (1) using a bladder diagram, (2) single post-TURBT instillation of mitomycin C (SPI-MMC), (3) detrusor muscle (DM) in the specimen, and (4) early re-TURBT in high-risk NMIBC.
We measured compliance with these QPIs and (1) recurrence rate at first follow-up cystoscopy (RRFFC), (2) rates of residual cancer, and (3) pT2 cancer at re-TURBT. Associations between QPI compliance, tumour features, and outcomes were assessed with multivariable logistic regression models.
Among 4246 new BC patients, SPI-MMC was used in 67% (2029/3023) NMIBC patients. In 1860 NMIBC patients undergoing TURBT, RRFFC, rate of residual cancer, and rate of pT2 at re-TURBT were 13% (116/888), 33% (212/653), and 2.9% (19/653), respectively. SPI-MMC was associated with lower RRFFC, independent of all variables including hospital volume and surgeon. Presence of DM in the specimen halved the likelihood of residual disease in pT1 cancers. The main limitation is the lack of a pre-QPI introduction cohort for comparison.
The implementation of a QI programme in Scotland appears to facilitate high-quality TURBT, which in a real-world setting is associated with low early recurrence/residual cancer and accurate pathological staging.
Following the first 3 yr of implementing a novel Quality Performance Indicator (QPI) programme in Scotland, we assessed compliance and outcomes in non–muscle-invasive bladder cancer. Evaluating over 4000 new bladder cancer patients, we found that the QPI programme was associated with low recurrence and accurate staging following the initial transurethral resection of bladder tumour.
Quality Indicators for Bladder Cancer Services: A Collaborative Review[Formula presented]
2020, European Urology
There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer.
To evaluate the optimal management of bladder cancer and propose quality indicators (QIs).
A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non–muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs.
For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care.
We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer.
After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.
EDITORIAL COMMENT
2019, Urology
Key elements for the education and counselling of patients treated with oral anticancer drugs
2019, European Journal of Oncology Nursing
Citation Excerpt :
This set can now be used by oncology teams to build clinical pathways or enhance care processes. In oncology, various Delphi-studies have been performed to develop QI (disease-specific, treatment specific, palliative care etc.) (Chung et al., 2008; van Overveld et al., 2017; Khare et al., 2017; Best et al., 2017; Nakazawa et al., 2016; Williams et al., 2018). Similarly to the development and review process described in these studies, our initial list of KE on OACD was based upon existing literature, which renders its international relevance.
The process of education and counselling of patients treated with oral anticancer drugs, aimed to achieve adequate self-management, involves different stakeholders (i.e. physicians, oncology nurses, pharmacists) from primary and secondary care. However, currently no guiding principles exist on how to organize and perform education and counselling for these patients. Therefore, the purpose of this study was to develop and build consensus on key elements for the education and counselling in patients on oral anticancer drugs.
A multi-method approach combining a literature search, semi-structured interviews with patients and healthcare professionals, and input from experts were used to develop an initial list of key elements. Subsequently, consensus was built in a two-round Delphi-study, involving patients and healthcare professionals from primary and secondary care. Key elements were retained if at least 80% of respondents in all groups considered the element as important or if in at least one group 90% consensus was reached.
The initial list contained 110 key elements, divided in 7 themes: coordination of care, patient contacts: style and content, medication counselling at the start of the treatment and during follow-up, psychosocial support, and involvement of family and friends. After the first Delphi round, 80% consensus was reached for 23 elements; 6 new key elements were added. After the second round, 80% consensus was reached for 51 out of 116 elements; 31 elements were added following the 90%-rule, yielding a list of 82 elements.
The final list of 82 key elements, obtained in this study, could be used to develop clinical pathways that guide adequate education and counselling of patients on oral anticancer drugs. Due to the open description, the implementation of these elements can be adapted to the specific context and composition of the oncology team.

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Original articleQuality indicators in the management of bladder cancer: A modified Delphi study

Highlights

Abstract

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Acknowledgments

Clin Genitourin Cancer

Int J Radiat Oncol Biol Phys

Ann Thorac Surg

Eur Urol

Urology

Urol Oncol

Eur Urol

Action on bladder cancer. Current perspectives in bladder cancer management

Int J Clin Pract

Canadian cancer statistics 2015

Cancer statistics, 2016

CA Cancer J Clin

Recommendations for the improvement of bladder cancer quality of care in Canada: a consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

Can Urol Assoc J

Quality of care in patients with bladder cancer: a case report?

Cancer

Understanding bladder cancer death: tumor biology versus physician practice

Cancer

Original article
Quality indicators in the management of bladder cancer: A modified Delphi study