Practice-based collaboration to improve the use of immediate intravesical therapy after resection for non-muscle-invasive bladder cancer
Barocas DA, Liu A, Burks FN, Suh RS, Schuster TG, Bradford T, Moylan DA, Knapp PM, Murtagh DS, Morris D, Dunn RL, Montie JE, Miller DC. J Urol. 2013 Jun 17. pii: S0022-5347(13)04620-X. doi: 10.1016/j.juro.2013.06.025. [Epub ahead of print]

Source

Department of Urologic Surgery, Vanderbilt University, Nashville, TN.

Abstract

PURPOSE:

Perioperative instillation of intravesical chemotherapy (IVC) after bladder tumor resection is supported by level I evidence showing a 30% decrease in tumor recurrence. Yet studies of administrative datasets show poor utilization in practice.

MATERIALS AND METHODS:

We prospectively evaluated use of perioperative IVC in a multi-practice quality improvement collaborative. Cases were categorized as ideal for use of IVC (1-2 papillary tumors, cTa/cT1, completely resected) and non-ideal. The reasons for not administering IVC in ideal cases were classified as appropriate or modifiable. Before and after comparative feedback and educational interventions, we calculated 'judicious use,' of IVC (non-use in non-ideal cases + use in ideal cases + appropriate non-use in ideal cases) and 'quality improvement potential,' (QIP, use in non-ideal cases + non-use in ideal cases attributable to modifiable factors.) RESULTS: We accrued 2,794 cases in 5 sites over 22 months. Use in ideal cases was 38% before intervention and 34.8% after (p=0.36), while use in non-ideal cases decreased from 15% to 12% (p=0.08). Overall, IVC was used judiciously in 83.0-85.7% of cases, while the remaining 14.3-17.0% represented QIP.

CONCLUSIONS:

Judicious use of perioperative IVC is relatively high in routine practice. Most instances of non-use represent appropriate clinical judgment. Utilization did not change after QI interventions, suggesting that there may a 'ceiling effect,' wherein it is difficult to improve care that is high quality at baseline. Moreover, reducing unnecessary use of an intervention may be easier than encouraging appropriate use of potentially toxic therapy.