The Quality of Care in Evaluating Patients Suspected of Having Bladder Cancer

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DESCRIPTION (provided by applicant): The presence of blood in the urine, or "hematuria", may herald the presence of urologic malignancy such as bladder cancer or kidney cancer; benign urologic disease such as kidney stones (nephrolithiasis), urinary tract infection; or intrinsic renal disease, such as glomerulonephritis. The proper evaluation of patients with hematuria is essential to identify the 1 person in 10 who may have a life-threatening malignancy or other treatable condition. Chief among these conditions is bladder cancer (BC), because of its high incidence and lethality. Guidelines from the American Urological Associate (AUA) and the National Cancer Collaborative Network (NCCN) call for evaluation of persons presenting with suspicion for urothelial carcinoma using office cystoscopy (endoscopic evaluation of the bladder) to rule out BC and, in many instances, an imaging study of the kidneys and ureters to rule out other malignancies. There is some evidence of insufficient adherence to guidelines for surveillance of patients with BC, but there is a gap in the evidence with respect to the initial evaluation of those suspected of harboring BC. Delayed or incomplete evaluation indicates poor adherence to published guidelines, and could contribute to sub-optimal BC outcomes. In fact, one theory, which has yet to be tested, is that racial variation in adherence to evaluation guidelines could explain the racial paradox in BC: while BC is more common among Whites, African-American patients present with higher-stage disease, and have a higher likelihood of disease-specific mortality. We propose several approaches to determine the current quality of evaluation of patients with hematuria, to identify racial variation in the timely and complete evaluation of hematuria and to determine the underlying reasons for such variation. First, we will look broadly at the Medicare dataset to determine the frequency of use of cystoscopy and imaging for patients with hematuria, and investigate whether there are racial differences in their use on a national level. Second, we will use a well-characterized prospective cohort of over 86,000 economically disadvantaged and racially diverse persons in the Southeastern US (The Southern Community Cohort Study) in order to identify the factors that may underlie racial variation in the timely and complete workup of hematuria, such as socio-economic status, educational attainment, healthcare access indicators. The remaining unexplained variation may be amenable to educational interventions among primary care providers. The ultimate aim of the proposed study is to identify gaps in the quality of care for patients with hematuria, which will become targets in a planned interventional study through a multi-center quality collaborative in which we participate.