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

描述(申请人提供)：尿中有血，或“血尿”，可能预示着泌尿系统恶性肿瘤的存在，如膀胱癌或肾癌；良性泌尿系统疾病，如肾结石(肾结石)，尿路感染；或内在肾脏疾病，如肾小球肾炎。对血尿患者的正确评估对于确定每10人中就有1人可能患有危及生命的恶性肿瘤或其他可治疗疾病至关重要。这些疾病中最主要的是膀胱癌，因为它的发病率和致命性很高。美国泌尿外科协会(AUA)和国家癌症合作网络(NCCN)的指南呼吁使用办公室膀胱镜检查(膀胱镜检查)对怀疑患有尿路上皮癌的人进行评估，以排除BC，在许多情况下，还要求对肾脏和输尿管进行成像研究，以排除其他恶性肿瘤。有一些证据表明，对BC患者的监测指南没有得到充分遵守，但对于那些被怀疑窝藏BC的人的初步评估，证据方面存在差距。延迟或不完整的评估表明对已公布的指南的遵从性较差，并可能导致次优的BC结果。事实上，一种尚未得到检验的理论是，遵循评估指南的种族差异可以解释卑诗省的种族悖论：尽管卑诗省在白人中更常见，但非裔美国人患者患有更高阶段的疾病，并有更高的疾病特异性死亡率。我们提出了几种方法来确定目前对血尿患者的评估质量，在及时和完整的血尿评估中识别种族差异，并确定这种差异的潜在原因。首先，我们将广泛研究联邦医疗保险的数据集，以确定血尿患者使用膀胱镜和成像的频率，并调查在全国范围内使用它们是否存在种族差异。其次，我们将使用美国东南部超过86,000名经济困难和种族多样化的前瞻性队列(南方社区队列研究)，以确定在及时和完整的血尿检查中可能存在种族差异的因素，如社会经济地位、教育程度、医疗保健可获得性指标。剩下的无法解释的差异可能是初级保健提供者中的教育干预所致。这项拟议研究的最终目的是确定血尿患者护理质量方面的差距，这将通过我们参与的多中心质量协作，成为计划中的干预性研究的目标。

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.