Trends and Disparities in Bladder Cancer Treatment

描述（由申请人提供）：膀胱癌是美国男性中第四大常见癌症，女性中第十二大常见癌症。它也是治疗每位患者最昂贵的癌症。据报告，膀胱癌复发、进展和生存率存在患者性别、人种/种族和年龄差异。质量差距和治疗不平等可能导致结果差异。与遗传或解剖特征等不可改变的因素相比，治疗不公平是一个可以改变的因素。因此，我们的研究将确定膀胱癌护理的质量差距，并阐明治疗差异，以告知未来的质量改进干预措施。膀胱癌的有效治疗是存在的，但在诊断的所有阶段可能未得到充分利用。治疗包括在初次经尿道膀胱肿瘤切除术后24小时内使用膀胱内化疗和使用根治性膀胱癌的新辅助化疗。据估计，在肿瘤切除术后未能立即使用膀胱内化疗（从而防止肿瘤复发）每年使美国损失约2000万美元。因此，增加指南一致性护理的使用有可能改善患者结局并减少差异，同时降低医疗保健成本。已观察到患者组之间的治疗差异，但结果并不一致。大多数研究没有全面评估膀胱癌护理，而是集中在一些治疗实践上，现有的研究也可能没有反映当代的治疗模式。我们建议全面评估膀胱癌治疗的整体和患者的性别，种族/民族，年龄（目标1）和日历时间（目标2），以确定质量差距和治疗不公平。我们的研究团队包括一名流行病学家，健康经济学家，两名泌尿科医生和一名生物统计学家/分析师。我们将在Kaiser Permanente Southern加州（KPSC）的大型、多样化、以社区为基础的会员中，对2001年至2013年期间诊断为膀胱癌的所有21岁或以上患者进行回顾性队列研究。我们将使用高质量的癌症登记和丰富的电子健康记录来评估9,000多名膀胱癌患者的护理。治疗实践将被编码为是/否，以表明对既定治疗建议的依从性。将使用多变量逻辑回归模型评价患者组间治疗依从性的差异。将采用Poisson回归或自回归综合移动平均（ARIMA）模型评价随时间推移的治疗实践。这些目标的完成将按患者性别、种族/民族、年龄和日历时间对各种膀胱癌治疗建议的推荐和实际治疗实践进行详细比较。未来质量 改进工作可在这些结果的基础上，以最有可能缩小差距、改善护理服务和患者结果的治疗差距为目标。

DESCRIPTION (provided by applicant): Bladder cancer is the fourth most common cancer among males and the twelfth most common cancer among females in the United States. It is also the most expensive cancer to treat on a per patient basis. Disparities in bladder cancer recurrence, progression and survival have been reported by patient sex, race/ethnicity, and age. Quality gaps and treatment inequity may contribute to outcomes disparities. In contrast to immutable factors such as genetic or anatomic characteristics, treatment inequity represents a modifiable factor. Thus, our study will identify quality gaps in bladder cancer care and elucidate treatment disparities in order to inform future quality improvement interventions. Effective treatments for bladder cancer exist but may be underutilized at all stages of diagnosis. Treatments include the use of intravesical chemotherapy within 24 hours of the initial transurethral resection of bladder tumor and use of neoadjuvant chemotherapy with radical cystectomy. Failure to use intravesical chemotherapy immediately post-tumor resection (and thus to prevent tumor recurrences) has been estimated to cost the United States around $20 million annually. Increasing the use of guideline-consistent care thus has the potential to improve patient outcomes and reduce disparities while also decreasing healthcare costs. Treatment disparities across patients group have been observed, although findings have not been consistent. Most studies have not comprehensively evaluated bladder cancer care but instead have focused on a few treatment practices, and existing research also may not reflect contemporary treatment patterns. We propose to comprehensively evaluate bladder cancer treatment overall and by patient sex, race/ethnicity, age (Aim 1) and calendar time (Aim 2) in order to identify quality gaps and treatment inequities. Our research team includes an epidemiologist, health economist, two urologists, and a biostatistician/analyst. We will create a retrospective cohort of all patients age 21 years or older diagnosed with bladder cancer during 2001- 2013 within the large, diverse, community-based membership of Kaiser Permanente Southern California (KPSC). We will use our high-quality cancer registry and rich electronic health record to evaluate care among over 9,000 bladder cancer patients. Treatment practices will be coded as yes/no to indicate adherence to well-established treatment recommendations. Multivariable logistic regression models will be used to evaluate differences in treatment adherence across patients groups. Poisson regression or Auto-Regressive Integrated Moving Average (ARIMA) models will be employed to evaluate treatment practices over time. The completion of these aims will provide a detailed comparison of recommended and actual treatment practices by patient sex, race/ethnicity, age, and calendar time for a wide range of bladder cancer treatment recommendations. Future quality improvement efforts may build upon the results to target the treatment gaps with the greatest potential to reduce disparities and improve care delivery and patient outcomes.