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

描述（由申请人提供）：尿液中存在血液或"血尿"可能预示着存在泌尿系统恶性肿瘤，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;或内源性肾病，如肾小球肾炎。对血尿患者进行适当的评估对于确定1/10的可能患有危及生命的恶性肿瘤或其他可治疗疾病的患者至关重要。这些疾病中最主要的是膀胱癌（BC），因为它的发病率和致死率很高。美国泌尿外科协会（AUA）和国家癌症协作网络（NCCN）的指南要求使用办公室膀胱镜检查（膀胱内窥镜评估）对疑似尿路上皮癌的患者进行评估，以排除BC，在许多情况下，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，对监测BC患者的指南的依从性不足，但在对那些怀疑患有BC的患者进行初步评估方面，证据存在差距。延迟或不完整的评价表明对公布的准则的遵守情况不佳，可能导致次优的业连成果。事实上，一个尚未得到验证的理论是，在遵守评估指南方面的种族差异可以解释BC中的种族悖论：虽然BC在白人中更常见，但非洲裔美国人患者的疾病分期更高，并且疾病特异性死亡率的可能性更高。我们提出了几种方法来确定目前的血尿患者的评价质量，以确定种族差异，及时和完整的血尿评价，并确定这种变化的根本原因。首先，我们将广泛地研究医疗保险数据集，以确定血尿患者使用膀胱镜检查和成像的频率，并调查在国家层面上是否存在种族差异。其次，我们将使用一个在美国东南部的86，000多名经济上处于不利地位和种族多样化的人的良好特征的前瞻性队列（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导致种族差异的因素，如社会经济地位，教育程度，医疗保健可及性指标。剩下的无法解释的变化可能是适合初级保健提供者之间的教育干预。拟议研究的最终目的是确定血尿患者护理质量的差距，通过我们参与的多中心质量合作，这将成为计划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.