Trends and Disparities in Bladder Cancer Treatment

描述(申请人提供)：膀胱癌在美国男性中排名第四，在女性中排名第十二。它也是每名患者治疗费用最高的癌症。患者性别、种族/民族和年龄在膀胱癌复发、进展和存活率方面的差异已有报道。质量差距和治疗不平等可能会导致结果差异。与遗传或解剖特征等不可改变的因素不同，待遇不平等是一个可改变的因素。因此，我们的研究将确定膀胱癌护理中的质量差距，并阐明治疗差异，以便为未来的质量改进干预措施提供信息。膀胱癌的有效治疗方法已经存在，但可能在诊断的所有阶段都未得到充分利用。治疗方法包括在初次经尿道膀胱肿瘤电切术后24小时内使用膀胱内化疗，以及在根治性膀胱切除术的基础上使用新辅助化疗。据估计，肿瘤切除后没有立即使用膀胱内化疗(从而防止肿瘤复发)每年给美国造成的损失约为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，减少差异，同时还降低医疗成本。已经观察到不同患者组之间的治疗差异，尽管结果并不一致。大多数研究没有全面评估膀胱癌的治疗，而是专注于少数治疗实践，现有的研究也可能没有反映当代的治疗模式。我们建议根据患者性别、种族/民族、年龄(目标1)和日历时间(目标2)对膀胱癌治疗进行全面综合评估，以确定质量差距和治疗不平等。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。我们将在南加州凯撒永久医院(KPSC)庞大的、多元化的、以社区为基础的会员中创建一个回顾队列，涵盖2001-2013年间所有被诊断为膀胱癌的21岁或以上患者。我们将利用我们高质量的癌症登记和丰富的电子健康记录来评估9000多名膀胱癌患者的护理。治疗实践将被编码为是/否，以表明遵守既定的治疗建议。多变量Logistic回归模型将用于评估不同患者组之间治疗依从性的差异。泊松回归或自回归综合移动平均(ARIMA)模型将被用来评估一段时间内的治疗实践。这些目标的完成将为广泛的膀胱癌治疗建议提供按患者性别、种族/民族、年龄和日历时间分类的推荐治疗做法和实际治疗做法的详细比较。未来质量 改进工作可能会以结果为基础，以最有潜力缩小差距、改善护理提供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.