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Identifying Better Practices for Early-stage Bladder Cancer

Hollingsworth, John Malcolm MD, MS*,†,‡; Zhang, Yun S. PhD*; Miller, David C. MD, MPH*,‡,§; Skolarus, Ted A. MD, MPH*,‡,§; Wood, David P. MD§; Lee, Cheryl T. MD§; Montie, James E. MD*,‡,§; Hollenbeck, Brent K. MD, MS*,‡,§

doi: 10.1097/MLR.0b013e3182353baf
Original Articles

Background: Practice guidelines for nonmuscle invasive (ie, early stage) bladder cancer are ambiguous, resulting in substantial practice variation without a clear patient benefit.

Objectives: To profile urologist practice styles and empirically derive better patterns of use for common bladder cancer services.

Research Design: Retrospective cohort.

Subjects: Elderly patients diagnosed with early-stage bladder cancer between January 1, 1992 and December 31, 2005 in Surveillance, Epidemiology, and End Results-Medicare linked data.

Measures: After identifying each patient's treating urologist, we fit multilevel models to obtain reliability-adjusted measures of the urologist's use of surveillance-associated (cytoscopy and urine cytology) and treatment-associated (intravesical therapy) services during the 2 years after diagnosis. We then used the Cox proportional hazards regression to evaluate the association between a patient's risk of bladder cancer death and his urologist's frequency of service use.

Results: Regardless of disease severity, no measurable patient benefit was associated with care delivery by a urologist residing in the highest quartile for cystoscopy or intravescial therapy use. However, maximal intensity of cytology use was associated with a lower risk of bladder cancer death for patients with high-grade stage Ta/Tis (highest vs. lowest intensity quartiles: hazard ratio, 0.73; 95% confidence interval, 0.56–0.95) and stage T1 disease (hazard ratio, 0.59; 95% confidence interval, 0.49–0.72).

Conclusions: Our analysis supports a more tailored approach to patients with early-stage bladder cancer. Further, it serves as an example for applying observational data to characterize better clinical practices in the absence of experimental studies.

*Dow Division of Health Services Research

Division of Endourology and Stone Disease, Department of Urology

Center for Health Outcomes & Policy

§Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, MI

The authors declare no conflict of interest.

Reprints: Brent K. Hollenbeck, MD, MS, North Campus Research Complex, 2800 Plymouth Road, Bldg 520, 3rd Floor, #3143, Ann Arbor, MI 48109-2800. E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.