Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study

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Narhari Timilshina Department of Medicine, University Health Network, Toronto, Ontario, Canada
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

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Antonio Finelli Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
Division of Urology and Surgical Oncology, University Health Network, Toronto, Ontario, Canada

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George Tomlinson Department of Medicine, University Health Network, Toronto, Ontario, Canada
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

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Beate Sander Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
The Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada
Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
Institute of Clinical Research Services, Toronto, Ontario, Canada
Public Health Ontario, Toronto, Ontario, Canada

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Shabbir M.H. Alibhai Department of Medicine, University Health Network, Toronto, Ontario, Canada
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

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Background: Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level. Methods: QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume. Results: The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59–71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%–100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65–74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1–2 patients with AS and 95.8% for those with ≥6 patients with AS annually). Conclusions: This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and QIs related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.

Submitted June 29, 2022; final revision received December 20, 2022; accepted for publication December 21, 2022.

Author contributions: Study concept and design: All authors. Data analysis: Timilshina, Tomlinson. Interpretation of results: All authors. Supervision: Finelli, Alibhai. Writing—original draft: Timilshina, Finelli, Alibhai. Writing—review & editing: Finelli, Tomlinson, Sander, Alibhai.

Disclosures: The authors have not received any financial contribution from any person or organization to support the preparation, results, analysis, or discussion of this article.

Acknowledgement: This study contracted ICES data & analytic services and used de-identified data from the ICES Data Repository, which is managed by ICES with support from its funders and partners: Canada’s Strategy for Patients-Oriented Research (SPOR), the Ontario SPOR Support unit, the Canadian Institute for Health Research and the Government of Ontario. This study was supported through provision of data by ICES and Ontario Health-Cancer Care Ontario and through funding support to ICES from an annual grant by the Ministry of Health and the Ontario Institute for Cancer Research. The opinions, results and conclusions reported in this paper are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred.

Correspondence: Shabbir M.H. Alibhai, MD, MSc, Department of Medicine, University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, 200 Elizabeth Street, Room EN14-214, Toronto, Ontario M5G 2C4, Canada. Email: Shabbir.Alibhai@uhn.ca

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