Although the monitoring of patients with advanced prostate cancer is essential to optimize treatment, little is known about adherence to guidelines. In this study we compared testing practices at an integrated urology/radiation oncology group practice with evidence-based guidelines and best practices.Electronic medical records up to December 2014 from the integrated urology/radiation oncology group practice were queried to identify patients who received androgen deprivation therapy and in whom advanced disease was staged as androgen deprivation therapy sensitive, subcastration resistant (incompletely defined probable castration resistant prostate cancer) or castration resistant after April 2011 and for 6 months or more. Frequency of prostate specific antigen and testosterone level testing as well as imaging (magnetic resonance imaging, computerized tomography, positron emission tomography/computerized tomography, bone scan or x-ray) was evaluated, and compared to national guidelines and best practices.Overall 346 patients with androgen deprivation therapy sensitive prostate cancer, 90 with subcastration resistant prostate cancer and 102 with castration resistant prostate cancer met the study inclusion criteria. On average, prostate specific antigen was tested every 4.7, 3.7 and 3.3 months for patients with androgen deprivation therapy sensitive disease, subcastration resistant prostate cancer and castration resistant prostate cancer, respectively, compared with the 3 to 12 months and 3 months recommendations of the National Comprehensive Cancer Network and RADAR (Prostate Cancer Radiographic Assessments for Detection of Advanced Recurrence) for patients with androgen deprivation therapy sensitive disease and nonmetastatic castration resistant prostate cancer, respectively. Testosterone levels were assessed within 6 months of classification for 23% and 46% of patients with subcastration resistant prostate cancer and castration resistant prostate cancer, respectively. Finally, 28% and 46% of patients with subcastration resistant prostate cancer and castration resistant prostate cancer, respectively, underwent some type of imaging within 6 months.This retrospective study of patients receiving androgen deprivation therapy at a particular integrated urology/radiation oncology group practice demonstrated adherence to prostate specific antigen best practices. However, there was some room for improvement in terms of testosterone testing and imaging.
The U.S. health care system is undergoing significant change as demands to improve medical quality and reduce health care costs expand. U.S. health care spending accounted for 16.9% of gross domestic product in 2013, the highest amount compared to other developed countries. On April 16, 2015 the U.S. Congress passed a historical piece of bipartisan legislation, the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). We describe the events leading up to the passage of MACRA, review the various components of MACRA and describe how MACRA will likely impact physician practices. We also suggest how best to prepare for compliance with the Centers for Medicare & Medicaid Services (CMS) MACRA final rule with comment period, which was released on October 14, 2016.A literature review of the quality measures defined by CMS before the passage of MACRA was performed as well as a review of the current MACRA final rule (Quality Payment Program) and related CMS commentary. An expert panel of health care consultants provided guidance concerning compliance with the final rule. Furthermore, case studies are described as examples to assist the urological community in meeting the expectations of MACRA.The Surgical Care Improvement Project process measures (current quality) for urological surgery are reviewed and their impact on surgical site infections is described. Details of MACRA and its Quality Payment Program framework, the Merit-based Incentive Payment System and Alternative Payment Models, are also described. A detailed understanding of and preparation for the implementation of MACRA will help physicians comply with the regulations which offer future opportunities for better reimbursement. Opportunities to comply with MACRA through Advanced Alternative Payment Models may mitigate the complexity of reporting under the alternate Merit-based Incentive Payment System. The development of bundled payment procedures in urology, similar to the Comprehensive Care for Joint Replacement program in orthopedics, may eventually qualify for Advanced Alternative Payment Model status.Physicians should be proactive, and lead the effort to improve medical quality and control health care related costs, the primary goals of MACRA. Academic and community urologists should collaborate and define optimal quality measures that are meaningful and relevant to the practice of urology, which is currently being done by the AUA (American Urological Association) Quality Registry program. The specialty of urology would benefit from a concerted effort to develop bundled payment models for a variety of urological procedures and seek CMS recognition as qualifying for Advanced Alternative Payment Models.
137 Background: Active surveillance (AS) is an important strategy to limit the overtreatment of low risk prostate cancer (PCa). A best practice was established for AS inclusion criteria and follow-up, aimed to measure past AS adoption rates, institute the best practice, then measure AS adoption. Methods: Patient biopsy and treatment data was retrieved from an integrated EMR (Allscripts). AS adoption rates were calculated using 4 methods: 1) All newly diagnosed PCa patients; 2) Newly diagnosed PCa patients treated at Genesis Healthcare Partners (GHP); 3) Patients eligible for AS treatment according to the National Comprehensive Cancer Network (NCCN) (very low risk and low risk categories) guidelines and treated at GHP; and 4) Patients eligible for AS treatment according to the UCSD/GHP best practice and treated at GHP, according to the following inclusion criteria: Stage T1c; PSA Density (PSAD) < 0.15 ng/mL/cc and absolute PSA level < 10 ng/mL; Gleason ≤6; ≤3 cores (+); No individual core with >50% involvement. Between 2013 and 2014, GHP physicians underwent an educational training program on the UCSD/GHP best practice. Comparative report cards on AS adoption were sent to all physicians. Results: See Table. Conclusions: AS adoption improved in those patients considered most eligible (according to evidence based guidelines) for AS following institution of an educational program and comparative reporting in a community practice. Selection criteria appear to significantly impact AS adoption rates. [Table: see text]
