Practice- vs Physician-Level Variation in Use of Active Surveillance for Men With Low-Risk Prostate Cancer

Abstract

Owing to concerns about overtreatment, urologists are increas-ingly using active surveillance (AS) as the initial management for men with low-risk prostate cancer. 1,2 Nonetheless, additional progress in this area requires a deeper understanding of the well-established and wide variation in use of AS. 3,4 Of particular in-terest from a quality improvement perspective is whether prac-tice patterns tend to vary widely even among urologists in the same practice and/or based on her or his panel size (ie, the vol-ume of men with low-risk prostate cancer a given urologist man-ages). In the context of limited resources, the availability of such information may be used to develop efficient improvement in-terventions aimed at optimizing the implementation of AS among diverse urologists and practice settings. Methods | The Michigan Urological Surgery Improvement Col-laborative is a consortium of 43 academic and community urol-ogy practices in Michigan that maintains a prospective clini-cal registry with detailed and validated clinical information for men newly diagnosed as having prostate cancer seen in par-ticipating practices. For this analysis, we identified all Michi-gan Urological Surgery Improvement Collaborative practices with at least 5 urologists who each managed 5 or more men with low-risk prostate cancer from January 2012 through July 2016. We then examined the proportion of men managed pri-marily with AS across practices and among urologists within each practice, adjusting for differences in patient age and co-morbidity. Finally, we fit a linear regression model to esti-mate the association between the proportion of patients en-tering AS and urologist panel size. Two-sided testing was performed, with P < .05 considered significant (StataCorp). Each practice obtained institutional review board ap-proval of not-regulated or exempt status or had an expedited review for collaborative participation. As a part of the institu-tional review board process at all participating sites, it was de-termined that given the quality improvement focus of the Michigan Urological Surgery Improvement Collaborative and the fact that the data it houses are (1) collected for quality im-provement and not human participants research and (2) is col-lected during routine care of patients (eg, does not require any changes or burdens beyond routine care processes), in-formed consent was not necessary.