Post-RP outcomes tool may support quality initiatives

Ann Arbor, MI-Developers of a novel metric for evaluating outcomes after radical prostatectomy are excited about its utility as a tool for supporting quality improvement initiatives to optimize patient recovery following the surgery.

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Known as NOTES (Notable Outcomes and Trackable Events after Surgery), the composite measure was created by members of the Michigan Urological Surgery Improvement Collaborative (MUSIC). MUSIC is a statewide, physician-led quality improvement program that is managed by the Coordinating Center housed at the University of Michigan, Ann Arbor and sponsored by Blue Cross Blue Shield of Michigan. NOTES captures eight variables chosen to represent outcomes consistent with uncomplicated surgery and early recovery: 

• no rectal injury

• estimated blood loss ≤400 mL (90^th percentile)

• length of stay ≤2 days

• drain placement ≤2 days

• catheter placement ≤16 days

• no indwelling catheter replacement

• no 30-day readmission

• no 30-day mortality.

The tool and findings from a first-time analysis of collected data were presented at the 2015 AUA annual meeting in New Orleans.

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“Recognizing the limitations of data from claims sources and traditional chart review for tracking outcomes, the elements of NOTES were chosen based on the general principles that the collected data would be unambiguous, accurate, meaningful, and actionable,” said first author Stacie Myers, BS, research assistant in urology at the University of Michigan and MUSIC database coordinator.

Next: Criteria ‘will allow comparisons between diverse practices’

Criteria ‘will allow comparisons between diverse practices’

“We believe NOTES will allow comparisons between diverse urological practices and help us to hone in on and identify quality improvement opportunities that can be targeted with interventions for improving outcomes.”

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The NOTES criteria were developed by a statewide consensus panel of expert urologists and were endorsed by MUSIC Patient Advocates.

“We considered feedback from post-RP patients invaluable for helping to identify criteria that would define a smooth and uncomplicated recovery after surgery,” said James Dupree, MD, assistant professor of urology at the University of Michigan.

Dr. MontieSpeaking to Urology Times, senior author James E. Montie, MD, emphasized the reliability of the NOTES data points.

“It is important that the data be consistent and unambiguous so that they could be accurately extracted by data abstractors,” said Dr. Montie, MUSIC co-director and professor of urology, University of Michigan.

The first analysis of the NOTES data encompassed 1,570 prostatectomy procedures performed in 33 MUSIC practices between April 2014 and March 2015.

Considering all patients, 21.7% of men experienced an event outside at least one of the criteria defining an uncomplicated NOTES pathway, and 7.5% had two or more such deviations. The most common deviations involved the drain placement (12.6%) and length of stay (8.1%) criteria. Rectal injury (0.5%) and mortality (0.3%) deviations were least common. Deviation rates for all other criteria ranged from 3.8% to 5.6%.

Looking across 24 urology practices contributing data for 10 or more surgeries, the percentage of cases with at least one deviation from the uncomplicated pathway varied significantly, ranging from 6.3% to 50%.

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“The finding of significant variation among the MUSIC practices suggests there are opportunities for quality improvement that ultimately will improve the surgical care received in Michigan by men with prostate cancer,” Myers said.

Next: Feedback for providers

Feedback for providers

To enable interpretation and action on the data, a quarterly report is being generated and disseminated automatically to MUSIC members. The report summarizes the deviation rates for individual surgeons, their practices, and the entire collaborative and presents them for the current and previous quarters, enabling identification of progress trends. Risk adjustment for race, age, insurance status, body mass index, Charlson comorbidity index, PSA, prostate volume, pathologic Gleason score, and pathologic T stage allows for equitable comparisons to other practices.

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Dr. Dupree“The limitations of claims data make it difficult for an individual surgeon or practice to determine how their patients are doing relative to others in the area, state, or nation. We think MUSIC NOTES addresses that issue and so empowers surgeons to improve quality of care within their practices,” said Dr. Dupree.

In addition to the stated criteria, NOTES is collecting information on specific complications that can guide understanding on the underlying cause(s) for criteria deviations.

And, the eight NOTES criteria are not set in stone.

“This is a process in evolution, and as we go forward and collect more data, the urologists in MUSIC will be involved in the process of deciding whether there is any need to revise the current criteria,” Dr. Montie said.

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