Authors Sampurno F, Earnest A, Kumari PB, et al.
Review Date July 2016
Citation Med J Aust 2016; 204 (8):e319
Although best practice guidelines exist to help in the care of men diagnosed with prostate cancer (CaP), it is unclear whether Australian men are receiving optimal care. A US study has shown that men with localised CaP in particular may not be receiving the highest standard of care and this was true across institutions.
The Prostate Cancer Outcomes registry (PCOR-Vic) was set up to help monitor the patterns of care and outcomes for men diagnosed with CaP in Victoria. Established in 2009, by 2013 the registry had collected data from 75% of the target population. The quality of care indicators are based on evidence that: active surveillance is appropriate as the first approach for many men with localised CaP; prompt active treatment is appropriate for men with locally advanced or high risk CaP with good life expectancy; and the proportion of positive surgical margins after radical prostatectomy is associated with biochemical recurrence.
To assess the quality of CaP care in Victoria according to three quality indicators reported by the PCOR-Vic.
Men diagnosed/treated with CaP (pathologically confirmed) in Victoria at a recruiting hospital, treated by a clinician who has given consent for patients to be contacted, are eligible to be included on the PCOR-Vic (started in 2009). The PCOR-Vic reports on 4 outcome measures (patient-reported urinary, bowel and sexual bother and survival) and 3 quality indicators (active treatment initiated in first 12 months for men with low risk disease, QI-1; active treatment not initiated in first 12 months for men with high risk or locally advanced CaP, QI-2; positive surgical margins following radical prostatectomy, QI-3). Data are collected from hospitals and private consulting suites by trained data collectors and men are phoned at 12 and 24 months to confirm treatment details and most recent PSA test results. Data on patients meeting QI criteria are given back to hospitals and clinicians.
For this study, trend analysis was conducted for each of the three QI measures on data collected between January 2009 and December 2013, to assess the changes in quality of prostate cancer care over this 5-year period.
Over the 5-year study period there was a downward trend in the proportion of men with low risk disease who underwent active treatment (QI-1: 45% to 34%; p=0.024), an upward trend (not statistically significant) in the percentage of those with high risk and locally advanced disease who received active treatment within 12 months of diagnosis (QI-2: 88% to 93%; p=0.181). In men with pathological T2 disease the PSM rate after radical prostatectomy initially rose slightly (2010) but then declined in the ensuing years (QI-3: 21% in 2009 to 12% in 2013; p=0.036).
Over the period 2009 to 2013, the care of men diagnosed with CaP improved according to the three quality indicators reported by the PCOR-Vic. Reasons for improvement may include improved knowledge of guidelines for managing low and high risk CaP, technical advances and feedback from the registry to clinicians and hospitals regarding their performance relative to peers.
Points to Note
- There is general agreement that regular monitoring of clinical performance in PCa is necessary to improve outcomes.
- The Victorian registry has shown improvements over 5 years in quality of care of men diagnosed with low and high risk CaP.
- The decline in men with low risk CaP receiving active treatments was encouraging as AS is one way of reducing the overtreatment associated with low risk disease.
- A strength of the registry is that it is community-based and comprehensive in the types of data collected.
- Limitation of the study: as the PCOR-Vic data were analysed as a whole, there may be institutional variations in quality improvement that were not detected; Gradual recruitment of hospitals to the PCOR-Vic means that not all hospitals had contributed the same amount of data.
- The study has demonstrated that clinical QIs are valuable in monitoring and perhaps helping to improve clinical outcomes.