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Estimating the optimal perioperative chemotherapy utilization rate for muscle-invasive bladder cancer

Karim S, Mackillop WJ, Brennan K, Peng Y, Siemens DR, Krzyzanowska MK, Booth CM. Cancer Med. 2019; 8(14):6258-71. Epub 2019 Aug 31. DOI:

Background — Identifying optimal chemotherapy (CT) utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of perioperative CT for muscle-invasive bladder cancer (MIBC).

Methods — The Ontario Cancer Registry and linked treated records were used to identify neoadjuvant and adjuvant CT rates among patients with MIBC during 2004-2013. Monte Carlo simulation was used to estimate the proportion of observed rate variation that could be due to chance alone. The criterion-based benchmarking approach was used to explore whether social and health-system factors were associated with CT rates. We also used the "pared-mean" approach to identify a benchmark population of hospitals with the highest treatment rates. Hospital CT rates were adjusted for case mix and simulated using a multi-level multivariable model and a parametric bootstrapping approach.

Results — The study population included 2581 patients; perioperative CT was delivered to 31% (798/2581). Multivariate analysis showed that treatment was strongly associated with patient socioeconomic status and hospital teaching status. The benchmark rate was 36%. Unadjusted CT rates were significantly different across hospitals (range 0%-52%, P < .001). The unadjusted benchmark perioperative CT rate was 45% (95% CI 40%-50%); utilization rate in nonbenchmark hospitals was 28% (95% CI 26%-30%). When using simulated CT rates adjusted for case mix, the benchmark CT rate was 41% (95% CI 35%-47%) and the nonbenchmark hospital CT rate was 30% (95% CI 28%-32%). The simulation analysis suggested that the observed component of variation (38%) was outside the 95% CI (22%-28%) of what could be expected due to chance alone.

Conclusions — There is significant systematic variation in perioperative CT rates for MIBC across hospitals in routine practice. The benchmark perioperative CT rate for MIBC is 36%-41%.

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