Physician-Led Approach Can Cut Unnecessary Testing in Prostate Cancer

VBCC - February 2012, Volume 3, No 1 - Prostate Cancer
Caroline Helwick

Feedback from their peers helped physicians refrain from ordering unnecessary tests for patients with newly diagnosed cancer, according to a recent study (Miller DC, et al. J Urol. 2011;186:844-849. Epub 2011 Jul 23).

Physicians ordered fewer tests after becoming more aware of practice guidelines and being presented with comparative data on tests they and their colleagues ordered. The program also improved the quality of care by reducing variations in practice patterns.

“The study is a great example of a new solution for an old problem,” said David C. Miller, MD, MPH, a urologist at the University of Michigan School of Medicine, Ann Arbor, and lead investigator. “Physicians are at the heart of the solution.”

The study was conducted by the Urological Surgery Quality Collab­orative, a consortium of 150 urologic surgeons in several Midwestern states and Virginia that formed in 2009 to find ways to improve healthcare quality and consistency.

Investigators examined the diagnostic practices of physicians treating 858 patients with early-, middle-, or late-stage prostate cancer. Among men with newly diagnosed cancer, 44% were classified as having low-risk cancer, 39% had intermediate-risk cancer, and 17% had high-risk cancer.

To look for metastases, overall urologists initially ordered bone scans for 25% of patients and computed tomography (CT) scans for 22%. Among the patients with low- or medium-risk cancer, for whom the benefits of these interventions are less established, bone scans were ordered initially for 31% of patients and CT scans for 28%.

The urologists then participated in a quality assurance intervention. They received comparative performance feedback and review, the results of the imaging studies, and the American Urological Association and National Comprehensive Cancer Network guidelines for staging evaluations in men with early-stage prostate cancer.

Ultimately, they began using an information collection form that included a summary of the practice guidelines.

At the program’s end, only 13% of patients received CT scans and 16% received bone scans.

The reduction in testing was especially notable among patients with low-risk cancer. Use of CT scans dropped from 14% to 2%, and the use of bone scans dropped from 10% to 1%.

In patients with early-stage cancer, for whom metastases are highly unlikely, screening tests can create more stress by uncovering benign findings that lead to further testing and can expose patients to radiation unnecessarily, the authors pointed out.

Dr Miller suggested that physicians may not practice in accordance with guidelines because they are unfamiliar with them or because they are comfortable with their own practice patterns, which may differ from the guidelines. He said the study demonstrates that positive changes can come from within medical practices through “physician-led approaches,” and that peer counseling may be better accepted than mandates from third-party payers and policymakers.

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