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Active surveillance (AS) has emerged as the preferred management strategy for many men with prostate cancer (PC); however, insufficient longitudinal monitoring may increase the risk of poor outcomes. We sought to determine rates of patients becoming lost to follow-up (LTFU) and associated risk factors in a large AS cohort. The Michigan Urologic Surgery Improvement Collaborative (MUSIC) maintains a prospective registry of PC patients from 44 academic and community urology practices. Over a 6-yr period (2011-2017), we identified patients managed with AS. LTFU was defined as any 18-mo period where no pertinent surveillance testing was entered in the registry. With a median surveillance period of 32 mo, the estimated 2-yr LTFU-free probability calculated by Kaplan-Meier method was 90% (95% confidence interval [CI]=89-92%). Both African American race (hazard ratio [HR]: 2.77, 95% CI=1.81-4.24) and Charlson comorbidity index ≥1 (HR: 1.55, 95% CI=1.08-2.23) were independently associated with increased risk of LTFU. There was variability in rates of estimated 2-yr LTFU-free survival across MUSIC practices, ranging from 52% (95% CI=21-100%) to 99% (95% CI=97-100%), with a median of 96% (interquartile range: 94-98%), although this did not reach statistical significance (p=0.076). These data reveal opportunities for urology practices to identify systems to reduce rates of LTFU and improve the long-term safety of AS. PATIENT SUMMARY: With a median observation period of 32 mo, an estimated 10% of patients will be lost to follow-up at the 2 yr time point while on AS. African American men and generally unhealthy patients were at increased risk, and there was variability from one urology practice to another. There is ample opportunity to improve the quality of the performance of AS.

Purpose Tissue-based gene expression classifiers (GECs) may assist with management decisions in patients with newly diagnosed prostate cancer. We sought to assess the current use of GEC tests and determine how the test results are associated with primary disease management. Methods In this observational study, patients diagnosed with localized prostate cancer were tracked through the Michigan Urological Surgery Improvement Collaborative registry. The utilization and results of three GECs (Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) were prospectively collected. Practice patterns, predictors of GEC use, and effect of GEC results on disease management were investigated. Results Of 3,966 newly diagnosed patients, 747 (18.8%) underwent GEC testing. The rate of GEC use in individual practices ranged from 0% to 93%, and patients undergoing GEC testing were more likely to have a lower prostate-specific antigen level, lower Gleason score, lower clinical T stage, and fewer positive cores (all P < .05). Among patients with clinical favorable risk of cancer, the rate of active surveillance (AS) differed significantly among patients with a GEC result above the threshold (46.2%), those with a GEC result below the threshold (75.9%), and those who did not undergo GEC (57.9%; P < .001 for comparison of the three groups). This results in an estimate that, for every nine men with favorable risk of cancer who undergo GEC testing, one additional patient may have their disease initially managed with AS. On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P = .006). Conclusion There is large variability in practice-level use and GEC tests ordered in patients with newly diagnosed, localized prostate cancer. In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS. Additional follow-up will help determine whether incorporation of GEC testing into initial patient care favorably affects clinical outcomes.

To identify clinical variables associated with a positive computed tomography (CT) scan and estimate the performance of imaging recommendations in patients from a diverse sample of urology practices.This study comprised 2380 men with newly diagnosed prostate cancer seen at 28 practices in the Michigan Urological Surgery Improvement Collaborative from March 2012 through September 2013. Data included age, prostate-specific antigen (PSA) level, Gleason score (GS), clinical T stage, total number of positive biopsy cores, whether or not the patient received a staging abdominal and/or pelvic CT scan, and CT scan result. We fit a multivariate logistic regression model to identify clinical variables associated with metastases detected by CT scan. We estimated the sensitivity and specificity of existing imaging recommendations.Among 643 men (27.4%) who underwent a staging CT scan, 62 men (9.6%) had a positive study. In the multivariate analysis, PSA, GS, and clinical T stage were independently associated with the occurrence of a positive CT scan (all P values.05). The American Urological Association's Best Practice Statements' recommendations for imaging when PSA level20 ng/mL or GS ≥ 8 or locally advanced cancer had a sensitivity of 87.3% and specificity of 82.6%. Compared with current practice, implementing this recommendation in the Michigan Urological Surgery Improvement Collaborative population was estimated to result in approximately 0.5% of positive study results being missed, and 26.1% of fewer study results overall.Successful implementation of CT imaging criterion of PSA level20, GS ≥ 8, or clinical stage ≥ T3 would ensure that CT scans are performed for almost all men who would have positive study results while reducing the number of negative study results.

Objective To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. Methods We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of “routine” home care use after prostatectomy by urology practice. We defined “routine” home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. Results We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% ( P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P .01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses ( P .01). Home health had an average payment of $1000 per episode. Conclusion Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.

To evaluate the performance of published guidelines compared with that of current practice for radiographic staging of men with newly diagnosed prostate cancer.Using data from the Michigan Urological Surgery Improvement Collaborative clinical registry, we identified 1509 men diagnosed with prostate cancer from March 2012 through June 2013. Clinical data included age, prostate-specific antigen (PSA) level, Gleason score (GS), clinical trial stage, number of biopsy cores, and bone scan (BS) results. We then fit a multivariate logistic regression model to examine the association between clinical variables and the occurrence of bone metastases. Because some patients did not undergo BS, we used established methods to correct for verification bias and estimate the diagnostic accuracy of published guidelines.Among 416 men who received a BS, 48 (11.5%) had evidence of bone metastases. Patients with bone metastases were older, with higher PSA levels and GS (all P.05). In multivariate analyses, PSA (P.001) and GS (P = .004) were the only independent predictors of positive BS. Guidelines from the American Urological Association and the National Comprehensive Cancer Network demonstrated similar performance in detecting bone metastases in our population, with fewer negative study results than those of the European Association of Urology guideline. Applying the American Urological Association recommendations (ie, image when PSA level20 ng/mL or GS ≥ 8) to current clinical practice, we estimate that1% of positive study results would be missed, whereas the number of negative study results would be reduced by 38%.Based on current practice patterns, more uniform application of existing guidelines would ensure that BS is performed for almost all men with bone metastases, while avoiding many negative imaging studies.

Introduction Collaboratives composed of surgeons or hospitals are an effective means to improve quality of care and value. Building on the success of the Collaborative Quality Initiatives program of BCBSM (Blue Cross and Blue Shield of Michigan) and Blue Care Network, MUSIC (Michigan Urological Surgery Improvement Collaborative) seeks to improve the quality of care for patients with prostate cancer across Michigan. Methods MUSIC was established in 2010. Support for data management and the coordinating center are provided by BCBSM. A private software vendor was selected to develop and support the web based data entry platform. Results MUSIC currently has 43 participating practices representing more than 200 urologists from diverse locations and practice types. Prospective data collection began in March 2011 and currently almost 9,000 cases of prostate biopsy or newly diagnosed prostate cancer have been entered in the registry. MUSIC priorities for quality improvement include fostering appropriate imaging for staging; making prostate biopsy more efficient and safe; improving outcomes after radical prostatectomy by tracking complications and patient reported outcomes, and providing collaborative learning in surgical technique; enhancing shared decision making between patients and providers; and evaluating the use of new oral antiandrogenic therapies. Conclusions MUSIC provides a unique opportunity for quality improvement initiatives in urology. Acceptance by urologists in various practice settings has been robust and indicates a commitment by members to positively contribute to better urological care through a shared learning environment.

Objective To assess the effectiveness of a feedback and educational intervention to increase documentation of clinical tumor-node-metastasis (TNM) stage among urologists in a statewide quality improvement collaborative. Methods The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a consortium of urology practices that aims to improve the quality and cost-efficiency of prostate cancer care. In pilot data collection activities, trained abstractors recorded medical record documentation of clinical TNM stage by participating urologists. We compared levels of TNM stage documentation in 12 MUSIC practices at baseline and after performance feedback and a collaborative-wide educational intervention. We examined patient and practice characteristics associated with documentation of TNM stage. Results We accrued 491 and 581 men with newly diagnosed prostate cancer during the baseline and postfeedback phases of data collection, respectively. At baseline, 58% of patients had clinical TNM staging in the medical record, ranging from 19% to 96% across 12 practices (P

We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer.MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns.A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p 0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods.An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.

We compared pathological outcomes after radical prostatectomy for a population based sample of men with low risk prostate cancer initially on active surveillance and undergoing delayed prostatectomy vs those treated with immediate surgery in order to better understand this expectant management approach outside of the context of academic cohorts. We hypothesized that delays in surgery due to initial surveillance would not impact surgical pathological outcomes.We performed a prospective cohort study of 2 groups of patients with NCCN low risk prostate cancer from practices in the Michigan Urological Surgery Improvement Collaborative, that is 1) men who chose initial active surveillance and went on to delayed prostatectomy and 2) men who chose immediate prostatectomy. Diagnoses occurred from January 2011 through August 2015. For these 2 groups we compared radical prostatectomy Gleason scores, and rates of extraprostatic disease, positive surgical margins, seminal vesicle invasion and lymph node metastases.During a median followup of 506 days 79 (6%) of 1,359 low risk men choosing initial surveillance transitioned to prostatectomy. Compared to those treated with immediate prostatectomy (778), men undergoing delayed surgery were more likely to have Gleason score 7 or greater disease (69.2% vs 48.8%, respectively, p=0.004), but were no more likely to have positive margins, extraprostatic extension, seminal vesicle invasion or lymph node metastases.Patients with low risk prostate cancer who enter active surveillance have higher grade disease at prostatectomy compared to those undergoing immediate surgery. However, the lack of difference in other adverse pathological outcomes suggests preservation of the window of curability.

INTRODUCTION AND OBJECTIVES: Little is known about longitudinal follow-up patterns for men on active surveillance (AS) for prostate cancer (CaP) or how this compares with guideline recommendations. In this context, we examined the rates of conversion to secondary therapy, and the frequency of follow-up PSA tests and prostate biopsy among men managed with AS in the diverse academic and community urology practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). METHODS: MUSIC is a consortium of 42 urology practices that maintains a prospective clinical registry with detailed and validated clinical data for all patients diagnosed with CaP. For this analysis, we identified all patients that entered AS and had at least two years of follow-up in the same practice. We first determined the percentage of patients who transitioned to secondary therapies. Next, we calculated the proportion of AS patients who received the minimum suggested 2year follow-up based on NCCN recommendations: at least 3 PSA tests and one repeat biopsy. We then compared the proportion of patients receiving recommendation concordant AS follow-up at the participating sites. RESULTS: We identified 513 patients that entered AS in MUSIC practices from 1/2012 to 9/2013. The median age of the cohort was 66, median PSA was 5.3 ng/mL (IQR 4.1-7.5 ng/mL), 75% of patients had Gleason 6 disease. Across the entire cohort, 15.6% transitioned to a secondary-treatment before reaching 2 years of follow-up (median time to treatment 1⁄4 13.4 months), with 63% of these patients undergoing prostatectomy. At a practice level, rates of treatment varied widely ranging from 0 to 33% (p1⁄40.002). Overall, 20.2% of patients entering AS received guideline-concordant PSA and biopsy surveillance over 2 years of follow-up; however, this proportion varied widely across MUSIC practices, ranging from 9.1% to 55.1% (p

A priority of MUSIC (Michigan Urological Surgery Improvement Collaborative) is to improve patient outcomes after radical prostatectomy. As part of these efforts we developed a novel system that uses unambiguous events to define an uncomplicated 30-day postoperative recovery and compares these outcomes across diverse urology practices.MUSIC used a consensus approach to develop an uncomplicated recovery pathway comprising a set of precise perioperative events that are reliably measured and collectively reflect resource utilization, technical complications and coordination of care. Events that occurred outside the uncomplicated recovery pathway were considered deviations, including rectal injury, high blood loss, extended length of stay, prolonged drain or catheter placement, catheter replacement, hospital readmission or mortality. For men undergoing radical prostatectomy trained abstractors prospectively recorded clinical and perioperative data in an electronic registry. When a deviation from the NOTES (Notable Outcomes and Trackable Events after Surgery) pathway occurred, precipitating events were described by abstractors and we analyzed the events.From April 2014 through July 2015 a total of 2,245 radical prostatectomies were performed by 100 surgeons in a total of 37 diverse participating MUSIC practices. In the 29 practices in which 10 or more radical prostatectomies were performed during the interval analyzed the risk adjusted deviation rate ranged from 0.0% to 46.1% (p0.0001). Anastomotic and gastrointestinal events were contributing factors in 50.2% of deviated cases.The novel NOTES system provides comparative data on unambiguous and actionable short-term outcomes after radical prostatectomy. The observed variation in outcomes across practices suggests opportunities for quality improvement initiatives. Decreasing anastomotic and gastrointestinal events represents a high impact opportunity for initial quality improvement efforts.

The potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men.To assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC).MUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy.We calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with10 yr LE (limited LE) undergoing a first biopsy. Our LE calculator was not designed for men aged66 yr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received.Among 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8-10).Among a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy.In this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE)10 yr. Implementing LE calculators in clinical practice may help refine patient selection for prostate biopsy.

We used data from MUSIC (Michigan Urological Surgery Improvement Collaborative) to evaluate the performance of published selection criteria for active surveillance in diverse urology practice settings.For several active surveillance guidelines we calculated the proportion of men meeting each set of selection criteria who actually entered active surveillance, defined as the sensitivity of the guideline. After identifying the most sensitive guideline for the entire cohort we compared demographic and tumor characteristics between patients who met this guideline and entered active surveillance, and those who received initial definitive therapy.Of 4,882 men with newly diagnosed prostate cancer 18% underwent active surveillance. When applied to the entire cohort, the sensitivity of published guidelines ranged from 49% in Toronto to 62% at Johns Hopkins. At a practice level the sensitivity of Johns Hopkins criteria varied widely from 27% to 84% (p0.001). Compared with men undergoing active surveillance, those meeting Johns Hopkins criteria who received definitive therapy were younger (p 0.001) and more likely to have a positive family history (p = 0.003), lower prostate specific antigen (p0.001), a greater number of positive cores (2 vs 1) on biopsy (p0.001) and a higher cancer volume in positive core(s) (p = 0.002).The sensitivity of published active surveillance selection criteria varies widely across diverse urology practices. Among patients meeting the most stringent criteria those who received initial definitive therapy had characteristics suggesting greater cancer risk, underscoring the nuanced clinical factors that influence treatment decisions.

INTRODUCTION AND OBJECTIVES: Clinical trial evidence and ASTRO/AUA guidelines support the use of adjuvant radiotherapy (aXRT) for select high-risk men who have undergone radical prostatectomy (RP). Reports suggest, however, that utilization of aXRT remains low. We sought to understand the current practice patterns regarding the use of aXRT among patients in Michigan with high-risk pathological features after RP. Additionally, we examined whether early salvage XRT (sXRT) is being utilized as an alternative strategy. METHODS: From a prospective cohort of patients undergoing RP between 3/2012-3/2014 by urologists participating in the Michigan Urological Surgery Improvement Collaborative (MUSIC), we identified all patients with final pathology showing pT3a disease or higher (pT3þ) and/or positive surgical margins (PSM). We excluded patients who failed to achieve a post-operative PSA nadir 0.1, patients with lymph node metastasis, and patients with

INTRODUCTION AND OBJECTIVES: Systematic 12-core transrectal ultrasound-guided biopsy (TRUSGB) is the recommended approach to diagnose prostate cancer (PCa). Overdiagnosis and sampling errors leading to incorrect risk stratification and treatment allocation represent major limitations. Multiparametric MRI is able to accurately identify PCa lesions within the prostate. Compared to random TRUSGB, MRI-guided targeted biopsy (MRGTB) has been shown to detect significant PCa in a higher proportion of men, using 1e4 cores instead of 12, and to reduce the diagnosis of insignificant PCa and thus overtreatment. Costs and technical limitations still prevent this promising approach from becoming the new standard in PCa diagnosis. The goal of the present study was to assess whether the added initial costs related to MRI are balanced with the benefits of MRGTB in a cost-effectiveness model. METHODS: A Markov model was developed to estimate the incremental cost-effectiveness ratio (ICER) over 10-, 15and 20 yr period. Study population consisted of men >50yr with a life expectancy >15yr and clinical suspicion of PCa. Based on previously published data, a simulation model taking into account the probability of men harboring PCa, the diagnostic accuracy of both procedures and the probability of being assigned to the various treatment options was developed. Medical (physician fees) and hospital costs (procedure fee, admission fee, tests andprocedures) basedonCanadiandatawere included. In order to avoid bias favoring MRGTB intervention, possible advantages of this intervention, such as decreased number of biopsy and change of PCa management, were not considered as base case but were tested in sensitivity analysis. ICER

Recent data suggest that increasing rates of hospitalization after prostate biopsy are mainly due to infections from fluoroquinolone-resistant bacteria. We report the initial results of a statewide quality improvement intervention aimed at reducing infection related hospitalizations after transrectal prostate biopsy.From March 2012 through May 2014 data on patient demographics, comorbidities, prophylactic antibiotics and post-biopsy complications were prospectively entered into an electronic registry by trained abstractors in 30 practices participating in the MUSIC. During this period each practice implemented one or both of the interventions aimed at addressing fluoroquinolone resistance, namely 1) use of rectal swab culture directed antibiotics or 2) augmented antibiotic prophylaxis with a second agent in addition to standard fluoroquinolone therapy. We identified all patients with an infection related hospitalization within 30 days after biopsy and validated these events with claims data for a subset of patients. We then compared the frequency of infection related hospitalizations before (5,028 biopsies) and after (4,087 biopsies) implementation of the quality improvement intervention.Overall the proportion of patients with infection related hospitalizations after prostate biopsy decreased by 53% from before to after implementation of the quality improvement intervention (1.19% before vs 0.56% after, p=0.002). Among post-implementation biopsies the rates of hospitalization were similar for patients receiving culture directed (0.47%) vs augmented (0.57%) prophylaxis. At a practice level the relative change in hospitalization rates varied from a 7.4% decrease to a 3.0% increase. Fourteen practices had no post-implementation hospitalizations.A statewide intervention aimed at addressing fluoroquinolone resistance reduced post-prostate biopsy infection related hospitalizations in Michigan by 53%.