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A Quality Review of Radical Cystectomy
*Otto Sandoval, *Andrew Blake, *Josh Barnes-Livermore, *Doug Salvador, *Brian Jumper, Craig Hawkins
Maine Medical Center, Portland, ME
Background: A delay of greater than 90 days from diagnosis of muscle invasive bladder cancer to radical cystectomy is associated with decreased cause-specific survival (Cancer 2009;115;1011-1020) Objective:To design and implement a quality improvement intervention resulting in a system of care that reliably achieves 100% of surgeries for patients with muscle invasive bladder cancer within 90 days of diagnosis.Design:Before and after comparison of the application of a Clinical Microsystems quality improvement intervention characterized by multidisciplinary improvement team, assessment of the current delivery system, design and testing of sequential process improvements, and feedback of results.Setting:One community /university-associated tertiary care and teaching institution with a multi-state referral base.Patients:Prior to intervention Sixty-six consecutive surgical candidates with T2 muscle invasive transitional cell carcinoma of the bladder underwent radical cystectomy between 2004 and 2009.Twenty-five percent of patients who did not have neoadjuvant chemotherapy did not undergo cystectomy < 90 days. Main Outcome measures:The percentage of patients exceeding 90 day interval between diagnosis and surgery.Time intervals between diagnosis and key points in the care process (i.e. discussion of treatment options, surgical intervention) were also measured.Results:Seven problem categories were identified, with 26 possible points of intervention recognized. The points of intervention were prioritized in terms of the impact and projected efficacy of intervention. The major contributors included scheduling, patient choice factors, and comorbidity evaluation.Preliminary results after implementation in 2011 indicate construction of a system that allows for 100% of the patients with T2 disease to undergo radical cystectomy within 90 days of diagnosis.Conclusion: Team members using the described quality improvement method effectively identified barriers to timely bladder cancer care and implemented changes that are promising for sustained reliable care.
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