Abstract：
BACKGROUND: Transurethral resection (TUR) is the mainstay for diagnosis, staging, and treatment of both high-grade and low-grade nonmuscle invasive bladder cancer (NMIBC). It is reported that 51% of initial transurethral resection of bladder tumors (iTURBT) does not contain muscle, which results in higher rates of clinical upstaging on repeat transurethral resection (reTUR) and worse oncologic outcomes. Presence of muscle on iTURBT specimen and performing reTUR within 6 weeks in high-risk NMIBC aids in accurate staging and, therefore, guides proper treatment.
OBJECTIVE: This study aimed to assess and improve TURBT quality by making surgeons aware of their practice patterns and setting improvement goals.
METHODS: Patients who received TURBT for a newly diagnosed bladder mass were analyzed by retrospective chart review for 9 months prior to quality improvement (QI) intervention. Data were collected pertaining to muscle presence/absence on biopsy, pathology of the tumor, risk stratification, whether reTUR was indicated, and time to reTUR. The primary endpoints were the presence of muscle on initial TURBT, whether a reTUR was performed when clinically indicated, and time to reTUR. Tumors requiring reTUR were defined as being HGT1 or HGTa >3 cm. The QI intervention, physician education, was then implemented by presenting initial performance results to the physicians, and a second dataset was then collected by prospective analysis for another 9 months to assess for changes in practice patterns. A total of 101 patients receiving TURBT were reviewed, including 52 patients prior to and 49 patients following QI intervention. Patients with a history of, or treatment for, bladder cancer were excluded, along with those without assessment of muscle on pathological analysis. Fisher\'s exact test was utilized to determine differences in categorical data by comparing each of the following groups prior to and following QI intervention: percent of muscle presence on iTURBT, percent reTUR performed when indicated, and mean time to reTUR in days. A p<0.05 was considered statistically significant.
RESULTS: After comparing the TURBT results before and after our QI intervention, we found a significant improvement in the number of patients receiving a reTUR when indicated, with 5/13 (38.5%) before compared to 15/19 (78.9%) after, p=0.03. The number of specimens on iTURBT with muscle present were not significantly different, with 38/52 (73.1%) before and 33/49 (67.3%) after, p=0.66. The average time to reTUR before (32.4 days; n=5; range, 21-50 days) and after (42.4 days; n=15; range, 11-77 days) QI intervention was also not significantly different, p=0.28.
CONCLUSIONS: Our data suggest that critical analysis of physician practice patterns followed by education and setting improvement goals can significantly impact clinical practices and improve quality of care. Future studies will be performed to determine the impact that these changes have on oncologic outcomes.
OBJECTIVE: This study aimed to assess and improve TURBT quality by making surgeons aware of their practice patterns and setting improvement goals.
METHODS: Patients who received TURBT for a newly diagnosed bladder mass were analyzed by retrospective chart review for 9 months prior to quality improvement (QI) intervention. Data were collected pertaining to muscle presence/absence on biopsy, pathology of the tumor, risk stratification, whether reTUR was indicated, and time to reTUR. The primary endpoints were the presence of muscle on initial TURBT, whether a reTUR was performed when clinically indicated, and time to reTUR. Tumors requiring reTUR were defined as being HGT1 or HGTa >3 cm. The QI intervention, physician education, was then implemented by presenting initial performance results to the physicians, and a second dataset was then collected by prospective analysis for another 9 months to assess for changes in practice patterns. A total of 101 patients receiving TURBT were reviewed, including 52 patients prior to and 49 patients following QI intervention. Patients with a history of, or treatment for, bladder cancer were excluded, along with those without assessment of muscle on pathological analysis. Fisher\'s exact test was utilized to determine differences in categorical data by comparing each of the following groups prior to and following QI intervention: percent of muscle presence on iTURBT, percent reTUR performed when indicated, and mean time to reTUR in days. A p<0.05 was considered statistically significant.
RESULTS: After comparing the TURBT results before and after our QI intervention, we found a significant improvement in the number of patients receiving a reTUR when indicated, with 5/13 (38.5%) before compared to 15/19 (78.9%) after, p=0.03. The number of specimens on iTURBT with muscle present were not significantly different, with 38/52 (73.1%) before and 33/49 (67.3%) after, p=0.66. The average time to reTUR before (32.4 days; n=5; range, 21-50 days) and after (42.4 days; n=15; range, 11-77 days) QI intervention was also not significantly different, p=0.28.
CONCLUSIONS: Our data suggest that critical analysis of physician practice patterns followed by education and setting improvement goals can significantly impact clinical practices and improve quality of care. Future studies will be performed to determine the impact that these changes have on oncologic outcomes.
摘要：
背景：经尿道电切术（TUR）是诊断的主要手段，分期,高级别和低级别非肌层浸润性膀胱癌（NMIBC）的治疗。据报道，最初经尿道膀胱肿瘤电切术（iTURBT）的51％不含肌肉，这导致重复经尿道电切术（reTUR）的临床升级率更高，肿瘤结局更差。在高风险NMIBC中，iTURBT标本上存在肌肉并在6周内进行reTUR有助于准确分期，因此,指导适当的治疗。
目的：本研究旨在通过使外科医生了解其实践模式并设定改进目标来评估和提高TURBT质量。
方法：在质量改进（QI）干预之前，通过回顾性图表分析9个月接受TURBT治疗的新诊断膀胱肿块患者。在活检中收集与肌肉存在/不存在有关的数据，肿瘤的病理学，风险分层，是否显示reTUR，和时间重新。主要终点是初始TURBT时肌肉的存在，临床指征时是否进行了reTUR，和时间重新。需要reTUR的肿瘤被定义为HGT1或HGTa>3cm。QI干预，医师教育,然后通过向医生提供初步表现结果来实施，然后通过另外9个月的前瞻性分析收集第二个数据集，以评估实践模式的变化。共有101例接受TURBT的患者进行了回顾，包括QI干预前的52例患者和QI干预后的49例患者。有病史的患者，或治疗，膀胱癌被排除，以及那些没有对肌肉进行病理分析的人。Fisher精确检验用于通过比较QI干预前后的以下各组来确定分类数据的差异：iTURBT上肌肉存在的百分比，指示时执行的reTUR百分比，以及以天为单位的平均时间。P<0.05被认为是统计学上显著的。
结果：比较QI干预前后的TURBT结果后，我们发现接受reTUR的患者数量显着改善，与之前的5/13（38.5％）相比，之后的15/19（78.9％），p=0.03。有肌肉存在的iTURBT上的标本数量没有显着差异，前38/52(73.1%)，后33/49(67.3%)，p=0.66。之前reTUR的平均时间(32.4天；n=5；范围，21-50天）和之后（42.4天；n=15；范围，11-77天）QI干预也没有显着差异，p=0.28。
结论：我们的数据表明，对医师实践模式进行严格分析，然后进行教育和制定改进目标，可以显着影响临床实践并提高护理质量。未来的研究将进行，以确定这些变化对肿瘤学结果的影响。
目的：本研究旨在通过使外科医生了解其实践模式并设定改进目标来评估和提高TURBT质量。
方法：在质量改进（QI）干预之前，通过回顾性图表分析9个月接受TURBT治疗的新诊断膀胱肿块患者。在活检中收集与肌肉存在/不存在有关的数据，肿瘤的病理学，风险分层，是否显示reTUR，和时间重新。主要终点是初始TURBT时肌肉的存在，临床指征时是否进行了reTUR，和时间重新。需要reTUR的肿瘤被定义为HGT1或HGTa>3cm。QI干预，医师教育,然后通过向医生提供初步表现结果来实施，然后通过另外9个月的前瞻性分析收集第二个数据集，以评估实践模式的变化。共有101例接受TURBT的患者进行了回顾，包括QI干预前的52例患者和QI干预后的49例患者。有病史的患者，或治疗，膀胱癌被排除，以及那些没有对肌肉进行病理分析的人。Fisher精确检验用于通过比较QI干预前后的以下各组来确定分类数据的差异：iTURBT上肌肉存在的百分比，指示时执行的reTUR百分比，以及以天为单位的平均时间。P<0.05被认为是统计学上显著的。
结果：比较QI干预前后的TURBT结果后，我们发现接受reTUR的患者数量显着改善，与之前的5/13（38.5％）相比，之后的15/19（78.9％），p=0.03。有肌肉存在的iTURBT上的标本数量没有显着差异，前38/52(73.1%)，后33/49(67.3%)，p=0.66。之前reTUR的平均时间(32.4天；n=5；范围，21-50天）和之后（42.4天；n=15；范围，11-77天）QI干预也没有显着差异，p=0.28。
结论：我们的数据表明，对医师实践模式进行严格分析，然后进行教育和制定改进目标，可以显着影响临床实践并提高护理质量。未来的研究将进行，以确定这些变化对肿瘤学结果的影响。
