The Influence of Access Related Factors on Adherence to Clinical Practice Guidelines for Muscle Invasive Bladder Cancer.

INTRODUCTION

Clinical guidelines for muscle invasive bladder cancer recommend radical cystectomy with pelvic lymph node dissection as the preferred treatment, although adherence to this guideline is variable. We tested whether access related characteristics are associated with guideline adherence for muscle invasive bladder cancer, and whether the association between access related characteristics and guideline adherence varies by geographic region.

METHODS

We analyzed 27,585 patients diagnosed with stage cT2 or cT3/cN0/cM0 urothelial carcinoma between 1998 and 2010 from the National Cancer Database, and examined the relationship between access related variables and treatment with radical cystectomy/pelvic lymph node dissection vs nonradical cystectomy/pelvic lymph node dissection. Multivariate logistic regression models evaluated associations between access related factors and treatment with radical cystectomy/pelvic lymph node dissection at national and geographically stratified levels.

RESULTS

A total of 6,386 (23.2%) patients underwent radical cystectomy/pelvic lymph node dissection for muscle invasive bladder cancer. Black patients were less likely to undergo radical cystectomy/pelvic lymph node dissection (OR 0.64) compared to white patients. Uninsured patients (OR 0.62) and those covered by Medicaid (OR 0.81) were less likely to undergo radical cystectomy/pelvic lymph node dissection compared to privately insured patients. Patients living more than 120 miles (OR 2.45) from the treatment hospital were more likely to undergo radical cystectomy/pelvic lymph node dissection than those living in the same zip code. Patients were more likely to undergo radical cystectomy/pelvic lymph node dissection if treated at an academic hospital (OR 2.32) compared to a community hospital, and if treated at a high volume center (OR 1.82) compared to a low volume center. Race, insurance status, income and hospital volume demonstrated significant between-region variation as predictors of treatment with radical cystectomy/pelvic lymph node dissection.

CONCLUSIONS

Access related factors are associated with disparities in guideline adherence for muscle invasive bladder cancer and the effect of these factors varies by geographic region.