Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study

Background: Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the popula-tion level. Methods: QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diag-nosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diag-nosis, and physician volume. Results: The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant var-iations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with >= 6 patients with AS annually). Conclusions: This study establishes a foundation for quality-of-care assessments and mon-itoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician vol-ume and QIs related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.J Natl Compr Canc Netw 2023;21(5):465-472.e9 doi: 10.6004/jnccn.2022.7256