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Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired. One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care. The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of care.

PurposeWe examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features.Materials and methodsWe analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021.ResultsWe found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively).ConclusionsThis study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

BackgroundThe University of California, San Francisco (UCSF) Cancer of the Prostate Risk Assessment (CAPRA) is a novel preoperative index which predicts the risk of biochemical recurrence after radical prostatectomy. The performance of the index is at least as good as the best available instruments based on clinical variables, and the 0 to 10 score is simple to calculate for both clinical and research purposes. This study used a large external dataset to validate CAPRA.MethodsData were abstracted from the Shared Equal Access Regional Cancer Hospital (SEARCH) database, a registry of men who underwent radical prostatectomy at 4 Veterans Affairs and 1 active military medical center. Of 2096 men in the database, 1346 (64%) had full data available to calculate the CAPRA score. Performance of the CAPRA score was assessed with proportional hazards regression, survival analysis, and the concordance (c) index.ResultsOf the studied patients, 41% were non-Caucasian, and their mean age was 62 years. Twenty-six percent suffered recurrence; median follow-up among patients who did not recur was 34 months. The hazard ratio (HR) for each 1-point increase in CAPRA was 1.39 (95% CI [confidence interval], 1.31-1.46). The 5-year recurrence-free survival rate ranged from 86% for CAPRA 0-1 patients to 21% for CAPRA 7-10 patients. Increasing CAPRA scores were significantly associated with increasing risk of adverse pathologic outcomes. The c-index for CAPRA for the validation set was 0.68, compared with 0.66 for the original development set.ConclusionsThe UCSF-CAPRA accurately predicted both biochemical and pathologic outcomes after radical prostatectomy among a large, diverse, cohort of men. These results validated the effectiveness of this powerful and straightforward instrument.