Accurate Documentation Contributes to Guideline Concordant Surveillance of Non-Muscle Invasive Bladder Cancer: a Multi-site VA Study
Vikram S. Lyall, MD1, A, Aziz Ould Ismail, MD2, David A. Haggstrom, MD3, Muta M. Issa, MD MBA4, Minhaj Siddiqui, MD5, Jeffrey Tosoian, MD MPH6, Elise K. Gatsby, MPH7, Florian Schroeck, MD MS2.
1Dartmouth Hitchcock Medical Center, Lebanon, NH, USA, 2White River Junction VA, White River Junction, VT, USA, 3Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA, 4Atlanta VA Medical Center, Atlanta, GA, USA, 5Baltimore VA Medical Center, Baltimore, MD, USA, 6Tennessee Valley VA Healthcare System, Nashville, TN, USA, 7VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.
BACKGROUND: Many patients with non-muscle invasive bladder cancer (NMIBC) do not undergo surveillance cystoscopy that is aligned with their risk for recurrence and progression. Our objective was to determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines.
METHODS: We prospectively collected data from cystoscopy encounter notes from four Department of Veteran Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline concordant surveillance interval. Pathologic features were abstracted from pathology reports and operative/clinical notes to generate a gold standard NMIBC risk classification for each encounter (low, intermediate, or high risk) based on the AUA guidelines. Accurate documentation was a clinician-recorded risk classification matching the gold standard. Clinician recommendations were guideline concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline.
RESULTS: Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk disease. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, p<0.05). Guideline concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, p<0.05). Accurate documentation resulted in a 52% and 19% increase in guideline concordant surveillance recommendation for low- and intermediate-risk disease, respectively (p<0.05).
CONCLUSIONS: Lack of accurate risk documentation was associated with fewer guideline concordant surveillance recommendations among low- and intermediate-risk patients. These patients undergo more frequent cystoscopy than recommended without a clear, improved oncologic outcome. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce over surveillance in this group that could prevent undue cost, anxiety, and procedural harms. 
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