The following is a summary of “Accurate Documentation Contributes to Guideline-concordant Surveillance of Nonmuscle Invasive Bladder Cancer: A Multisite Department of Veterans Affairs Study,” published in the November 2023 issue of Urology by Lyall, et al.

For a study, researchers sought to investigate the association between accurate documentation of bladder cancer risk and the concordance of clinician surveillance recommendations with the guidelines set by the American Urological Association (AUA) among patients diagnosed with nonmuscle invasive bladder cancer (NMIBC).

Prospective data was collected from cystoscopy encounter notes across four Department of Veterans Affairs (VA) sites. They aimed to determine if the documentation accurately reflected the NMIBC risk and if the clinician’s surveillance recommendation aligned with AUA guidelines. Accuracy was defined as clinician-recorded risk classification matching the gold standard assigned by the research team. Guideline concordance was determined by evaluating if the clinician’s recorded surveillance interval adhered to the AUA guideline.

Of 296 encounters, risk categorization was found to be 75 low-risk, 98 intermediate-risk, and 123 high-risk NMIBC cases. Accurate risk documentation was found in 52% of encounters, with lower rates for low-risk cases (36% vs. 52% and 62% for intermediate- and high-risk, respectively; P < .05). Guideline-concordant surveillance recommendations were also less common in low-risk cases (67% vs. 89% and 94% for intermediate- and high-risk, respectively; P < .05). Accurate documentation correlated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk diseases, respectively (P < .05).

Accurate documentation of bladder cancer risk was associated with higher rates of guideline-concordant surveillance recommendations, particularly for low- and intermediate-risk patients. Implementing strategies to facilitate accurate risk assessment and documentation could potentially reduce the overuse of surveillance, preventing unnecessary costs, anxiety, and procedural harm in the patient group.

Source: goldjournal.net/article/S0090-4295(23)00729-X/fulltext