Shared Medical Appointments for Prostate Cancer Active Surveillance Follow-Up Visits.

PURPOSE: To accommodate for the rapidly increasing patient volume and follow-up visits of men with prostate cancer on active surveillance (AS), we carried out a quality improvement project to secure high-quality care and enhance patient experience. MATERIALS AND METHODS: We proposed an innovative clinic systems redesign - "Shared Medical Appointments" (SMAs) - in which multiple patients were seen in a group format at the same time by the health care team led by a urologist leading the Institution's AS program. RESULTS: We piloted four SMAs during July-November 2019. Running the SMAs was feasible and improved the contact time for each patient while at the same time being time- and resource efficient for the healthcare providers and using the standard billing processes. The group dynamic was open and pleasant. The majority of patients rated their overall experience with SMA as excellent. Almost all patients responded that they were likely or very likely to attend another SMA in the future. All patients said that they would either definitely or probably recommend this visit type to a friend of family member with prostate cancer. Most patients rated their overall satisfaction with the SMA as extremely high. CONCLUSIONS: Utilizing SMAs for AS follow-up visits was feasible and acceptable. Our promising findings suggest that SMAs can ensure high-quality patient care. Well-controlled studies comparing SMAs to individual usual care visits should be conducted with endpoints including knowledge, patient and staff satisfaction, anxiety and quality-of-life outcomes, AS adherence, process measures and resource utilization.

Assessing Quality and Safety of an Advanced Practice Provider-led Active Surveillance Clinic for Men with Prostate Cancer.

Purpose: We implemented an advanced practice provider (APP)-led clinic to aid in managing the growing population of men on active surveillance (AS) for prostate cancer. Our objective was to evaluate the quality and safety of an established APP-led AS clinic by comparing outcomes with urologist-led biopsies, defined in terms of adherence to scheduled visits and biopsy complications. Materials and Methods: We performed a retrospective review of 2341 consecutive patients treated in an AS clinic at a high-volume referral center between 2000-2019. We examined the rate of no-show or same-day cancellation of visits for APPs versus urologists and compared the risk of biopsy complications between these providers. Generalized estimating equations were used to account for repeated visits and biopsies. Results: There were significantly more no-shows at APP visits (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.16-1.70, p <0.001); however, this only amounted to one no-show every 41 visits. There was no evidence of increased biopsy complications with APPs (OR 0.37, 95% CI 0.05-2.49, p =0.3). Patients were not prospectively assigned to APP or urologist management; therefore, unmeasured patient differences could bias our results. Conclusions: We demonstrated that in an established APP-led AS clinic at a high-volume center, APPs achieved acceptable patient adherence to scheduled visits and biopsy complications. Because patients were not continuously managed by one type of provider, further prospective studies are needed to establish equivalent pathologic outcomes in APP-managed AS.

Quality improvement initiative to reduce variability and improve stewardship of antimicrobial prophylaxis for transrectal prostate needle biopsy.

PURPOSE: To assess the impact of implementing the recommendations included in the 2014 American Urological Association (AUA) white paper on complications of transrectal prostate needle biopsy (PNB). METHODS: In the outpatient setting of a single tertiary-care institution, prophylactic antibiotic use and rate of infectious complications were compared before and after implementation by nursing of a standardized algorithm to select antibiotic prophylaxis (derived from the recommendations of the AUA white paper). The 584 patients in cohort A (January 2011-January 2012) received antimicrobial prophylaxis at the discretion of the treating physician; 654 patients in cohort B (January 2014-January 2015) received standardized risk-adapted antibiotic prophylaxis. Data on antibiotics administered and infectious complications were analyzed. RESULTS: Fluoroquinolone was the most common prophylactic regimen in both cohorts. In cohort A, 73% of men received a single-drug regimen, although 19 different regimens were utilized with duration of 72 h. In cohort B, 97% received 1 of 4 standardized single-drug antibiotic regimens for duration of 24 h. Infectious complications occurred in 19 men (3.3%) in cohort A, and in 18 men (2.8%) in cohort B (difference - 0.5%; one-sided 95% CI 1.1%). No clinically relevant increase in infectious complication rates was found after implementing this quality improvement initiative. CONCLUSIONS: Use of a standardized risk-adapted approach to select antibiotic prophylaxis for PNB by nursing staff reduced the duration of antimicrobial prophylaxis and number of antibiotic regimens used, without increasing the rate of infectious complications. Our findings validate the current AUA recommendations for antibiotic prophylaxis.

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy.

INTRODUCTION: The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone. METHODS: All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient. RESULTS: Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001). CONCLUSIONS: Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

Napping in college students and its relationship with nighttime sleep.

UNLABELLED: Abstract. OBJECTIVE: To examine the habit of napping and its relationship with nighttime sleep in college students. PARTICIPANTS: Four hundred and forty undergraduate students who responded to an anonymous online survey in April 2010. METHODS: Three questions were asked to determine the frequency, length, and timing of napping during the past month. Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI). RESULTS: The PSQI score significantly differed among self-reported nap-frequency (p=.047) and nap-length (p=.017) groups, with those who napped more than 3 times per week and those who napped more than 2 hours having the poorest sleep quality. Students who napped between 6 and 9 pm had shorter sleep on school nights compared with students in other nap-timing groups (p=.002). CONCLUSIONS: College students who are self-reported frequent, long, and late nappers may have a higher risk of poor nighttime sleep quality and more severe sleep deprivation.