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Background: Studies have demonstrated that Black men may undergo definitive prostate cancer (CaP) treatment less often than men of other races, but it is unclear whether they are avoiding overtreatment of low‐risk disease or experiencing a reduction in appropriate care. The authors' aim was to assess the role of race as it relates to treatment benefit in access to CaP treatment in a single‐payer population. Methods: The authors used the Veterans Health Administration (VHA) Corporate Data Warehouse to perform a retrospective cohort study of veterans diagnosed with low‐ or intermediate‐risk CaP between 2011 and 2017. Results: The authors identified 35,427 men with incident low‐ or intermediate‐risk CaP. When they controlled for covariates, Black men had 1.05 times the odds of receiving treatment in comparison with non‐Black men (P <.001), and high‐treatment‐benefit men had 1.4 times the odds of receiving treatment in comparison with those in the low‐treatment‐benefit group (P <.001). The interaction of race and treatment benefit was significant, with Black men in the high‐treatment‐benefit category less likely to receive treatment than non‐Black men in the same treatment category (odds ratio, 0.89; P <.001). Conclusions: Although race does appear to influence the receipt of definitive treatment in the VHA, this relationship varies in the context of the patient's treatment benefit, with Black men receiving less definitive treatment in high‐benefit situations. The influence of patient race at high treatment benefit levels invites further investigation into the driving forces behind this persistent disparity in this consequential group. Race appears to influence the receipt of definitive treatment in the Veterans Health Administration, and this relationship varies in the context of the patient's treatment benefit, with Black men receiving less definitive treatment in high‐benefit situations. The influence of patient race at high treatment benefit levels invites further investigation into the driving forces behind this persistent disparity in this consequential group. [ABSTRACT FROM AUTHOR]

Background: Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism.Objective: To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.Design: Retrospective cohort study.Setting: U.S. Veterans Health Administration.Participants: Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes.Measurements: Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP.Results: 4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time.Limitations: Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism.Conclusion: In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.Primary Funding Source: National Institutes of Health. [ABSTRACT FROM AUTHOR]

Background: Although prostate‐specific antigen (PSA) testing is used for prostate cancer detection and posttreatment surveillance, thresholds in these settings differ. The screening cutoff of 4.0 ng/mL may be inappropriately used during postsurgery surveillance, where 0.2 ng/mL is typically used, creating missed opportunities for effective salvage radiation treatment. We performed a study to determine whether guideline concordance with annual postoperative PSA surveillance increases when PSA values exceed 4 ng/mL, which represents a screening threshold that is not relevant after surgery. Methods: We used US Veterans Health Administration data to perform a retrospective longitudinal cohort study of men diagnosed with nonmetastatic prostate cancer from 2005 to 2008 who underwent radical prostatectomy. We used logistic regression to examine the association between postoperative PSA levels and receipt of an annual PSA test. Results: Among 10 400 men and 38 901 person‐years of follow‐up, annual guideline concordance decreased from 95% in year 1 to 79% in year 7. After adjustment, guideline concordance was lower for the youngest and oldest men, Black, and unmarried men. Guideline concordance significantly increased as PSA exceeded 4 ng/mL (adjusted odds ratio 2.20 PSA > 4‐6 ng/mL vs PSA > 1‐4 ng/mL, 95% confidence interval 1.20‐4.03; P =.01). Conclusions: Guideline concordance with prostate cancer surveillance increased when PSA values exceeded 4 ng/mL, suggesting a screening threshold not relevant after prostate cancer surgery, where 0.2 ng/mL is considered treatment failure, is impacting cancer surveillance quality. Clarification of PSA thresholds for early detection vs cancer surveillance, as well as emphasizing adherence for younger and Black men, appears warranted. [ABSTRACT FROM AUTHOR]

1. Identify opportunities to improve perioperative communication about goals for patients with urologic serious illness. 2. Understand the value of having both Palliative Care Specialists and Urologists involved in preoperative conversations about patient goals. A joint Urology-Palliative Care team approach to navigating patient goals is warranted in advance of surgery for patients with urologic serious illness. In coordination, Urologists and PC can offer complementary contributions to different parts of a goals of care conversations, covering both goals of care generally and developing shared understanding of risks and realistic expectations of what surgery can achieve. Care for urologic serious illness often includes surgery; preoperative shared decision making about patient goals is often inadequately implemented in surgical settings. To understand perspectives on improving perioperative communication about goals for patients facing urologic serious illness. We conducted 37 semi-structured interviews with Palliative Care Physicians (PC) (11), Urologists (13) and interdisciplinary clinicians (13) at fourteen geographically distributed Veteran Health Administration (VHA) sites. The analytic approach relied on content analysis with dual review; analysis is conducted separately by provider type and triangulated. 1) In existing pre-operative workflows: "patients are not [always] aware that we might be able to palliate their symptoms without surgery" (URO). 2) Goal of surgery is often something patients really need help understanding, e.g. "It's gonna help temporarily, but it's not gonna help long term" (PC). 3) PC is not in the position to have the part of the goal of care conversation that clarifies the goal of the surgery: "it's very hard for non-surgeon to have a robust goals of care discussion with the patient who's co-managed with surgery unless surgery is able to give you a sense of what to expect." (PC) 4) A team approach to clarifying and navigating patient goals is warranted: "how do we work together to sort of think about prognosis, how to plan ahead for care after the surgery and then setting sort of real realistic expectations and goals for after the surgery?"(PC). 5) In coordination, Urologists and PC can offer complementary contributions to different parts of a goals of care conversation: "the interventionists would better know how effective the intervention is going to be, but PC probably has much better perspective on how the patient is doing overall." (URO) Patients will benefit from a urology-PC team approach to clarifying goals of care and surgery. Shared Decision Making / Advance Care Planning / Surgical / Palliative Care [ABSTRACT FROM AUTHOR]

1. Identify time points along the perioperative continuum where PC and Urology can be better integrated. 2. Understand the importance of the perioperative period as a focus for future interventions to improve quality of care in patients facing urologic serious illness. Stakeholder interviews reveal a general overall need to create a culture change so that palliative care is integrated appropriately for patients with urologic serious illness. Many urologic serious illnesses are treated with surgical procedures, which may put patients at a further risk of diminished quality of life. To understand stakeholder perceptions on integrating perioperative Palliative Care (PC) for patients with serious urologic illness. We conducted semi-structured interviews with purposefully sampled palliative care physicians (11), urologists (13), and clinical team members (13) at eleven geographically distributed Veteran Health Administration sites. Team-based thematic analysis was conducted to consensus with a dual review in Atlas.ti. We identified one general overall theme and three themes representing needs along the perioperative continuum as opportunities for integrating PC and urology. The general overall need was to "change culture" so that PC is not a "last resort" and "ideally, we would be starting palliative [care], when [we] start curative [treatment]." Opportunity 1: Utilizing telehealth and team member role expansion when discussing diagnosis and treatment options, with urologic surgery as a potential treatment, allows for multiple conversations "so they're not rushed in 15 minutes to mentally deal with the new diagnosis of cancer." Opportunity 2: Creating a process to ensure goal of surgery conversations occur with both urologists and PC, since "urologic procedures can have complications that significantly impact quality of life," which "would require changing how our workflow is structured." Opportunity 3: During the pre-operative visits, there can be interdisciplinary input and evaluation of the patient prior to surgery, so that the patient can "have a sort of joint meeting with us and the urologist." This represented the last point in time to de-escalate and offer non-surgical options prior to surgery. The study informs future interventions to improve the quality of care by integrating palliative care with urology. Future work can build on these findings by implementing the opportunities and determining how it impacts patient outcomes. Interdisciplinary Teamwork/Professionalism/Qualitative and Mixed Methods Research [ABSTRACT FROM AUTHOR]

Objectives: To determine if an automatically calculated electronic health record score can estimate intermediate-term life expectancy in men with prostate cancer to provide guideline concordant care.Methods: We identified all men (n = 36,591) diagnosed with prostate cancer in 2013-2015 in the VHA. Of the 36,591, 35,364 (96.6%) had an available Care Assessment Needs (CAN) score (range: 0-99) automatically calculated in the 30 days prior to the date of diagnosis. It was designed to estimate short-term risks of hospitalization and mortality. We fit unadjusted and multivariable Cox proportional hazards regression models to determine the association between the CAN score and overall survival among men with prostate cancer. We compared CAN score performance to two established comorbidity measures: The Charlson Comorbidity Index and Prostate Cancer Comorbidity Index (PCCI).Results: Among 35,364 men, the CAN score correlated with overall stage, with mean scores of 46.5 ( ± 22.4), 58.0 ( ± 24.4), and 68.1 ( ± 24.3) in localized, locally advanced, and metastatic disease, respectively. In both unadjusted and adjusted models for prostate cancer risk, the CAN score was independently associated with survival (HR = 1.23 95%CI 1.22-1.24 & adjusted HR = 1.17 95%CI 1.16-1.18 per 5-unit change, respectively). The CAN score (overall C-Index 0.74) yielded better discrimination (AUC = 0.76) than PCCI (AUC = 0.65) or Charlson Comorbidity Index (AUC = 0.66) for 5-year survival.Conclusion: The CAN score is strongly associated with intermediate-term survival following a prostate cancer diagnosis. The CAN score is an example of how learning health care systems can implement multi-dimensional tools to provide fully automated life expectancy estimates to facilitate patient-centered cancer care. [ABSTRACT FROM AUTHOR]

Purpose: Accurate life expectancy estimates are required to inform prostate cancer treatment decisions. However, few models are specific to the population served or easily implemented in a clinical setting. We sought to create life expectancy estimates specific to Veterans diagnosed with prostate cancer.Materials and Methods: Using national Veterans Health Administration electronic health records, we identified Veterans diagnosed with prostate cancer between 2000 and 2015. We abstracted demographics, comorbidities, oncologic staging, and treatment information. We fit Cox Proportional Hazards models to determine the impact of age, comorbidity, cancer risk, and race on survival. We stratified life expectancy estimates by age, comorbidity and cancer stage.Results: Our analytic cohort included 145,678 patients. Survival modeling demonstrated the importance of age and comorbidity across all cancer risk categories. Life expectancy estimates generated from age and comorbidity data were predictive of overall survival (C-index 0.676, 95% CI 0.674-0.679) and visualized using Kaplan-Meier plots and heatmaps stratified by age and comorbidity. Separate life expectancy estimates were generated for patients with localized or advanced disease. These life expectancy estimates calibrate well across prostate cancer risk categories.Conclusions: Life expectancy estimates are essential to providing patient-centered prostate cancer care. We developed accessible life expectancy estimation tools for Veterans diagnosed with prostate cancer that can be used in routine clinical practice to inform medical-decision making. [ABSTRACT FROM AUTHOR]