Introduction: Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators with associated benchmarks created utilizing available evidence and expert opinion to inform and measure future performance. Herein we report real-life benchmark performance for the management of muscle invasive bladder cancer (MIBC) relative to expert opinion guidance. Methods: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009 and 2013. Electronic records of treatment from 1,573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators first as median values obtained across hospitals or providers as well as a “pared-mean” approach to identify a benchmark population of "top performance" as defined as the best outcome accomplished for at least 10 percent of the population. Results: Overall, performance in Ontario across all indicators fell short of expert-opinion determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark>6, percent of institutions meeting benchmark=20%), percent of patients with MIBC referred pre-operatively to Medical Oncology (MO; benchmark>90%, percent of institutions meeting benchmark=2%) and Radiation Oncology (RO; benchmark>50%, percent of institutions meeting benchmark=0%), time to cystectomy within 6 weeks of TURBT in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark=0%), percent of patients with adequate lymph node dissection (defined as>14 nodes, benchmark>85%, percent of institutions meeting benchmark= 0%), percent of patients with positive margins post RC (benchmark <10%, percent of institutions meeting benchmark=46%), and 90 day mortality (benchmark <5%, percent of institutions meeting benchmark=37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly under-estimated benchmarks that were possible by top-performing hospitals. Conclusions: Performance through the majority of BC quality of care indicators fall short of benchmarks proposed by expert-opinion. Different methodologies such as a pared-mean approach of top performers may provide more realistic benchmarking. SOURCE OF Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by CIHI.
