Michigan Urological Surgery Improvement Collaborative (MUSIC)

Year 8

Report Period (March 27, 2019 – October 29, 2019)

Progress Report

A. Executive Summary

MUSIC continues to make great strides in making Michigan #1 in urologic care. There are 46 participating urology practices and more than 250 urologists that collectively represent 90% of the urologists in the state. The commitment and collaboration of the urologists, mid-level providers, staff and 12 patient advocates is critical to the program’s continued progress. In terms of the clinical registry, MUSIC now has collected data for more than 67,000 patients with, or at-risk for, prostate cancer, nearly 18,000 patients who have had kidney stone surgery, and over 1,900 patients diagnosed with a small renal mass.

MUSIC continues to drive improvements in the quality and cost-efficiency of prostate cancer care. Examples of MUSIC’s prostate-related quality improvement (QI) successes include the optimization of imaging for men with newly diagnosed cancer, a 50% reduction in transrectal ultrasound guided prostate biopsy-related infectious hospitalizations, and an improvement in treatment appropriateness with a statewide rate of active surveillance approaching 80% for men with low-risk prostate cancer. MUSIC is now expanding these efforts with the development of a prostate MRI quality assurance program, and statewide support for the implementation of office- based transperineal prostate biopsy to further reduce the rate of prostate biopsy-related infectious hospitalizations. We are continuing our efforts to improve radical prostatectomy outcomes via the collection and measurement of peri-operative complications and patient- reported functional outcomes. This work also includes strategies such as Surgical Skills Workshops and peer-to-peer video review as mechanisms for improvement. In other prostate- related work, MUSIC is continuing to support the implementation of a patient-centered decision making tool for newly diagnosed prostate cancer patients, Personal Patient Profile-Prostate (P3P), In addition, MUSIC is collaborating with the Michigan Radiation Oncology Quality Collaborative (MROQC) to improve patient selection and quality control for early salvage radiation therapy for post-radical prostatectomy patients with biochemical recurrence. We also are preparing to launch our second randomized clinical trial, the Genomics in Michigan to AdJust Outcomes in Prostate CanceR (G-MAJOR) study supported by the National Institute of Health (NIH) to understand the clinical utility of genomic classifiers in newly diagnosed favorable-risk prostate cancer patients.

In other work, MUSIC is continuing its efforts to make Michigan #1 in kidney stone care. MUSIC ROCKS (Reducing Operative Complications from Kidney Stones) has collected data on nearly 18,000 patients treated with Ureteroscopy (URS) and/or Shockwave Lithotripsy (SWL). In early work to reduce avoidable emergency department visits after URS, we created patient education materials for the management of stent-related symptoms, as well as a Pain-control Optimization Pathway (POP) to provide physicians and patients guidance on pain management after surgery. We are now expanding these efforts with a “grassroots” approach to QI which included a group of urologists from five diverse urology practices considering local opportunities and strategies for reducing the risk of operative complications after ureteroscopy, and now charging the rest of the collaborative to do the same. In other work, as MUSIC aims to develop appropriateness guidelines for the use of ureteral stents during ureteroscopy, we formed a panel of 17 MUSIC urologists representing diverse practices and regions within Michigan who are participating in a six-month process that will culminate in a consensus around proposed ureteral stent criteria and guidelines. Finally, MUSIC ROCKS is initiating efforts to enhance treatment appropriateness with the formation of a working group comprised of MUSIC urologists focused on developing specific criteria and guidance regarding SWL appropriateness.

MUSIC’s newest program, MUSIC KIDNEY, is focused on improving the quality of care for patients with small renal mass diagnoses. MUSIC KIDNEY officially launched in January 2019 with eleven MUSIC practices currently participating and at least four more sites expected to join by the end of the year. MUSIC KIDNEY’s primary objectives include improving guideline adherence and documentation to optimize the management of patients with small renal masses (≤ 7cm) and reducing the overall burden of treatment for these patients. Current efforts are focused on enhancing the frequency and quality of the documentation of tumor complexity (RENL score) as it correlates with treatment decision and pathological outcomes regardless of tumor size and is critical to our ability to identify opportunities for improvement. MUSIC KIDNEY is also in the process of formalizing and disseminating MUSIC-specific guidelines for the utilization of chest imaging for patients with small renal mass diagnoses.

Vital Performance Statistics

QI initiative** Overall Rate (2019 Rate)* Target
Reduce TRUS biopsy-related infectious hospitalizations 0.7%** (0.7%) <0.8%
Improve medical record documentation of Clinical TNM Staging (maintenance metric) 87% (93%) >85%
Improve patterns of care in radiographic staging of men with newly diagnosed prostate cancer Bone Scan

  • Indicated = 77% (N/A)
  • Not-Indicated = 6% (N/A)

CT Scan

  • Indicated = 67% (N/A)
  • Not Indicated = 7% (N/A)
Indicated = > 95%
Not-Indicated = < 10%
NOTES: Reduce readmissions after radical prostatectomy 4.4% (4.1%) <17%<3.9%
Improve Patient Reported Outcomes following Radical Prostatectomy

  • Increase MUSIC PRO patient enrollment to 70% of the collaborative prostatectomy population
  • Increase the percent of patients with early return to good urinary function
PRO enrollment: 56% (81%) Percent of patients with early return to good urinary function to:

  • 3 months = 64% (65%)
  • 6 months = 83% (81%)
PRO Enrollment ≥ 70% Urinary Function:
3 months ≥ 75%
6 months ≥ 90%
Increase the overall rate of Active Surveillance (AS) in favorable risk patients and reduce variation in utilization across practices and providers
  • Consideration of AS = 64% (84%)
  • Confirmatory testing in AS Eligible Patients = 30% (51%)
  • Verified AS = 55% (67%)
  • Performance of Recommended Follow-Up Over 30 Months =16% (N/A due to 30-month runout)
TBD –Establishing specific goals
Reduce the rate of emergency department (ED) visits, as well hospitalizations within 30 days after ureteroscopy (URS) and improve the appropriateness of shockwave lithotripsy (SWL)
  • ED visits after URS = 8.7% (7.5%)
  • Appropriateness of SWL = TBD
  • Decrease avoidable ED visits (~30% of all ED visits) by 25 – 33% = 7.9% – 7.7% (7% – 6.8% post-intervention)
  • Appropriateness of SWL = TBD
Improve the quality of care for patients with small renal mass diagnoses
  • RENL documentation = 33% (41%)
  • Chest imaging utilization and appropriateness per MUSIC guidelines = TBD (guidelines introduced October 2019)
  • Rate of treatment for benign masses = TBD
Metrics defined; In process of establishing goals

*“Overall rate” indicates the rate since MUSIC inception, including performance pre and post-intervention.
The rate in parentheses is the performance solely for 2019.
**Post-intervention rate

Recent Successes (a list of MUSIC’s major accomplishments in the last 6 months)

  • Recruited Memorial Healthcare – Urology (2 participating urologists), into MUSIC for a current total of 46 participating practices
  • Completed in-person “implementation and dissemination” quality improvement site visits with 44 MUSIC practices in 2019. The goal of these visits is to educate all MUSIC members on our collaborative’s vast QI portfolio, demonstrating where the practice stands compared to the rest of the collaborative, and disseminate resources that support MUSIC’s QI interventions.
  • Advanced efforts in the statewide adoption of office-based transperineal prostate biopsy
    • Trained 14 MUSIC urologists via in-person proctored sessions on the office-based transperineal biopsy technique, which can serve as an alternative to transrectal ultrasound guided biopsy. The goal of this work is to further decrease the risk of infection after prostate biopsy and lessen the use of antibiotics.
    • Hosted MUSIC’s first Transperineal Procedures Skills Workshop where more than 70 participants including > 60 MUSIC urologists had the opportunity to learn skills and techniques for performing transperineal biopsy procedures, engaging in hands-on proctored biopsy and spaceOAR simulation.
  • Continued development of the prostate MRI quality assurance program:
    • Collected data on 2,500 additional prostate MRIs (> 7,500 total) and 1,000 fusion biopsies (> 2,500 total)
    • Organized and attended multidisciplinary review of fusion biopsy data with 4 additional MUSIC practices (total of 11 practices have had these reviews) and conducted second round reviews with 3 practices. These meetings include urologists and radiologists as they examine MRI images, fusion system data,and pathology reports for selected cases with discordant pathology and radiology results to identify sources of error and opportunities for improvement.
    • Assembled a Radiology Working Group with representation from 12 radiologists from seven MUSIC practices to provide input and expertise concerning MUSIC’s prostate MRI and fusion biopsy quality assurance program e.g., feedback on data points, analyses to consider, insight on changes or trends in the use of prostate MRI etc.
  • Enhancing patient-centered decision making among newly diagnosed prostate cancer patients
    • Eleven MUSIC practices (three since the last report), including 35 MUSIC urologists, are now offering P3P to their patients.
    • Conducted a formal evaluation of the use of P3P which included phone interviews with physicians and staff from 16 MUSIC practices, 8 that have implemented P3P and 8 that have not implemented with the goals of understanding how practices are implementing P3P, facilitators and barriers to implementation, and perceptions of urologists and clinic staff about P3P
  • As part of the Notable Outcomes and Trackable Events after Surgery (NOTES) initiative, we continue to look for ways to reduce readmissions after radical prostatectomy (RP). We are currently taking a practice-level approach where we are targeting the higher volume, higher readmission practices and evaluating the RP process from the time a patient decides to have surgery through 30 days’ post-discharge. We have completed the in depth process analysis using the Lean methodology at two higher volume practices and began acting on identified opportunities for improvement at one site, and soon will commence with the second site. Lessons learned from the practice-level process analyses will be shared with the larger collaborative.
  • In support of our efforts to improve radical prostatectomy outcomes through the use of surgical video review, we continued to develop and refine a video library that will be made publically available by the end of the year.
  • Implemented the Michigan Pain-control Optimization Pathway (MPOP) for ureteroscopy and vasectomy, developing and disseminating physician and patient resources to MUSIC members.
  • Initiated a collaboration with the Michigan Radiation Oncology Quality Consortium (MROQC) focused on improving the use of early salvage radiation therapy patients with biochemical recurrence following radical prostatectomy.
  • Secured NIH funding for MUSIC’s second randomized clinical trial, Genomics in Michigan to AdJust Outcomes in Prostate CanceR (G-MAJOR). This study will evaluate the clinical utility of genomic classifiers in newly diagnosed favorable-risk prostate cancer patients. MUSIC plans to spend the next 3 – 6 months recruiting and onboarding MUSIC participating sites with a goal of launching the trial by second quarter 2020.
  • MUSIC ROCKS
    • Completed the monthly ROCKS ED visit working group calls, a grassroots effort aimed at identifying local opportunities and strategies for reducing ED visits after ureteroscopy. Key lessons learned and takeaways were shared with the broader collaborative at the October statewide gathering and all MUSIC practices have been tasked with identifying their own local opportunities and strategies for improvement.
    • Established a panel of 17 MUSIC urologists to participate in a six-month process that will culminate in a consensus around proposed ureteral sent criteria and guidelines.
    • Formed a coalition of urologists focused on optimizing treatment outcomes with appropriate case selection for shockwave lithotripsy
    • Established a pilot ROCKS Patient Reported Outcomes (PROs) process at one MUSIC practice to 1) ensure adequate pain management following the implementation of MPOP for URS and recommendation for zero opioids and 2) understand the feasibility of collecting PROs for ROCKS patients with a goal of creating an electronic infrastructure for collaborative-wide ROCKS PROs collection in 2020.
  • MUSIC KIDNEY
    • Continued to focus on growing the registry with data now on more than 1,900 patients with small renal mass diagnoses
    • Disseminated the RENL placards to MUSIC practices via the implementation and dissemination site visits
    • Established MUSIC chest imaging guidelines to be formally disseminated via a placard to be used in clinic
  • MIPS Quality Clinical Data Registry (QCDR)
    • Successfully submitted the 2018 reporting period data validation execution report
    • Approved as a 2020 MIPS QCDR for the quality and improvement activities components of the MIPS Quality Payment Program
  • Presented 21 MUSIC abstracts (12 prostate, 7 ROCKS, and 2 KIDNEY) to the American Urological Association (AUA) 2019 Annual Meeting with 44 MUSIC urologists serving as authors/co-authors.
  • Two additional scientific manuscripts accepted for publication (a complete list of MUSIC publications can be found here: http://musicurology.com/publications/)

Future Directions/Plans

1. Prostatebiopsy

We continue to meet our target for reducing biopsy-related infectious hospitalizations of < 1%, but are determined to see if we can decrease the rate even further while also improving antibiotic stewardship. Our past efforts focused around transrectal ultrasound-guided (TRUS) prostate biopsy and as we continue to look for ways to improve, we are now shifting our focus to transperineal prostate biopsy as an alternative approach that demonstrates a nearly 0% risk of infection while also allowing for fewer antibiotics. In support of our efforts, BCBSM approved a modifier-22 for BCBSM PPO patients to help offset the expenses associated with implementing the new approach. MUSIC recently conducted its first Transperineal Procedures Skills Workshop where participants had the opportunity to learn skills and techniques for performing transperineal biopsy procedures, engaging in hands-on proctored biopsy and spaceOAR simulation. There are currently 14 urologists across 5 practices that have been trained on transperineal prostate biopsy and the Coordinating Center will continue to support urologists that are interested in adopting the new approach, helping them to understand the equipment needs and associated costs via a thorough site assessment, and providing in-person proctoring when ready to implement.

2. Prostate MRI and Fusion Biopsy

We have collected data on over 7,500 prostate MRIs and 2,500 fusion biopsies. The Coordinating Center disseminates practice-level MRI and Fusion Biopsies Scorecards to practices ordering and performing these tests and have organized and attended multidisciplinary review of fusion biopsy data at all MUSIC practices that have performed at least 30 fusion biopsies (11 MUSIC practices in total) and conducted second round reviews with three of these practices. At these meetings, local urologists and radiologists examine MRI images, fusion system data, and pathology reports for selected cases with discordant pathology and radiology results to identify sources of error and opportunities for improvement. As additional MUSIC practices are performing an increasing number of fusion biopsies, we will soon be conducting multi-disciplinary reviews with these additional groups. We recently began collecting MRI data on patients with negative prostate biopsies so that we can calculate the negative predictive value (NPV) of prostate MRI across the state. Collection of this data is important as improvements in the NPV of prostate MRI could ultimately lead to a reduction in unnecessary biopsies thereby reducing cost and morbidity for urologic patients. We are currently working with radiology colleagues on the development of an MRI/fusion biopsy composite score that can be provided to each practice to help evaluate the overall success of the prostate MRI quality assurance program. A prostate MRI interpretation workshop at the January 2020 collaborative-wide gathering.

3. Post-operative course following RP

In our efforts to improve radical prostatectomy outcomes, as part of the Notable Outcomes and Trackable Events after Surgery (NOTES) program, we are continuing to examine strategies for reducing readmissions within 30 days following surgery. We are now taking a practice-level approach, working with the higher volume radical prostatectomy practices to better understand local processes and key drivers for readmissions. As we identify opportunities and strategies for improvement, we hope to not only make change at the local level, but also disseminate the information and lessons learned to the broader collaborative. We have evaluated the processes for two higher volume practices and are now in the process of acting on some of the key opportunities for improvement. MUSIC also continues to support the implementation of the BCBSM Michigan Pain-control Optimization Pathway (MPOP) that aims to safely limit, if appropriate, the number of opioid tablets a patient receives following radical prostatectomy. MUSIC has already been able to successfully reduce the mean number of pills prescribed per procedure from 10 pills to 6 pills and reduced the number of refills by 50%.

4. Patient Reported Outcomes and VIDEO

MUSIC’s Patient Reported Outcomes (PRO) program continues to grow with more than 6,000 patients enrolled. We remain focused on our goals of enrolling at least 70% of radical prostatectomies into MUSIC PRO and also achieving best in world early social continence (0 – 1 pads/day) after radical prostatectomy with a goal of 75% of patients achieving this outcome at 3 months and 90% at six months. In considering our strategies to improve, we continue to provide surgeons feedback on outcomes and provide specific physician education tools regarding urinary incontinence risk factors. We developed and will soon disseminate a urinary incontinence educational brochure for physicians to give to give to their patients undergoing surgery and continue to promote survivorship activities such as pelvic floor therapy with resources made available via askMUSIC. Further, we have conducted 9 surgical skills workshops over the last 2.5 years and developed a video library to house the radical prostatectomy videos and serve as an interactive platform for physicians to discuss variances in technique and what may lead to better outcomes. However, despite all of these efforts, we have been unable to make a significant impact in improving patients’ functional outcomes after surgery. The Coordinating Center, in conjunction with MUSIC members, will continue to consider strategies for improvement.

5. Treatment Appropriateness

MUSIC continues its work to improve treatment appropriateness for men with newly diagnosed prostate cancer. As part of the in-person implementation and dissemination site visits, we review each practice’s performance on the six active surveillance measures and discuss specific areas for improvement. The Coordinating Center continues to advocate for the use of the AS Roadmap and supporting resources which are now also available electronically via askMUSIC. We are collaborating with the Department of Learning Health Sciences at Michigan Medicine to leverage machine learning to create a predictor for treatment-free probability for newly diagnosed prostate cancer patients considering active surveillance. Furthermore, as Primary Care Physicians (PCPs) may follow patients on Active Surveillance, we are using both MUSIC registry and claims data to investigate factors that impact a patient’s likelihood to stay on Active Surveillance and understand if there is a difference if the patient is following with a urologist versus a PCP. As patient-centered decision making is also a key component of treatment appropriateness, MUSIC continues to leverage from the Personal Patient Profile-Prostate (P3P), to assist in shared decision making for patients with localized prostate cancer. The Coordinating Center, in partnership with the Movember Foundation, will continue to offer this as a resource to MUSIC members and support local practice implementation.

6. Other Prostate-Related Work

We are focused on enhancing patient selection and quality assurance for early salvage radiation therapy for post-radical prostatectomy patients through the evaluation of MUSIC data, practice- level performance feedback and a collaboration with the Michigan Radiation Oncology Quality Collaborative (MROQC). In other news, MUSIC continues to monitor the study cohort from our first randomized clinical trial, the Genomics in Michigan ImpactiNg Observation or Radiation (G- MINOR), and is preparing to evaluate and present data related to the efficacy of a genomic biomarker on adjuvant treatment decisions in patients at high-risk for cancer recurrence after radical prostatectomy at the January 2020 collaborative-wide gathering. We are also preparing to launch our second randomized clinical trial, the Genomics in Michigan to AdJust Outcomes in Prostate CanceR (G-MAJOR) study supported by the National Institute of Health (NIH) to understand the clinical utility of genomic classifiers in newly diagnosed favorable-risk prostate cancer patients. We are actively recruiting MUSIC practices to participate and plan to initiate the study by second quarter 2020. We also continue to engage in several Movember Foundation initiatives, including GAP3 (Active Surveillance Database) and the TrueNTH Global Registry which is an international effort to compare and reduce variation in prostate cancer outcomes.

7. ROCKS(Reducing Operative Complications following Kidneystone Surgery)

MUSIC ROCKS has collected data on nearly 18,000 patients treated with Ureteroscopy (URS) and/or Shockwave Lithotripsy (SWL). In early work to reduce avoidable emergency department visits after URS, we created patient education materials for the management of stent-related symptoms, as well as a MUSIC Pain-control Optimization Pathway (POP) to provide physicians and patients guidance on pain management after surgery. We are now expanding these efforts with a “grassroots” approach to quality improvement, challenging practices to consider local opportunities and strategies for reducing the risk of operative complications after kidney stone surgery. In other work, as MUSIC aims to develop appropriateness guidelines for the use of ureteral stents during ureteroscopy, we formed an expert panel of 17 MUSIC urologists whom are participating in a six-month process that will culminate in a consensus around proposed ureteral sent criteria and guidelines. We are also evaluating the use of post-operative imaging after ureteroscopy, recognizing significant variation among practices and an opportunity for improvement as we aim to decrease risks associated with hydronephrosis and residual stones.

We are also initiating efforts to enhance treatment appropriateness with plans to develop a brochure that can help to educate patients on the difference between URS and SWL and provide some guidance on when one procedure would be more appropriate than the other. Further, as a means to ensure appropriate pain management for patients undergoing ureteroscopy since the implementation of MPOP for URS and the recommendation of a zero opioid pathway, MUSIC initiated a manual PROs pilot process at one MUSIC practice. Patient feedback is collected at baseline, 7 days post-surgery and 6 weeks post-surgery. The data will be analyzed later this year and the findings will be shared with the collaborative in January 2020. While this work will ideally substantiate the use of no opioids after ureteroscopy, we plan to leverage from the lessons learned and in the next 6 months develop an electronic infrastructure for capturing PROs for URS and SWL patients within the MUSIC registry.

8. KIDNEY

MUSIC KIDNEY’s primary objectives include improving guideline adherence and documentation to optimize the management of patients with small renal masses (≤ 7cm) and reducing the overall burden of treatment for these patients. Current efforts are focused on enhancing the frequency and quality of the documentation of tumor complexity (RENL score) as it correlates with treatment decision and pathological outcomes regardless of tumor size and is critical to our ability to identify opportunities for improvement. MUSIC KIDNEY is also formalizing MUSIC- specific guidelines for the utilization of chest imaging for patients with small renal mass diagnoses. We are investigating the opportunity for avoiding intervention (e.g., nephrectomy) for benign renal masses with a goal of reducing the overall burden of treatment for patients with small renal masses and optimizing the use of renal mass biopsy. Further, while our current focus is on patients with small renal mass diagnoses, we are now allowing practices to enter patients with larger renal masses (> 7 cm) so that we can consider potential improvement opportunities for this population. This expansion is currently optional for all MUSIC practices.