The Institute of Medicine’s definition of quality is “the magnitude to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”¹ Quality of care can be quantitatively measured using quality indicators (QIs) that provide the benchmark for appropriate basic care that should be provided (basic care, or the “floor”). In comparison, clinical guidelines represent the highest level of care with supporting evidence (optimal care, or the “ceiling”). However, not all clinical guidelines are based on studies with diverse patients representing the U.S. population.^2,3

According to Donabedian, quality can be assessed from three sequential domains: structure, process, and outcomes (Table 1).⁴ Structural QIs evaluate setting characteristics in which care takes place, which can have the propensity to influence the processes of care that can diminish or enhance outcomes quality. All clinical interactions between physician and patients, such as diagnoses and treatments, represent process quality measures. Outcomes refer to changes in a patient’s current or future health status that can be attributed to antecedent health care. Quality is often measured using outcomes analyses. However, there are inherent limitations when analyzing outcomes that result from multifactorial components within and outside a health care system that determine the quality of care. Establishing whether an outcome is due to a specific structure or process is challenging. For example, did a patient have a negative margin after a radical prostatectomy because of his disease characteristics or because of his surgeon’s expertise or technique? However, outcomes research can identify disparities in care and be utilized to make external validity comparisons after controlling for factors, such as comorbidities.

Table 1. Donabedian Framework^1,4

Koh et al. recently conducted a systematic review of QIs in urology and identified 57 sets of QIs, with the majority focusing on surgical metrics for prostate, bladder, and testicular malignancies.⁵ The review identified two QI categories for women: pregnancy-specific urinary tract infection QIs and our previously developed urinary incontinence QIs for women.⁶ Using these urinary incontinence QIs, we demonstrated deficiencies in the care provided in two different clinical settings for all women, with older women receiving worse care.⁶ We also developed QIs for the management of pelvic organ prolapse.⁷ Although few QIs specific to women’s urological conditions exist, there are numerous quality-of-care studies, including qualitative work identifying patient priorities. In our prior analysis of sling outcomes in a Latina population, a largely understudied population in the urologic literature, we found that cure rates were satisfactory in patients with either pure stress or mixed incontinence despite persistent urge symptoms⁸, paralleling outcomes in White women. Uberoi et al. conducted focus groups inquiring about mid-urethral sling mesh complications among women and found that patients with complications prioritized prompt referral to specialists familiar with mesh complications and the availability of multidisciplinary care.⁹

Unfortunately, as with quality-of-care research in many fields, there is a great need for improvement in the urological care for women. There remains an overuse of cystoscopy for women with recurrent urinary tract infections, despite the fact that diagnostic cystoscopy is low yield and not indicated in uncomplicated cases.¹⁰ Despite the evidence supporting the use of vaginal estrogen for management of genitourinary syndrome of menopause and recurrent urinary tract infection, there remain challenges disseminating this practice due to (unfounded) concerns of systemic estrogen use.^11,12 Referral patterns for microscopic hematuria among women have been found to generate unnecessary expenditures (new consultation, cystoscopy, and CT urogram) due to a lack of guideline adherence for initiation of a specialty referral.¹³ A prospective analysis to define properly collected urine specimens in women during the workup of microscopic hematuria supports the use of catheterization to improve sample quality rather than provide an unnecessary workup.¹⁴ Racial and ethnic differences among women with overactive bladder have also been documented. Syan et al. found that female sex, younger age, White race, higher annual income, and prior use of oral medications were associated with receiving advanced therapies, such as sacral neuromodulation.¹⁵

In urological oncology, prior studies identified sex-specific differences in outcomes among patients diagnosed with renal cell carcinoma and bladder cancer. Metcalf et al analyzed gender differences in managing clinical T1a renal cell carcinoma before and after the 2009 American Urological Association guidelines, recommending nephron sparing treatments.¹⁶ They identified that, although the overall rates of radical nephrectomy decreased, women had higher odds of undergoing a radical nephrectomy (OR = 1.27, P < 0.001) despite lower odds of pathologic staging (OR = 0.75, P = 0.024).¹⁶ Although the incidence of bladder cancer is lower among women, they have more advanced disease at diagnosis and worse outcomes. Dobruch et al conducted a systematic review of bladder cancer outcomes and found that men were more likely to undergo guideline-concordant imaging.¹⁷ They also found higher cancer-specific mortality among women after controlling for tumor stage and treatment modality.¹⁷ Utilizing an Ohio state cancer database, Bukavina et al found that female biological sex, Black race, and higher neighborhood poverty level were associated with worse bladder cancer-specific mortality.¹⁸ Scosyrev et al. found Black women were more likely to have muscle invasive bladder cancer at the time of diagnosis compared to White women.¹⁹ Further research is needed to determine whether these differences in outcomes between men and women reflect disparities in care versus differences in biology.

Due to the gendered nature of urologic evaluations and genitourinary anatomy, it is important to consider the role of sex as a biological variable to advance the quality of care among women. Additionally, when analyzing structural quality, incorporating the intersectionality of patient and community demographics, such as ethnicity, gender, sex, age, and socioeconomic status, is essential to understanding quality-of-care metrics. Since guidelines are largely based on studies of homogenous populations, recruiting diverse patients in clinical research is an important next step. Although many strides have been made in understanding the quality of urological care and outcomes among women, there remains a need to improve sex-specific quality measures. Developing health equity QIs in urology is an important and attainable goal. Lastly, identifying disparities and improving urological care for women helps further care for all patients.