In the wake of the National Academy of Medicine’s report, “Improving Diagnosis in Health Care,” the concept of diagnostic excellence has emerged as a model to support the delivery of effective, patient-centered care of the highest quality. As defined by Yang et al in their seminal JAMA publication, “Diagnostic excellence refers to an optimal process to attain an accurate and precise explanation about a patient’s condition. An optimal process would be timely, cost-effective, convenient, and understandable to the patient. An accurate and precise diagnosis gains clinical value insofar as it leads to better choices in treatment.”¹

Given the absence of a corresponding medical specialty, urology is relatively unique among surgical specialties, with a breadth of common diagnostic processes bridging primary care and specialist practice. Against this backdrop, the AUA has developed practice guidelines for numerous conditions prevalent in primary care as well as urology, for which additional clinical guidance often is lacking. These evidence-based documents have evolved toward increasingly risk-stratified recommendations featuring individualized evaluation that aim to reduce avoidable harms and costs while focusing attention and resources on patients in greatest need. Salient examples include AUA’s 2020 guideline for the evaluation of hematuria and the recently updated 2023 guideline supporting the early detection of prostate cancer. To date, the principles of diagnostic excellence have not been explicitly articulated into AUA’s research and education activities, though the foundation for this is well established.

The principle of diagnostic excellence spans the dimensions of quality outlined by the Institute of Medicine in 2001—care that is safe, effective, patient centered, timely, efficient, and equitable. While all of these dimensions are of critical importance, the urgency of addressing inequity has appropriately gained increased attention and focus. With respect to urologic conditions, some of the most salient and long-standing equity gaps have been observed in prostate cancer.² Most notably, Black men experience higher incidence rates, more aggressive disease, and poorer survival compared to their White counterparts.³ In addition, they are more likely to be diagnosed at a younger age, to have a higher PSA, and to have advanced prostate cancer at the time of diagnosis. These disparities likely are multifactorial, influenced by biological, socioeconomic, and health care system factors. However, one critical aspect contributing to these disparities is the variation in diagnostic practices and resources available to urologists, primary care providers, and Black men to support the early detection of prostate cancer.^4-6

Despite their greater burden of prostate cancer, Black men were underrepresented in clinical trials of prostate cancer screening. Whereas Black men comprise 13% of the US population and account for 30% of prostate cancer deaths in the US, Black men account for <1% of participants across the international trials of prostate cancer screening.⁷ The US Preventive Services Task Force explicitly recommends that physicians communicate to Black men their increased risk of developing and dying from prostate cancer,⁵ yet less than one-third of primary care physicians (PCPs) report routinely discussing this with patients,⁶ and there is currently a paucity of instrumental supports for these conversations.^8,9 Many existing guidelines lack specificity for this population, leading to potential underdiagnosis, delays in appropriate management, and suboptimal outcomes.

The updated AUA Early Detection of Prostate Cancer guideline in 2023 recommends prostate cancer screening beginning at age 40 to 45 years for men with an increased risk of developing prostate cancer due to Black ancestry, germline mutations, and strong family history of prostate cancer. Typically, the PCP serves as the initial contact in the evaluation process for men who meet the existing criteria for, and are likely to benefit from, prostate cancer screening. Evidence indicates that PCPs may improve the implementation of risk-stratified prostate cancer screening when given the appropriate tools, such as a screening algorithm.¹⁰ However, providers, particularly PCPs, may lack the necessary knowledge and tools to effectively diagnose prostate cancer in high-risk men. For example, PCPs may not be cognizant of the newest AUA guidelines on prostate cancer screening, and alternative recommendations are not designed for the PCP audience and/or do not specifically call out the need for early screening in higher-risk in Black men. The AUA Science & Quality Council is eager to elevate and highlight the many ways providers in our specialty live the values of diagnostic excellence—stay tuned for more to come in this space!