Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project

BACKGROUND: Several treatment options for clinically localized prostate cancer currently exist under the established guidelines. We aim to assess nationally representative trends in treatment over time and determine potential geographic variation using two large national claims registries. METHODS: Men with prostate cancer insured by Medicare (1998-2006) or a private insurer (Ingenix database, 2002-2006) were identified using International Classification of Diseases-9 and Current Procedural Terminology-4 codes. Geographic variation and trends in the type of treatment utilized over time were assessed. Geographic data were mapped using the GeoCommons online mapping platform. Predictors of any treatment were determined using a hierarchical generalized linear mixed model using the logit link function. RESULTS: The use of radical prostatectomy increased, 33-48%, in the privately insured i3 database while remaining stable at 12% in the Medicare population. There was a rapid uptake in the use of newer technologies over time in both the Medicare and i3 cohorts. The use of laparoscopic-assisted prostatectomy increased from 1% in 2002 to 41% in 2006 in i3 patients, whereas the incidence increased from 3% in 2002 to 35% in 2006 for Medicare patients. The use of neoadjuvant/adjuvant androgen deprivation therapy was lower in the i3 cohort and has decreased over time in both i3 and Medicare. Physician density had an impact on the type of primary treatment received in the New England region; however, this trend was not seen in the western or southern regions of the United States. CONCLUSIONS: Using two large national claims registries, we have demonstrated trends over time and substantial geographic variation in the type of primary treatment used for localized prostate cancer. Specifically, there has been a large increase in the use of newer technologies (that is, laparoscopic-assisted prostatectomy and intensity-modulated radiation therapy). These results elucidate the need for improved data collection on prostate cancer treatment outcomes to reduce unwarranted variation in care

Using an abdominal phantom to teach urology residents ultrasound-guided percutaneous needle placement

ABSTRACT Introduction: To assess the effect of a hands-on ultrasound training session to teach urologic trainees ultrasound-guided percutaneous needle placement. Materials and methods: University of California, San Francisco (UCSF) urology residents completed a time trial, placing a needle into a phantom model target under ultrasound guidance. Participants were randomized into three educational exposure groups: Group 1's time trial occurred prior to any teaching intervention, group 2's after experiencing a hands-on training module, and group 3's after exposure to both the training module and one-on-one attending feedback. Needle placement speed and accuracy as well as trainees' perceived confidence in utilizing ultrasound were measured. Results: The study cohort consisted of 15 resident trainees. Seven were randomized to group 1, three to group 2, and five to group 3. All residents reported minimal prior ultrasound experience. Their confidence in using ultrasound improved significantly after completing the training module with the most significant improvement seen among junior residents. Time to needle placement was fastest after receiving attending feedback (46.6sec in group 3 vs. 82.7sec in groups 1 and 2, p<0.01). Accuracy also improved with attending feedback, though the number of repositioning attempts did not differ significantly between groups. Conclusions: A hands-on training module and use of an abdominal phantom trainer increased resident confidence and skill in their use of ultrasound to guide percutaneous needle positioning. Attending feedback is critical for improving accuracy in needle guidance toward a target. Ultrasound-guided needle positioning is a teachable skill and can be applicable to multiple urologic procedures

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Uncovering the Burden of Urologic Disease: Admissions Patterns at the Main Teaching Hospital of Ethiopia

Background: Limited data exists profiling the urologic needs of populations in sub-Saharan Africa. As the region builds training programs for urology, such data can inform strategic program planning and investment. The objective of this study was to describe admissions patterns for urologic disease at an academic medical center in Ethiopia. Methods: Retrospective review of admission, discharge, and operative logs of the urology service from November 2011 to October 2014 was conducted at Tikur Anbessa Specialized Hospital. Data were collected on patient demographics, length of hospital stay, specific diagnoses, condition classifications, and procedures performed, generating descriptive statistics. Results: A total of 1,149 urologic procedures were reviewed. Patients were predominantly male (74%) with median age of 43 years. The most common condition was urolithiasis (31%), followed by malignant tumors (25%) and benign tumors (14%). Almost half of patients underwent open surgical procedures (47%). Median inpatient stay was 14 days. Conclusions: The breadth and volume of patients treated hints at the large, unmet burden of urologic disease in Ethiopia. A large percentage of patients underwent open procedures and had prolonged inpatient lengths of stay. Continued research to understand urologic disease patterns and increase access to specialty care in this setting is needed.Keywords: Ethiopia; Sub-Saharan Africa; Urological Surgical Procedures; Health Care Utilization

Variation and Predictors of Surgical Case Costs among Urologists.

IntroductionShifts in the health care delivery system have emphasized providing cost-efficient care. The operating room comprises a significant proportion of hospital costs. Analysis of practice variation in operating room supply use can provide insight into opportunities for cost reduction and improved efficiency without compromising outcomes.MethodsA retrospective review was conducted of urological procedures performed at the University of California San Francisco Medical Center from September 2012 through December 2015. Supply costs for individual cases were itemized and aggregated using the institution negotiated rate. Operative time was monetized. Supply cost was analyzed with multivariate mixed effects models evaluating surgeon experience and surgeon volume.ResultsThe majority of common urological procedures demonstrate significant variation among surgeons in supply, time and overall cost. Surgeon annual procedure specific volume was a significant predictor of lower cost in multivariate analysis of supply cost (p = 0.016) and correlated with a lower likelihood of the case supply cost being in the top quintile (p &lt;0.001). Surgeon experience was not a significant predictor of absolute supply cost or being in the top quintile of supply cost.ConclusionsSignificant variation exists among supply costs of high volume procedures. Higher surgeon procedure specific volume predicts lower operating room supply costs. Targeting procedures with variation for cost optimization via standardization could have a substantial impact on operating room costs and efficiency. The experience of high volume surgeons may be useful to guide optimal supply use given their comparatively lower costs

Conservative Management of High-grade Renal Trauma Does Not Lead to Prolonged Hospital Stay.

OBJECTIVE:To evaluate the effect of conservative management of high-grade renal trauma on length of hospitalization, we aim to describe characteristics of patients with high-grade renal trauma that are associated with an increased length of stay (LOS) and the effect of conservative vs surgical management on hospital LOS. METHODS:A retrospective review of all patients who suffered unilateral high-grade renal trauma (grade 3 or higher) from September 1977 to August 2012 at San Francisco General Hospital in San Francisco, CA was performed. Patients' demographic information, mechanism of injury, injury grade, data about associated injuries, hospital LOS, and management were collected. Descriptive analysis was performed using chi-square, ordered logistic regression, and linear regression analysis. Multivariable analysis was performed using a Fine-Gray model of competing risks survival analysis, adjusting for trauma type, grade, surgery, associated injury, and complications. RESULTS:The cohort consisted of 408 patients with high-grade unilateral renal trauma of which 257 patients underwent renal exploration. The adjusted multivariable analysis revealed that trauma type, injury grades, nongenitourinary surgery, associated injuries, and complications were associated with increased hospital LOS (P &lt;.01 for all). Renal exploration compared to conservative management for high-grade renal trauma was not associated with an increased hospital LOS (P = .10). CONCLUSION:There is no significant difference between conservative and surgical management of high-grade renal trauma in terms of hospital LOS. Conservative management of high-grade renal trauma does not impact patients' length of hospitalization