Outcome of primary resurfacing hip replacement: evaluation of risk factors for early revision: 12,093 replacements from the Australian Joint Registry

BACKGROUND AND PURPOSE: The outcome of modern resurfacing remains to be determined. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) started collection of data on hip resurfacing at a time when modern resurfacing was started in Australia. The rate of resurfacing has been higher in Australia than in many other countries. As a result, the AOANJRR has one of the largest series of resurfacing procedures. This study was undertaken to determine the results of this series and the risk factors associated with revision. PATIENTS AND METHODS: Data from the AOANJRR were used to analyze the survivorship of 12,093 primary resurfacing hip replacements reported to the Joint Replacement Registry between September 1999 and December 2008. This was compared to the results of primary conventional total hip replacement reported during the same period. The Kaplan-Meier method and proportional hazards models were used to determine risk factors such as age, sex, femoral component size, primary diagnosis, and implant design. RESULTS: Female patients had a higher revision rate than males; however, after adjusting for head size, the revision rates were similar. Prostheses with head sizes of less than 50 mm had a higher revision rate than those with head sizes of 50 mm or more. At 8 years, the cumulative per cent revision of hip resurfacing was 5.3 (4.6-6.2), as compared to 4.0 (3.8-4.2) for total hip replacement. However, in osteoarthritis patients aged less than 55 years with head sizes of 50 mm or more, the 7-year cumulative per cent revision for hip resurfacing was 3.0 (2.2-4.2). Also, hips with dysplasia and some implant designs had an increased risk of revision. INTERPRETATION: Risk factors for revision of resurfacing were older patients, smaller femoral head size, patients with developmental dysplasia, and certain implant designs. These results highlight the importance of patient and prosthesis selection in optimizing the outcome of hip resurfacing

Urologic emergencies.

The diagnosis and management of urologic emergencies are incorporated into the basic training of all urology residents. In institutions without access to urologic services, it is usually left to the General Surgeon or Emergency Medicine physician to provide timely care. This article discusses diagnoses that are important to recognize and treatment that is practically meaningful for the non-Urologist to identify and treat. The non-Urology provider, after reading this article, will have a better understanding and a higher comfort level with treating patients with urologic emergencies

“I Only Want To See the Doctor” Comparison of Patient Satisfaction between Urology Physicians and Advanced Practice Providers

Introduction There is a projected national shortage of urologists in the coming decade. The American Urological Association supports the incorporation of advanced practice providers (APPs) into urologic practices. However, there has been limited research addressing the effect of increased utilization of APPs in the urologic setting and available research about patient satisfaction with APPs is mostly limited to primary care and non-surgical specialties. We are seeking to understand patient satisfaction with APPs in a urologic setting. The subspecialty nature of urologic practice leads us to believe that there may be measurable and meaningful differences in patient satisfaction. Materials & Methods We performed a retrospective assessment of patient satisfaction surveys administered over a 3 month period at a single high-volume academic urology practice in Maine. Patients were queried shortly after an encounter with one of 8 APPs or 8 physicians. Seven survey questions, relating specifically to patient satisfaction, were abstracted for analysis. These were derived from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS). Responses to individual survey questions were assessed between provider category. The independent effect of provider type on patient satisfaction was assessed with multivariable analysis, controlling for available patient characteristics (age, race, gender, marital status). Results We analyzed responses from 1018 patient encounters. Patients seeing APPs (vs a physician) tended to be older (79.9% of APP patient encounters were with patients over age 60, while 76.5% of physician encounters were with patients over age 60), more likely female (25.7% vs 17.5%), non-white (4.1% vs 2.5%), and less likely to be married or with a partner (69.1% vs 74.6%). On univariable analysis there were no significant differences between APPS and physicians in any of the 7 metrics measuring patient satisfaction. Following adjustment for covariates, there were still no differences in patient satisfaction as demonstrated in the Table. Conclusions Despite the subspecialty nature of urologic practice, use of APPs is not associated with diminished patient satisfaction. While this finding suggests that patient satisfaction will not be reduced by increased utilization of APPs, more broadly, further research needs to clarify the most appropriate role for APPs within an outpatient urology practice. We plan further research to examine specific diagnoses and investigate the most appropriate role for outpatient urology APPs. Further, our study does not assess other clinically relevant patient outcomes, and more research needs to be done to examine the safety and efficacy of APP integration. Finally, it is important to examine our study’s findings in a more broadly representative population as our patient population does not reflect the national averages. Nonetheless, given the impending national shortage of urologic physicians, our findings support the notion that APPs can be integrated into urologic care without decreasing overall patient satisfaction

Review of the comparative effectiveness of radical prostatectomy, radiation therapy, or expectant management of localized prostate cancer in registry data.

Evidence regarding the effectiveness of treatment for prostate cancer is primarily based on randomized controlled trials. Long-term outcomes are generally difficult to evaluate within experimental studies and may benefit from large pools of observational data. We conducted a systematic review of administrative and registry studies to evaluate the comparative effectiveness of treatment for clinically localized prostate cancer on overall and prostate-cancer specific mortality. MATERIALS AND METHODS: In accordance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P, 2015), we conducted a systematic search of Ovid Medline and Embase (1946-February 2017) and identified studies that evaluated the relationship between types of treatment for localized prostate cancer and mortality. Additional articles were identified through manual search. Randomized, prospective, and single institution studies were excluded. The risk of bias for each study was evaluated with the Newcastle Ottawa scale. Multivariable adjusted hazard ratios were reported to evaluate overall and cancer-specific mortality. RESULTS: We screened 4,721 studies and included for review, 19 that were published between 2001 and 2015. The pooled population included 228,444 patients. Countries of origin included the United States, Canada, China, Switzerland, the Netherlands, and Sweden, and the sources included administrative (n = 6) and cancer registry or prostate databases (n = 11). Overall and cancer-specific mortality were lowest among definitive treatment arms as compared to conservative therapy with no treatment, observation, or active surveillance. Radiotherapy was associated with worse overall and cancer-specific mortality than radical prostatectomy. CONCLUSION: Although observational studies using large, population-based cohorts have the potential for bias, we found consistent evidence that high-quality observational studies may be used to evaluate the comparative effectiveness of prostate cancer treatment. Methodologic limitations of observational data should be considered

Prostate cancer navigation: initial experience and association with time to care.

OBJECTIVE: To evaluate factors associated with use of patient navigation in a prostate cancer population and identify whether navigation is associated with prolonged time to care. Cancer patient navigation has been shown to improve access to cancer screening, diagnosis, and treatment, but little is known about patient navigation in prostate cancer care. METHODS: All men diagnosed with localized prostate cancer between 2009 and 2015 were abstracted from the MaineHealth multi-specialty tumor registry. Regression analyses controlling for patient-, disease-, and system-level factors evaluated characteristics associated with navigation utilization. The association between navigation utilization, barriers to care, and longer time to treatment was assessed with Cox proportional hazards regression. RESULTS: Of the patient population (n = 1587), 85% of men were navigated. Navigation use was associated with earlier year of diagnosis, treatment by a high-volume urologist, and lower risk disease (p \u3c 0.05). Treatment delay was associated with low-risk disease (vs: intermediate OR 0.62, 95% CI 0.46-0.85 and high OR 0.16, 95% CI 0.1-0.25) and receipt of navigation services (OR 1.65, 95% CI 1.12-2.45) but not distance to care, insurance, or treatment choice. CONCLUSIONS: We observed that patients with low-risk prostate cancer were more likely to utilize navigation, but traditional barriers to care were not associated with utilization. Navigation was associated with longer time to treatment, which likely reflects clinically appropriate delays associated with greater shared decision making. Time to treatment may not be the ideal metric for evaluating navigation in prostate cancer; shared decision making, patient satisfaction, and psychosocial outcomes may be more appropriate

Pathologic nodal downstaging in men with clinically involved lymph nodes undergoing radical prostatectomy: Implications for definitive locoregional therapy.

A prostate cancer (CaP) patient with nonmetastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. We compare overall survival (OS) between cN+ men that underwent radical prostatectomy (RP) and were found to have negative node status (pN) with those found to have positive nodal status (pN+), and assess predictors of discordant nodal status. We queried the National Cancer Data Base between 2004 and 2015 for patients that were cT1-3 cN+ cM0 CaP treated with RP. Patients with 0 nodes, cT4, or cM1 disease were excluded. We compared groups based on pathologic nodal status: Discordant (cN+ -\u3e pN) & Concordant (cN+ -\u3e pN+). Kaplan Meier estimations were used to compare OS. Logistic regression was used to determine possible predictors of nodal status. We find that of 6470 cN+ patients, 1,367 (21.1%) underwent RP, 866 (13.4%) had confirmed nodal status. Discordant status was found in 159 (18.4%) and concordant staging in 707 (81.6%). Differences exist in PSA at diagnosis (7.3 vs. 11.2), biopsy group, # of nodes examined (7 vs. 10), race, and Charlson index. Discordant staging had longer OS compared to Concordant staging (P = 0.007) and similar OS to a 3:1 matched cohort of high risk localized CaP patients used as reference (P = 0.46). Lower Gleason Score (GG1-3) was associated with an increased likelihood of discordant staging. Clinical nodal staging is associated with a substantial false positive rate. Discordant status had better OS than Concordant status and similar OS to matched patients with localized CaP. Clinical nodal staging may inappropriately lead to noncurative therapy in a substantial number of men with potentially curable disease

Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy.

CONTEXT: Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE: To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION: A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS: Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS: Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY: This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy

Systematic review of the volume-outcome relationship for radical prostatectomy.

CONTEXT: Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE: To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION: A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS: Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS: Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY: This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy