Understanding fragmentation of prostate cancer survivorship care

BACKGROUND: Cancer survivors are particularly prone to the effects of a fragmented health care delivery system. The implications of fragmented cancer care across providers likely include greater spending and worse quality of care. For this reason, the authors measured relations between increasing fragmentation of cancer care, expenditures, and quality of care among prostate cancer survivors. METHODS: A total of 67,736 patients diagnosed with prostate cancer between 1992 and 2005 were identified using Surveillance, Epidemiology, and End Results (SEER)‐Medicare data. Using the Herfindahl‐Hirschman Index and a measure of the average number of prostate cancer providers over time, patients were sorted into 3 fragmentation groups (low, intermediate, and high). The authors then examined annual per capita survivorship expenditures and a measure of quality (ie, repetitive prostate‐specific antigen [PSA] testing within 30 days) according to their fragmentation exposure using multinomial logistic regression. RESULTS: Patients with highly fragmented cancer care tended to be younger, white, and of higher socioeconomic status (all P < .001). Prostate cancer survivorship interventions were most common among patients with the highest fragmentation of care across providers ( P < .001). After adjustment for clinical characteristics and prostate cancer survivorship interventions, higher degrees of fragmentation continued to be associated with repetitive PSA testing (13.6% for high vs 7.0% for low fragmentation; P < .001) and greater spending, particularly among patients not treated with androgen deprivation therapy. CONCLUSIONS: Fragmented prostate cancer survivorship care is expensive and associated with potentially unnecessary services. Efforts to improve care coordination via current policy initiatives, electronic medical records, and the implementation of cancer survivorship tools may help to decrease fragmentation of care and mitigate downstream consequences for prostate cancer survivors. Cancer 2011;. © 2011 American Cancer Society. Fragmented prostate cancer survivorship care is expensive and associated with potentially unnecessary services. Efforts to improve care coordination via current policy initiatives, electronic medical records, and the implementation of cancer survivorship tools may help to decrease fragmentation of care and mitigate downstream consequences for prostate cancer survivors.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91344/1/26601_ftp.pd

Comparison of Neuromuscular Injuries to the Surgeon during Hand-Assisted and Standard Laparoscopic Urologic Surgery

Background and Purpose: Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. Materials and Methods: A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. Results: Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). Conclusion: Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63117/1/end.2005.19.377.pd

Importance of Perioperative Processes of Care for Length of Hospital Stay after Laparoscopic Surgery

Background and Purpose: The technologic imperative has prompted the adoption of complex laparoscopic techniques by physicians with various degrees of skill. We sought to measure the impact of both case mix and physician practice (perioperative process/risk factors) on length of stay (LOS)—a common benchmark— after laparoscopic surgery. Patients and Methods: We identified 911 patients undergoing laparoscopic retroperitoneal surgery between 1996 and 2004, who comprise our study population. Patients remaining in the hospital >5 days—the 90th percentile for the sample—were classified as having a prolonged LOS. Adjusted models were developed to determine the independent association of case mix and process measures with a prolonged LOS. The likelihood ratio test was used to discern the improvement of fit of the process model compared with the case-mix model. Results: Among factors related to case mix and structure of care, increasing age (odds ratio [OR] 1.1; 95% CI 1.0, 1.2), less surgeon experience (OR 6.1; 95% CI 2.1, 17.2), male gender (OR 2.1; 95% CI 1.2, 4.0), and American Society of Anesthesiologists score of 3 or 4 (OR 7.2; 95% CI 2.2, 23.3) were independently associated with a prolonged LOS. The need for a transfusion (OR 9.4; 95% CI 33.9, 23.2), the development of a postoperative complication (OR 4.6; 95% CI 2.2, 9.5), and longer operative time (OR 1.5; 95% CI 1.3, 1.8) explained additional variation in prolonged LOS outcomes when considering perioperative process/risk factors in the model. Perioperative factors significantly improved the fit of the model (χ 2 statistic 101.8; p < 0.0001). Conclusions: Significant variation in outcomes is explained by factors describing aspects of surgical expertise. Variability in the surgical skill set is likely greatest during the laparoscopic learning curve, which raises a quality-of-care concern during the initial implementation of the technique. Policies attempting to smooth the laparoscopic learning curve, such as mentoring and skill measurement prior to credentialing, could improve the quality of care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63271/1/end.2006.20.776.pd

Five-year survival after surgical treatment for kidney cancer

BACKGROUND. Kidney cancer's rising incidence is largely attributable to the increased detection of small renal masses. Although surgery rates have paralleled this incidence trend, mortality continues to rise, calling into question the necessity of surgery for all patients with renal masses. Using a population-based cohort, a competing risk analysis was performed to estimate patient survival after surgery for kidney cancer, as a function of patient age and tumor size at diagnosis. METHODS. With data from the Surveillance, Epidemiology, and End Results Program (1983–2002), a cohort was assembled of 26,618 patients with surgically treated, local-regional kidney cancer. Patients were sorted into 20 age-tumor size categories and the numbers of patients that were alive, dead from kidney cancer, and dead from other causes were tabulated. Poisson regression models were fitted to obtain estimates of cancer-specific and competing-cause mortality. RESULTS. Age-specific kidney cancer mortality was stable across all size strata but varied inversely with tumor size. Patients with the smallest tumors enjoyed the lowest cancer-specific mortality (5% for masses ≤4 cm). Competing-cause mortality rose with increasing patient age. The estimated 5-year competing-cause mortality for elderly subjects (≥70 years) was 28.2% (95% confidence interval [CI]: 25.9%–30.8%), irrespective of tumor size. CONCLUSIONS. Despite surgical therapy, competing-cause mortality for patients with renal masses rises with increasing patient age. After 5 years, one-third of elderly patients (≥70 years) will die from other causes, suggesting the need for prospective studies to evaluate the role of active surveillance as an initial therapeutic approach for some small renal masses. Cancer 2007. © 2007 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/55991/1/22600_ftp.pd

Understanding Potential Intraoperative Impediments for Learning Laparoscopic Nephrectomy

Purpose: We evaluated factors that impact the ability to learn hand-assisted laparoscopic donor nephrectomy (HALDN) to identify impediments to diffusion of this procedure. Methods: From February 2002 to June 2004, we collected data from our institutional database on 70 patients who underwent HALDN. Time for individual steps of the procedure (colon mobilization, kidney/ureter mobilization, renal vein tributary dissection, renal hilum dissection, removal of the kidney, and overall time) were recorded. The impact of patient factors on surgical times was assessed using a general linear model. The impact of individual operative steps on overall operative time was assessed using Pearson correlation. The influence of case experience and training level were evaluated graphically and in a multivariable model. Results: A total of 13 residents, 2 fellows, and 1 attending surgeon participated in procedures for 70 patients. Body mass index (P = 0.03) and male sex (P = 0.04) prolonged operative times. Colon mobilization and hilar dissection were most correlated with overall operative time. While experience improved operative times for several steps, level of training appeared more likely to influence the time for individual operative steps. Conclusions: Impediments to learning HALDN include patient factors, level of training, and particular surgical steps. Repeated exposure at increasing levels of training may improve diffusion of laparoscopic nephrectomy among urologists.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63194/1/end.2008.0439.pd

Effects of the Medicare Modernization Act on Spending for Outpatient Surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/1/hesr12807_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/2/hesr12807-sup-0001-AppendixSA1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/3/hesr12807.pd

The utility of lockout valve reservoirs in preventing autoinflation in penile prostheses

Introduction : Autoinflation is a troublesomecomplication following penile prosthesisplacement that may be potentiated by prevesicalscarring following radical prostatectomy. Weevaluated the frequency of autoinflation andother complications following penile prosthesisplacement in radical prostatectomy patients andcontrols as a surrogate to establishing theutility of lockout reservoirs in preventingautoinflation. Methods : 139 prostheses (including 14with lockout reservoirs) were placed in 132 men(including 35 post-prostatectomy patients) overa 5 1 / 2 year period at our institution. Outcomesassessed include postoperative complicationsand the need for revision or replacement of theprosthesis. Multivariable regression analysiswas used to determine the association ofpatient, device-specific, and perioperativecharacteristics with these outcomes. Results : There was no difference in thepostoperative complication and re-operationrates between post-prostatectomy patients andcontrols (both p > 0.77). The incidence ofautoinflation in post-prostatectomy patientsand controls was 3% and 5%, respectively( p > 0.99). Patients with prior prostheseswere 3 times as likely to develop apostoperative complication or requireprosthesis revision ( p = 0.02). Conclusion : Penile prostheses are welltolerated in post-prostatectomy patients withcomparable outcomes to those men with organicerectile dysfunction. The frequency ofautoinflation does not appear to be increasedin post-prostatectomy patients. Initialresults with the lockout valve reservoir inpreventing autoinflation are encouraging thoughadditional study is warranted to justify theirroutine use.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/43865/1/11255_2004_Article_5119589.pd

Resurrecting immortal‐time bias in the study of readmissions

ObjectiveTo compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods.Data Sources20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014.Study DesignRetrospective cohort study comparing 30‐day readmission rates.Data Collection/Extraction MethodsPatients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified.Principal FindingsCystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal‐time bias.ConclusionsWe found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/1/hesr13252-sup-0001-Authormatrix.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/2/hesr13252.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/3/hesr13252_am.pd

The Use of Social Media in Endourology: An Analysis of the 2013 World Congress of Endourology Meeting

Objective: To examine the use of social media within Endourology by reporting on its utilization during the 2013 World Congress of Endourology (WCE) annual meeting. Materials and Methods: Two social media platforms were analyzed for this study: Twitter (San Francisco, CA) and LinkedIn (Mountain View, CA). For Twitter, a third-party analysis service (Tweetreach) was used to quantitatively analyze all tweets with the hashtags #WCE2013 and #WCE13 during a 7-day period surrounding the WCE. Two reviewers independently classified tweet content using a predefined Twitter-specific classification system. Tweet sentiment was determined using sentiment analysis software (Semantria, Inc., Amherst, MA). Finally, the penetration of Twitter and LinkedIn within the WCE faculty was assessed by means of a manual search. Results: During the study period, 335 tweets had the hashtag #WCE2013 or #WCE13. Content originated from 68 users resulting in a mean of 47 tweets/day and 4.9 tweets/contributor. Conference-related tweets had a reach of 38,141 unique Twitter accounts and an online exposure of 188,629 impressions. Physicians generated the majority of the content (63%), of which 55.8% were not attending the meeting. More tweets were informative (56.7%) versus uninformative (43.3%), and 17.9% had links to an external web citation. The mean sentiment score was 0.13 (range ?0.90 to 1.80); 13.1%, 57.0%, and 29.9% of tweets were negative, neutral, and positive in sentiment, respectively. Of 302 WCE meeting faculty, 150 (49.7%) had registered LinkedIn accounts while only 52 (17.2%) had Twitter accounts, and only 19.2% tweeted during the meeting. Conclusions: Despite a relatively low number of Twitter users, tweeting about the WCE meeting dramatically increased its online exposure with dissemination of content that was mostly informative including engagement with physicians not attending the conference. While half of faculty at WCE 2013 had LinkedIn accounts, their social media footprint in Twitter was limited.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140078/1/end.2014.0329.pd

Trends in the Treatment of Adults with Ureteropelvic Junction Obstruction

Background and Purpose: Minimally invasive pyeloplasty is an effective treatment for patients with ureteropelvic junction obstruction that offers quicker convalescence than open pyeloplasty. Technical challenges, however, may have limited its dissemination. We examined population trends and determinants of surgical options for ureteropelvic junction obstruction. Patients and Methods: Using the State Inpatient and Ambulatory Surgery Databases for Florida, we identified adults who underwent ureteropelvic junction obstruction repair between 2001 and 2009. After determining the surgical approach (minimally invasive pyeloplasty, open pyeloplasty, or endopyelotomy), we estimated annual utilization rates and the effects of patient, surgeon, and hospital predictors on surgery type, using multilevel multinomial logistic regression. Results: Rates of minimally invasive pyeloplasty increased 360% (P for monotonic trendPeer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140371/1/end.2012.0017.pd