Primary Palliative Care in Urology: Quality Improvement Summit 2021-2022

INTRODUCTION

The AUA convened a 2021-2022 Quality Improvement Summit to bring together interdisciplinary providers to inform the current state and to discuss potential strategies for integrating primary palliative care into urology practice. We hypothesized that the Summit findings would inform a scalable primary palliative care model for urology.

METHODS

The 3-part summit reached a total of 160 interdisciplinary health care professionals. Webinar 1, "Building a Primary Palliative Care Model for Urology," focused on a urologist's role in palliative care. Webinar 2, "Perspectives on Increasing the Use of Palliative Care in Advanced Urologic Disease," addressed barriers to possible implementation of a primary palliative care model. The in-person Summit, "Laying the Foundation for Primary Palliative Care in Urology," focused on operationalization of primary palliative care, clinical innovations needed, and relevant metrics.

RESULTS

Participants agreed that palliative care is needed early in the disease course for patients with advanced disease, including those with benign and malignant conditions. The group agreed about the important domains that should be addressed as well as the interdisciplinary providers who are best suited to address each domain. There was consensus that a primary "quarterback" was needed, encapsulated in a conceptual model-UroPal-with a urologist at the hub of care.

CONCLUSIONS

The Summit provides the field of urology with a framework and specific steps that can be taken to move urology-palliative care integration forward. Urologists are uniquely positioned to provide primary palliative care for their many patients with serious illness, both in the surgical and chronic care contexts.

Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections

PURPOSE

Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach.

MATERIALS AND METHODS

This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme.

RESULTS

Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms.

CONCLUSIONS

Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

Contribution of Hypersensitivity to Postureteroscopy Ureteral Stent Pain: Findings From Study to Enhance Understanding of Stent-associated Symptoms

OBJECTIVE

To examine the relationships between preoperative hypersensitivity to pain and central sensitization, and postoperative ureteral stent pain after ureteroscopy (URS) for urinary stones.

METHODS

Adults enrolled in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) underwent quantitative sensory testing (QST) prior to URS and stent placement. Hypersensitivity to mechanical pain was assessed using a pressure algometer. Participants rated their pain intensity to pressure applied to the ipsilateral flank area and lower abdominal quadrant on the side of planned stent placement, and the contralateral forearm (control). Pressure pain thresholds were also assessed. Central sensitization was assessed by applying a pointed stimulator (pinprick) and calculating the temporal summation. Postoperative stent pain intensity and interference were assessed using PROMIS questionnaires. Data were analyzed using repeated-measures mixed-effects linear models.

RESULTS

Among the 412 participants, the median age was 54.0years, and 46% were female. Higher preoperative pain ratings to 2 kg and 4 kg mechanical pressure to the ipsilateral flank and abdominal areas were associated with higher postoperative stent pain intensity with the stent in situ. Greater degree of central sensitization preoperatively, manifesting as higher temporal summation, was associated with higher postoperative pain intensity. Factors associated with preoperative hypersensitivity on QST included female sex, presence of chronic pain conditions, widespread pain, and depression.

CONCLUSION

Hypersensitivity to pain and central sensitization preoperatively was associated with postoperative ureteral stent pain, suggesting a physiologic basis for stent symptom variation. QST may identify patients more likely to develop stent pain after URS and could inform selection for preventive and interventional strategies.

Examining the role of frailty on treatment patterns and complications among older women undergoing procedure-based treatment for urinary incontinence

BACKGROUND

Aging beyond 65 years is associated with increased prevalence of urinary incontinence (UI), frailty, and increased complication rate with UI treatments. To investigate this relationship, we examined frailty as a predictor of procedure-based UI treatment patterns and urologic complications in Medicare-eligible women.

METHODS

We identified women undergoing procedures for UI between 2011-2018 in the 5% limited Medicare data set. A Claims-based Frailty Index (CFI) using data from the 12-months prior to the index procedure defined frailty (CFI≥0.25). Urologic complications were assessed during the 12-months following the index procedure. We used unadjusted logistic regression models to calculate odds of having a specific type of UI procedure based on frailty status. Odds of post-procedure urologic complications were examined with logistic regression adjusted for age and race.

RESULTS

We identified 21,783 women who underwent a procedure-based intervention for UI, of whom 3,826 (17.5%) were frail. Frail women with stress UI were 2.6 times more likely to receive periurethral bulking (95%CI 2.26-2.95), compared to non-frail. Conversely, frailty was associated with lower odds of receiving a Sling or Burch colposuspension. Among women with urgency UI or overactive bladder (OAB), compared to non-frail, frailty was associated with higher odds of both sacral neuromodulation (OR=1.21, 95%CI 1.11-1.33) and intravesical Botox (OR=1.16, 95%CI 1.06-1.28), but lower odds of receiving posterior tibial nerve stimulation. Frailty was associated with higher odds of post-procedure urologic complications (OR=1.64, 95%CI 1.47-1.81).

CONCLUSIONS

Frailty status may influence treatment choice for treatment of stress or urgency UI symptoms and increase the odds of post-procedural complications in older women.

Leveraging behavioral modification technology for the prevention of kidney stones

PURPOSE OF REVIEW

The purpose of this review is to examine the use of technology to help promote and maintain behaviors that decrease stone recurrence.

RECENT FINDINGS

Behavior change is a complex process with various interacting components. Recent developments have sought to utilize technology in combination with behavioral change techniques to promote behavior that lowers stone recurrence risk. Smart water bottles are becoming a popular way to accurately measure fluid intake with variable impact on adherence to the recommended daily fluid intake. Mobile apps have also been explored as a method to improve fluid intake. Interventions that combine smart water bottles, mobile apps, and behavioral change techniques have shown the most promise in promoting increased daily fluid intake. Other technologies, such as smart pill dispensers and hydration monitors, have potential applications in promoting behavioral change for stone disease but have yet to be evaluated for this purpose.

SUMMARY

There is a limited number of studies exploring technology as a means to promote and maintain behaviors that decrease urinary stone recurrence. Future research is needed to elucidate how to maximize the potential of these technologies and better understand which behavioral change techniques best promote habit formation for the prevention of stones.

Rural For-Profit Hospitals Are Associated With Higher Commercial Prices for 3 Common Urological Procedures

INTRODUCTION

Rural patients lack access to urological services, and high local prices may dissuade underinsured patients from surgery. We sought to describe commercially insured prices for 3 urological procedures at rural vs metropolitan and for-profit vs nonprofit hospitals.

METHODS

A cross-sectional analysis of commercially insured prices from the Turquoise Health Transparency data set was performed for ureteroscopy with laser lithotripsy, transurethral resection of bladder tumor, and transurethral resection of prostate. Hospital characteristics were linked using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Linear modeling analyzed median hospital price and its association with hospital characteristics.

RESULTS

Overall, 1,532 hospitals reported urological prices in Turquoise. Median prices for each procedure were higher at rural for-profits (ureteroscopy $16,522, transurethral resection of bladder tumor $5,393, transurethral resection of prostate $9,999) vs rural nonprofits (ureteroscopy $4,512, transurethral resection of bladder tumor $2,788, transurethral resection of prostate $3,881) and metropolitan for-profits (ureteroscopy $5,411, transurethral resection of bladder tumor $3,420, transurethral resection of prostate $4,874). Rural for-profit status was independently associated with 160% higher price for ureteroscopy (relative cost ratio 2.60, P < .001), 50% higher for transurethral resection of bladder tumor (relative cost ratio 1.50, P = .002), and 113% higher for transurethral resection of prostate (relative cost ratio 2.13, P < .001).

CONCLUSIONS

Prices are higher for 3 common urological surgeries at rural for-profit hospitals. Differential pricing may contribute to disparities for underinsured rural residents who lack access to nonprofit facilities. Interventions that facilitate transportation and price shopping may improve access to affordable urological care.

Incidence and cost of potentially avoidable emergency department visits for urolithiasis

OBJECTIVES

Urolithiasis represents a leading cause of emergency department (ED) presentation nationally, affecting approximately 10% of Americans. However, most patients require neither hospital admission nor surgical intervention. This study investigates patient and facility factors associated with potentially avoidable ED visits and their economic consequences.

STUDY DESIGN

Retrospective analysis.

METHODS

Patients presenting to the ED for index urolithiasis events were selected using Florida and New York all-payer data from the 2016 Healthcare Cost and Utilization Project state databases. Avoidable visits were defined as subsequent ED encounters following initial ED presentation that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations and associated costs.

RESULTS

Of the 167,102 ED encounters for urolithiasis, 7.9% were potentially avoidable, totaling $94,702,972 in potential yearly cost savings. Mean encounter-level costs were higher for unavoidable vs avoidable visits ($5885 vs $2098). In contrast, mean episode-based costs were similar for avoidable and unavoidable episodes ($7200 vs $7284). Receiving care in small metropolitan (vs large metropolitan) communities was associated with potentially avoidable visits, whereas increased comorbidities and Hispanic ethnicity were protective against avoidable visits.

CONCLUSIONS

The incidence of ED use for subsequent urolithiasis care reveals opportunity for enhanced outpatient availability to reduce hospital-based costs. Several nonclinical factors are associated with potentially avoidable ED visits for urolithiasis, which, if appropriately targeted, may represent an opportunity to reduce health care spending without compromising the quality of care delivery.

Discrete-Choice Experiment to Understand the Preferences of Patients with Hormone-Sensitive Prostate Cancer in the USA, Canada, and the UK

BACKGROUND

Treatment options for patients with metastatic hormone-sensitive prostate cancer (mHSPC) have broadened, and treatment decisions can have a long-lasting impact on patients' quality of life. Data on patient preferences can improve therapeutic decision-making by helping physicians suggest treatments that align with patients' values and needs.

OBJECTIVE

This study aims to quantify patient preferences for attributes of chemohormonal therapies among patients with mHSPC in the USA, Canada, and the UK.

METHODS

A discrete-choice experiment survey instrument was developed and administered to patients with high- and very-high-risk localized prostate cancer and mHSPC. Patients chose between baseline androgen-deprivation therapy (ADT) alone and experimentally designed, hypothetical treatment alternatives representing chemohormonal therapies. Choices were analyzed using logit models to derive the relative importance of attributes for each country and to evaluate differences and similarities among patients across countries.

RESULTS

A total of 550 respondents completed the survey (USA, 200; Canada, 200; UK, 150); the mean age of respondents was 64.3 years. Treatment choices revealed that patients were most concerned with treatment efficacy. However, treatment-related convenience factors, such as route of drug administration and frequency of monitoring visits, were as important as some treatment-related side effects, such as skin rash, nausea, and fatigue. Patient preferences across countries were similar, although patients in Canada appeared to be more affected by concomitant steroid use.

CONCLUSION

Patients with mHSPC believe the use of ADT alone is insufficient when more effective treatments are available. Efficacy is the most significant driver of patient choices. Treatment-related convenience factors can be as important as safety concerns for patients.

Patients' Experiences With the Removal of a Ureteral Stent: Insights From In-depth Interviews With Participants in the USDRN STENTS Qualitative Cohort Study

OBJECTIVE

To describe the experiences of patients undergoing stent removal in the USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS), a prospective, observational cohort study of patients with short-term ureteral stent placement post-ureteroscopy.

METHODS

We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) painful or bothersome aspects of stent removal, (2) symptoms immediately after removal, and (3) symptoms in the days following removal. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis.

RESULTS

The 38 participants interviewed were aged 13-77 years, 55% female, and 95% White. Interviews were conducted 7-30 days after stent removal. Almost all participants (n = 31) described that they experienced either pain or discomfort during stent removal, but for most (n = 25) pain was of short duration. Many participants (n = 21) described anticipatory anxiety related to the procedure, and several (n = 11) discussed discomfort arising from lack of privacy or feeling exposed. Interactions with medical providers often helped put participants at ease, but also increased discomfort for some. Following stent removal, several participants described lingering pain and/or urinary symptoms, but these largely resolved within 24 hours. A few participants described symptoms persisting for more than a day post stent removal.

CONCLUSION

These findings on patients' experiences during and shortly after ureteral stent removal, particularly the psychological distress they experienced, identify opportunities for improvement in patient care. Clear communication from providers about what to expect with the removal procedure, and the possibility of delayed pain, may help patients adapt to discomfort.

The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study

Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

Disparities in Prostate Cancer Screening for Transgender Women: An Analysis of the MarketScan Database

OBJECTIVE

To describe the prevalence of PSA screening amongst transgender women. A transgender individual is someone whose gender identity differs from their birth sex or the societal norms of that assigned sex. There are no formal guidelines regarding PSA screening in transgender women, even though they retain prostatic tissue throughout the gender-affirming process, and there is a lack of existing data to adequately inform clinical practice.

METHODS

We identified a cohort of transgender women in the IBM MarketScan dataset using ICD codes. The patient...s eligibility for inclusion was determined on an annual basis for the years 2013-2019. For each year, we required continuous enrollment, 3 months of post-transgender diagnosis follow-up, and aged 40-80 without a prior diagnosis of prostate malignancy. This cohort was compared to cisgender men with similar eligibility criteria. The proportions of individuals undergoing PSA screening were compared using log-binomial regression.

RESULTS

A group of 2957 transgender women met the inclusion criteria. We saw significantly lower PSA screening rates among transgender individuals for ages 40-54 and 55-69, but higher rates within the age group 70-80 (P.ß<.ß.001 for all).

CONCLUSION

This is the first study evaluating PSA screening rates for insured transgender women. While the rates for screening in transgender women over the age of 70 are higher, the overall rate of screening for all other age groups lags below the general population in this dataset. Further investigation is necessary to provide equitable care for the transgender community.

Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS

PURPOSE

The STudy to Enhance uNderstanding of sTent-associated Symptoms sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS

This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms.

RESULTS

A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in stent-associated symptoms on postoperative day 1. While pain intensity decreased ∼50% from postoperative day 1 to postoperative day 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity (P = .004). Having chronic pain conditions (P < .001), prior severe stent pain (P = .021), and depressive symptoms at baseline (P < .001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of stent-associated symptoms.

CONCLUSIONS

In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (eg, age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of stent-associated symptoms.

Medication Payments by Insurers and Patients for the Treatment of Metastatic Castrate-Resistant Prostate Cancer

PURPOSE

The implications of high prices for cancer drugs on health care costs and patients' financial burdens are a growing concern. Patients with metastatic castrate-resistant prostate cancer (mCRPC) are often candidates for multiple first-line systemic therapies with similar impacts on life expectancy. However, little is known about the gross and out-of-pocket (OOP) payments associated with each of these drugs for patients with employer-sponsored health insurance. We therefore aimed to determine the gross and OOP payments of first-line drugs for mCRPC and how the payments vary across drugs.

METHODS

This retrospective cohort study included 4,298 patients with prostate cancer who initiated therapy with one of six drugs approved for first-line treatment of mCRPC between July 1, 2013, and June 30, 2019. We compared gross and OOP payments during the 6 months after initiation of treatment for mCRPC using private payer claims data across patients using different first-line drugs.

RESULTS

Gross payments varied across drugs. Over the 6 months after the index prescription, mean unadjusted gross drug payments were highest for patients receiving sipuleucel-T ($115,525 USD) and lowest for patients using docetaxel ($12,804 USD). OOP payments were lower than gross drug payments; mean 6-month OOP payments were highest for cabazitaxel ($1,044 USD) and lowest for docetaxel ($296 USD). There was a wide distribution of OOP payments within drug types.

CONCLUSION

Drugs for mCRPC are expensive with large differences in payments by drug type. OOP payments among patients with employer-sponsored health insurance are much lower than gross drug payments, and they vary both across and within first-line drug types, with some patients making very high OOP payments. Although lowering drug prices would reduce pharmaceutical spending for patients with mCRPC, decreasing patient financial burden requires understanding an individual patient's benefit design.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis

BACKGROUND

There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction.

PATIENTS AND METHODS

Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction.

RESULTS

Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate.

CONCLUSIONS

Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

Outcomes Database to Prospectively Assess the Changing Therapy Landscape in Renal Cell Carcinoma (ODYSSEY RCC)

TPS739

Background: The landscape for treatment of metastatic renal cell carcinoma (mRCC) has changed dramatically over the past 7 years with the approvals of tyrosine kinase inhibitors and immune-oncology (IO) agents alone or in combination for untreated mRCC. However, multiple knowledge gaps remain. While active surveillance remains an option for selected pts, prospective evidence on selection of and outcomes for pts is limited. Recent phase III trials all used a common comparator, sunitinib, so no comparative effectiveness data on the new IO-based regimens exists. There are also no routinely used predictive biomarkers in mRCC pt management. Therefore, a better understanding of the biologic determinants associated with cancer heterogeneity and clinical outcomes through blood, tumor, and radiographic based assessments is needed. Importantly, longitudinal changes in health-related quality of life (QOL) and symptom burden of patients with mRCC initiated on new IO–based regimens outside of an interventional clinical trial are poorly understood. Pt reported outcomes (PRO) are rarely captured in a systematic manner. Addressing the evidence gap for how real world pts symptomatically change with treatment combinations and sequences over time is a pressing unmet need. Methods: This is a prospective, observational cohort, phase IV study of 800 mRCC pts in the US. Pts must: be age ≥19 at informed consent; have a diagnosis of mRCC (any histology) with no prior systemic therapy for mRCC (surgery and radiation therapy, prior neoadjuvant/adjuvant therapy for non-mRCC, and pts currently not on systemic therapy and being observed are all permitted); and be able to comply with completion of PROs. Those being treated for active malignancies other than mRCC or not intending to undergo follow up care at a study site within PCORnet are excluded. Pts will undergo consent and baseline assessments, including research blood collection and processing, by the study site team. A novel aspect of this study is the use of PCORnet and Medicare data to minimize data collection burden on sites. PCORnet, the National Patient-Centered Clinical Research Network, is a network of networks that curates EHR data from multiple health systems using a common data model. This allows subsequent follow up to be centrally coordinated by the coordinating center. PRO will be collected at baseline (pre-treatment), every 3 mos for 2 yrs, and then every 6 mos until end of follow up (minimum 18 mos follow-up; maximum 36 mos follow-up). The primary objective is to determine distinct patterns of change in QOL and symptom burden of mRCC pts receiving therapy. Secondary objectives include quantifying the time to treatment discontinuation of pts, identifying patterns of clinical management in the real world setting of mRCC pts on various treatment regimens, and evaluating overall survival of mRCC pts. ClinicalTrials.gov Identifier: NCT04919122 Clinical trial information: NCT04919122 .

Surgical Evaluation in Patients Undergoing Radiation Therapy for Early-Stage Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is used to treat stage I non-small cell lung cancer (NSCLC) in nonsurgical candidates, although guidelines specify that inoperability be determined in multidisciplinary fashion. We characterized NSCLC patients treated with SBRT undergoing thoracic surgical evaluation (TSUe) and quantified TSUe's impact on time to treatment, receipt of diagnostic staging procedures, and health care costs.

METHODS

Adults with newly diagnosed NSCLC undergoing SBRT were identified in the MarketScan all-payer claims database (2014-2018). TSUe was defined as an outpatient encounter with a thoracic surgeon or multispecialty group. Time to treatment and total costs in the 6 months preceding treatment were examined using multivariable regression by receipt of TSUe, adjusting for demographic and clinical factors.

RESULTS

Of 1894 patients, 36.3% (n = 687) underwent TSUe. Compared with patients without TSUe, these patients were younger (mean age, 73.6 vs 76.3 years) and more likely to undergo invasive biopsy/staging procedures (90% vs 82%) or pulmonary function testing (80.6% vs 69.5%). Patients undergoing TSUe had a median time to treatment of 64 days (interquartile range, 43-98 days), compared with 44 days (interquartile range, 29-70 days) for no TSUe. Adjusted time to treatment was 43% longer (incident rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001) with TSUe. Patients undergoing TSUe also incurred 30% higher costs (adjusted cost ratio, 1.30; 95% CI, 1.20-1.41; P < .001).

CONCLUSIONS

Among patients with early-stage NSCLC undergoing SBRT as primary treatment, a minority are evaluated by a thoracic surgeon. Because they have a longer time to treatment, more invasive diagnostic procedures, and higher costs, this represents a targetable gap to make workup protocols more efficient.

End-of-Life Care for Patients With Metastatic Renal Cell Carcinoma in the Era of Oral Anticancer Therapy

PURPOSE

New therapies including oral anticancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC). However, little is known about the quality of end-of-life (EOL) care and systemic therapy use at EOL in patients receiving OAAs or with mRCC.

METHODS

We retrospectively analyzed EOL care for decedents with mRCC in two parallel cohorts: (1) patients (RCC diagnosed 2004-2015) from the University of North Carolina's Cancer Information and Population Health Resource (CIPHR) and (2) patients (diagnosed 2007-2015) from SEER-Medicare. We assessed hospice use in the last 30 days of life and existing measures of poor-quality EOL care: systemic therapy, hospital admission, intensive care unit admission, and > 1 ED visit in the last 30 days of life; hospice initiation in the last 3 days of life; and in-hospital death. Associations between OAA use, patient and provider characteristics, and EOL care were examined using multivariable logistic regression.

RESULTS

We identified 410 decedents in the CIPHR cohort (53.4% received OAA) and 1,508 in SEER-Medicare (43.5% received OAA). Prior OAA use was associated with increased systemic therapy in the last 30 days of life in both cohorts (CIPHR: 26.5% v 11.0%; P < .001; SEER-Medicare: 23.4% v 11.7%; P < .001), increased in-hospital death in CIPHR, and increased hospice in the last 30 days in SEER-Medicare. Older patients were less likely to receive systemic therapy or be admitted in the last 30 days or die in hospital.

CONCLUSION

Patients with mRCC who received OAAs and younger patients experienced more aggressive EOL care, suggesting opportunities to optimize high-quality EOL care in these groups.

Predictors of hospital bypass for rural residents seeking common elective surgery

BACKGROUND

Surgical bypass occurs when rural residents receive surgical care at a nonlocal hospital. Given limited knowledge of current bypass rates, we evaluated rates and predictors of bypass for common procedures.

METHODS

We used 2014 to 2016 all-payer claims data from the Healthcare Cost and Utilization Project State Inpatient Databases to study rural patients from 13 states who underwent 1 of 11 common elective surgical procedures. Bypass was measured by whether a patient received elective surgical care at the closest hospital offering the requested procedure or another nonlocal hospital. Bypass probability was then modeled as a function of patient-level and hospital-level characteristics.

RESULTS

Of the 121,297 rural elective surgery visits in our sample, 78,268 (64.5%) bypassed their local hospital. Bypass rate was greatest for coronary artery bypass graft or valve replacement (74.8%) and lowest for laparoscopic cholecystectomy (53.7%). In addition, average bypass rate was greatest for surgeries with the highest risk of intraoperative blood loss and postoperative complications. The probability of bypass significantly (P < .001) increased for patients who were younger, privately insured, and lived farther from the closest hospital. In addition, the probability of bypass significantly (P < .001) increased for patients whose local hospital had fewer full-time equivalents, lower operating margin, and fewer recommendations from previous patients.

CONCLUSION

Among rural patients seeking elective surgery, bypass of the local hospital was common among both low-risk and high-risk procedures. These findings suggest that there is a substantial amount of bypass, which may negatively impact a hospital's financial performance and, hence, wellbeing of the local community.

Association of Rural Hospital For-Profit Status With Higher Publicly Reported Prices for the Components of Inpatient Hematuria Evaluation Among Commercially Insured Patients

INTRODUCTION

Rural patients have limited access to urological care and are vulnerable to high local prices. Little is known about price variation for urological conditions. We aimed to compare reported commercial prices for the components of inpatient hematuria evaluation between for-profit vs not-for-profit and rural vs metropolitan hospitals.

METHODS

We abstracted commercial prices for the components of intermediate- and high-risk hematuria evaluation from a price transparency data set. We compared hospital characteristics between those that do and do not report prices for a hematuria evaluation using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Generalized linear modelling evaluated the association between hospital ownership and rural/metropolitan status with prices of intermediate- and high-risk evaluations.

RESULTS

Of all hospitals, 17% of for-profits and 22% of not-for-profits report prices for hematuria evaluation. For intermediate-risk, median price at rural for-profit hospitals was $6,393 (interquartile range [IQR] $2,357-$9,295) compared to $1,482 (IQR $906-$2,348) at rural not-for-profits and $2,645 (IQR $1,491-$4,863) at metropolitan for-profits. For high-risk, rural for-profit hospitals' median price was $11,151 (IQR $5,826-$14,366) vs $3,431 (IQR $2,474-$5,156) at rural not-for-profits and $4,188 (IQR $1,973-$8,663) at metropolitan for-profits. Rural for-profit status was associated with an additional higher price for intermediate- (relative cost ratio 1.62, 95% CI 1.16-2.28, P = .005) and high-risk evaluations (relative cost ratio 1.50, 95% CI 1.15-1.97, P = .003).

CONCLUSIONS

Rural for-profit hospitals report high prices for components of inpatient hematuria evaluation. Patients should be aware of prices at these facilities. These differences may dissuade patients from undergoing evaluation and lead to disparities.

Comparison of Cost and Perioperative Outcomes Among Patients Undergoing Simple Prostatectomy and Laser Enucleation of the Prostate

Introduction: Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g., >80 g). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic-assisted simple prostatectomy, has increased for the treatment of large gland BPH, studies comparing the outcomes and cost of these modalities in a contemporary cohort are lacking. Methods: All-payer data from Healthcare Cost and Utilization Project State Databases from Florida, New York, California, and Maryland from 2016 to 2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and cost of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30-day revisits, and index hospitalization cost among the two operations. Results: Of the 2032 patients in the cohort, 1067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. Thirty-day revisit rates among the operations were equivalent (odds ratio 0.89, 95% confidence interval 0.63-1.27, p = 0.05). The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7291 vs $6442, p = 0.04). However, our sub-group analysis examining high-volume centers revealed no significant differences in cost ($6184 vs $5353, p = 0.1). Conclusions: Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30-day revisits. The SP was less expensive than LEP overall; however, among high-volume facilities, the cost of both operations was reduced, such that they were equivalent.

Oral Anticancer Agent (OAA) Adherence and Survival in Elderly Patients With Metastatic Renal Cell Carcinoma (mRCC)

OBJECTIVE

To examine real-world adherence to oral anticancer agents (OAAs) and its association with outcomes among Medicare beneficiaries with metastatic renal cell carcinoma (mRCC).

METHODS

SEER-Medicare retrospective cohort study of patients with metastatic renal cell carcinoma (mRCC) who received an OAA between 2007 and 2015. We examined A) adherence and B) overall and disease-specific 2-year survival landmarked at 3 months after OAA initiation. Adherence was assessed by calculating the proportion of days covered (PDC) within 3 months of OAA initiation, with adherent use being defined as PDC > 80%.

RESULTS

A total of 905 patients met study criteria, of whom 445 patients (49.2%) were categorized as adherent to initial OAA treatment. Adjusting for clinical and demographic factors revealed decreased odds of adherence associated with living within an impoverished neighborhood (OR 0.49, CI 0.0.33 - 0.74) and out-of-pocket costs > $200 (OR 0.68, CI 0.47-.98). Adherence was associated with improved 2-year survival in univariate analysis (logrank test, P = .01) and a non-significant trend toward an association with decreased all-cause (HR 0.87, CI 0.72 - 1.05) and RCC-specific survival (HR 0.84, CI 0.69 - 1.03) in multivariable analysis.

CONCLUSION

Local poverty levels and high out-of-pocket costs are associated with poor initial adherence to OAA therapy in Medicare beneficiaries with mRCC, which in turn, suggests a trend toward poor overall and disease-specific survival. Efforts to improve outcomes in the broader mRCC population should incorporate OAA adherence and economic factors.

Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents

PURPOSE

In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs.

METHODS

This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality.

RESULTS

The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality.

CONCLUSIONS

Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.

Adverse outcomes after minimally invasive surgery for pelvic organ prolapse in women 65 years and older in the United States

INTRODUCTION AND HYPOTHESIS

To describe complications at the time of surgery, 90-day readmission and 1-year reoperation rates after minimally invasive pelvic organ prolapse (POP) in women > 65 years of age in the US using Medicare 5% Limited Data Set (LDS) Files.

METHODS

Medicare is a federally funded insurance program in the US for individuals 65 and older. Currently, 98% of individuals over the age of 65 in the US are covered by Medicare. We identified women undergoing minimally invasive POP surgery, defined as laparoscopic or vaginal surgery, in the inpatient and outpatient settings from 2011-2017. Patient and surgical characteristics as well as adverse events were abstracted. We used logistic regression for complications at index surgery and Cox proportional hazards regression models for time to readmission and time to reoperations.

RESULTS

A total of 11,779 women met inclusion criteria. The mean age was 72 (SD ± 8) years; the majority were White (91%). Most procedures were vaginal (76%) and did not include hysterectomy (68%). The rate of complications was 12%; vaginal hysterectomy (aOR 2.4, 95% CI 2.2-2.7) was the factor most strongly associated with increased odds of complications. The 90-day readmission rate was 7.3%. The most common reason for readmission was infection (2.0%), three quarters of which were urinary tract infections. Medicaid eligibility (aHR 1.5, 95% CI 1.3-1.8) and concurrent sling procedures (aHR 1.2, 95% CI 1.04-1.4) were associated with a higher risk of 90-day readmission. The 1-year reoperation rate was 4.5%. The most common type of reoperation was a sling procedure (1.8%). Obliterative POP surgery (aHR 0.6, 95% CI 0.4-0.9) was associated with a lower risk of reoperation than other types of surgery.

CONCLUSIONS

US women 65 years and older who are also eligible to receive Medicaid are at higher risk of 90-day readmission following minimally invasive surgery for POP with the most common reason for readmission being UTI.

Influence of Clinical and Sociodemographic Factors on the Management, Costs and Outcomes of Acute Urinary Retention in the Acute Care Setting

INTRODUCTION

We evaluated clinical and sociodemographic factors that influence care pathways following acute urinary retention with attention to subsequent bladder outlet procedures.

METHODS

This was a retrospective cohort study examining patients who presented for emergent care with concomitant diagnoses of urinary retention and benign prostatic hyperplasia in New York and Florida in 2016. Using Healthcare Cost and Utilization Project data, patients were followed throughout a calendar year across subsequent encounters for recurrent urinary retention and bladder outlet procedures. Multivariable logistic and linear regression were utilized to identify factors associated with recurrent urinary retention, subsequent outlet procedures and the cost of retention-related encounters.

RESULTS

Among 30,827 patients, 12,286 (39.9%) were ≥80 years of age. Though 5,409 (17.5%) experienced multiple retention-related encounters, only 1,987 (6.4%) received a bladder outlet procedure within the calendar year. Covariates associated with repeat urinary retention included older age (OR 1.31, p <0.001), Black race (OR 1.18, p=0.001), Medicare insurance (OR 1.16, p=0.005) and lower education level (OR 1.13, p=0.03). Age ≥80 years (OR 0.53, p <0.001), Elixhauser Comorbidity Index score ≥3 (OR 0.31, p <0.001), Medicaid status (OR 0.52, p <0.001) and lower education level were associated with lower odds of receiving a bladder outlet procedure. Episode-based costs favored single retention encounters vs repeat encounters ($15,285.96 vs $28,451.21, p <0.001) and undergoing an outlet procedure vs foregoing one ($16,223.38 vs $17,690.54, p=0.002).

CONCLUSIONS

Sociodemographic factors are associated with recurrent retention episodes and the decision to undergo a bladder outlet procedure following an episode of urinary retention. Despite the cost benefits associated with preventing repeated episodes of urinary retention, merely 6.4% of patients presenting with acute urinary retention underwent a bladder outlet procedure during the study period. Our findings suggest that early intervention among individuals experiencing urinary retention may confer cost and duration of care benefits.

Patient preferences for treatment and outcomes in hormone-sensitive prostate cancer (HSPC)

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Background: Treatment options for patients with HSPC have broadened, and data regarding patient preferences for therapies can aid in therapeutic decision-making. This study evaluated the impact of attributes associated with therapies for US patients with locally advanced prostate cancer (LAPC) or metastatic HSPC (mHSPC) from the perspective of patient preferences. Methods: An online discrete choice experiment (DCE) was developed for patients with LAPC or mHSPC. The DCE included 12 questions designed to systematically require tradeoffs between treatment attributes of efficacy (5-year overall survival [OS]), tolerability (fatigue, skin rash, neurotoxicity, and common chemotherapy-related toxicity), and convenience (administration factors [route, frequency, and setting], concomitant use of steroids, and monitoring requirements). Respondents could choose androgen deprivation therapy (ADT) alone or with hypothetical therapies that improved 5-year OS but had additional adverse events (AEs). Attribute-specific importance weights measuring their relative impact on treatment choices were estimated using a mixed-logit model, which also controlled for heterogeneity in preferences. Results: From September 3 to October 14, 2021, 82 respondents (mean age 61 years) completed the survey (LAPC, n = 40; mHSPC, n = 42), with 61 (74.4%) receiving ADT at the time of the survey. Respondents reported treatment efficacy (36% [95% confidence interval (CI) 22, 49]) as the most important aspect of treatment choice, followed by changes in chemotherapy-related toxicity (13% [95% CI 3, 22]) and the need for concomitant steroid use (12% [95% CI 5, 19]). Respondents considered monitoring requirements (8% [95% CI 5, 19]) to be more important than fatigue (5% [95% CI 2, 13]). Administration factors were comparable in importance to therapy AEs (Table). Respondents preferred, by at least 10 percentage points, adding therapies to ADT that could improve 5-year OS, at the detriment of additional AEs. Conclusions: After efficacy, convenience was considered to impact treatment choices at a rate comparable to tolerability issues, potentially influenced by perceived COVID-19 exposure risks. Patients with LAPC and mHSPC prioritize efficacy despite the detriment of additional AEs.[Table: see text]

Patient, provider, and hospital factors associated with oral anti-neoplastic agent initiation and adherence in older patients with metastatic renal cell carcinoma

INTRODUCTION

Oral anti-neoplastic agents (OAAs) for metastatic renal cell carcinoma (mRCC) are associated with increased cancer-specific survival. However, racial disparities in survival persist and older adults have the lowest rates of cancer-specific survival. Research from other cancers demonstrates specialty access is associated with high-quality cancer care, but older adults receive cancer treatment less often than younger adults. We therefore examined whether patient, provider, and hospital characteristics were associated with OAA initiation, adherence, and cancer-specific survival after initiation and whether race, ethnicity, and/or age was associated with an increased likelihood of seeing a medical oncologist for diagnosis of mRCC.

PATIENTS AND METHODS

We used Surveillance, Epidemiology, and End Results (SEER)Medicare data to identify patients ≥65 years of age who were diagnosed with mRCC from 2007 to 2015 and enrolled in Medicare Part D. Insurance claims were used to identify receipt of OAAs within twelve months of metastatic diagnosis, calculate proportion of days covered, and to identify the primary cancer provider and hospital. We examined provider and hospital characteristics associated with OAA initiation, adherence, and all-cause mortality after OAA initiation.

RESULTS

We identified 2792 patients who met inclusion criteria. Increased OAA initiation was associated with access to a medical oncologist. Patients were less likely to begin OAA treatment if their primary oncologic provider was a urologist (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.49-0.77). Provider/hospital characteristics were not associated with differences in OAA adherence or mortality. Patients who started sorafenib (odds ratio [OR] 0.50; 95% CI 0.29-0.86), were older (aged >81 OR 0.56; 95% CI 0.34-0.92), and those living in high poverty ZIP codes (OR 0.48; 95% CI 0.29-0.80) were less likely to adhere to OAA treatment. Furthermore, provider characteristics did not account for differences in mortality once an OAA was initiated. Last, only age > 81 years was statistically and clinically associated with a decreased relative risk of seeing a medical oncologist (risk ratio [RR] 0.87; CI 0.82-0.92).

CONCLUSION

Provider/hospital factors, specifically, being seen by a medical oncologist for mRCC diagnosis, are associated with OAA initiation. Older patients were less likely to see a medical oncologist; however, race and/or ethnicity was not associated with differences in seeing a medical oncologist. Patient factors are more critical to OAA adherence and mortality after OAA initiation than provider/hospital factors.

Predicting postoperative complications in pediatric surgery: A novel pediatric comorbidity index

INTRODUCTION/BACKGROUND

Comorbidity-driven surgical risk assessment is essential for informed patient counseling, risk-stratification, and outcomes-based health-services research. Existing mortality-focused comorbidity indices have had mixed success at risk-adjustment in children.

OBJECTIVE

To develop a new comorbidity-driven multispecialty surgical risk index predicting 30-day postoperative complications in children.

STUDY DESIGN

This retrospective cohort study investigated children undergoing surgical procedures across seven specialties in 2014-2015 using the MarketScan® Research databases. The risk index was derived separately for ambulatory and inpatient surgery patients using logistic regression with backward selection. The performance of the novel index in discriminating postoperative complications vis-à-vis three existing comorbidity indices was compared using bootstrapping and area under the receiver operating characteristics curves (AUC).

RESULTS

We identified 190,629 ambulatory and 22,633 inpatient patients. The novel index had the best performance for discriminating postoperative complications for inpatients (AUC 0.76, 95% confidence interval [CI] 0.75-0.77) relative to the Charlson Comorbidity Index (CCI, 0.56, 95% CI 0.56-0.57), Van Walraven Index (VWI, 0.60, 95% CI 0.60-0.61), and Rhee Score (RS, 0.69, 95% CI 0.68-0.70). In the ambulatory cohort, the novel index outperformed all three existing indices, though none demonstrated excellent discriminatory ability for complications (novel score 0.68, 95% CI 0.67-0.68; CCI 0.53, 95% CI 0.52-0.53; VWI 0.53, 95% CI 0.52-0.53; RS 0.50, 95% CI 0.49-0.50).

DISCUSSION

In both inpatient and ambulatory pediatric settings, our novel comorbidity index demonstrated better performance at predicting postoperative complications than three widely used alternatives. This index will be useful for research and may be adaptable to clinical settings to identify high-risk patients and facilitate perioperative planning.

CONCLUSION

We developed a novel pediatric comorbidity index with better performance at predicting postoperative complications than three widely used alternatives.

Predicting in-hospital length of stay: a two-stage modeling approach to account for highly skewed data

Background

In the early stages of the COVID-19 pandemic our institution was interested in forecasting how long surgical patients receiving elective procedures would spend in the hospital. Initial examination of our models indicated that, due to the skewed nature of the length of stay, accurate prediction was challenging and we instead opted for a simpler classification model. In this work we perform a deeper examination of predicting in-hospital length of stay.

Methods

We used electronic health record data on length of stay from 42,209 elective surgeries. We compare different loss-functions (mean squared error, mean absolute error, mean relative error), algorithms (LASSO, Random Forests, multilayer perceptron) and data transformations (log and truncation). We also assess the performance of two stage hybrid classification-regression approach.

Results

Our results show that while it is possible to accurately predict short length of stays, predicting longer length of stay is extremely challenging. As such, we opt for a two-stage model that first classifies patients into long versus short length of stays and then a second stage that fits a regresssor among those predicted to have a short length of stay.

Discussion

The results indicate both the challenges and considerations necessary to applying machine-learning methods to skewed outcomes.

Conclusions

Two-stage models allow those developing clinical decision support tools to explicitly acknowledge where they can and cannot make accurate predictions.

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS

BACKGROUND

Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.

METHODS

In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.

RESULTS

The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.

CONCLUSIONS

This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.

Factors associated with the quality of end-of-life care for patients with metastatic renal cell carcinoma

300

Background: Although oral anti-cancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC), most patients still die from the disease. High quality end-of-life (EOL) care remains a crucial component of optimal care for patients with mRCC, but neither it nor systemic therapy use at EOL have been well characterized in these patients. Methods: We conducted a retrospective study of decedents with mRCC in 2 cohorts analyzed in parallel: 1) patients aged ≥18 years (diagnosed with RCC in 2004 through 2015) drawn from the University of North Carolina Cancer Information Population Health Resource (NC-CIPHR) and 2) patients aged ≥66 years (diagnosed with RCC in 2007 through 2015) from SEER-Medicare. OAA use was measured from date of mRCC diagnosis until 30 days prior to death. We assessed use of hospice in the last 30 days of life as well as established measures of low EOL care quality: receipt of systemic therapy, hospital admission, and ICU admission in last 30 days of life, and death in hospital. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence limits (95%CL) for associations between OAA use, patient and provider characteristics, and EOL care quality in both cohorts. Results: We identified 410 (NC-CIPHR) and 1508 (SEER-Medicare) patients with median ages of 69 and 75 years, respectively. 53.4% and 43.5% of decedents received an OAA in NC-CIPHR and SEER-Medicare, respectively. OAA use was associated with increased systemic therapy in the last 30 days prior to death in both datasets, increased hospice in the last 30 days prior to death in SEER-Medicare, and increased death in hospital in NC-CIPHR. OAA use was not associated with inpatient or ICU admission near EOL in both cohorts. Older patients were less likely to receive chemotherapy, be admitted, or die in the hospital near EOL in both cohorts. Dual-enrolled beneficiaries (Medicare and Medicaid) had decreased likelihood of hospice use in 30 days prior to death (OR = 0.71; 95%CL: 0.54, 0.94) and increased death in hospital (OR = 1.40; 95%CL: 1.02, 1.93) in SEER-Medicare. Conclusions: Patients with mRCC who received OAAs were more likely to receive systemic therapy at the EOL, however, they were also more likely to receive hospice care at EOL in the SEER-Medicare cohort with no differences in hospitalization near EOL. Future directions include characterization of EOL care in the era of immunotherapy treatments. [Table: see text]

Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non-Index Hospitals

OBJECTIVE

To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease.

METHODS

All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively.

RESULTS

Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non-index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p <0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode-based costs were higher in the non-index setting, with a mean difference of $783 (Non-index: $13,672, 95% CI $13,292 - $14,053; Index: $12,889, 95% CI $12,677 - $13,102; p < 0.001).

CONCLUSIONS

Re-presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode-related health encounters, longer time to definitive surgery, and increased costs.

Real-World Utilization of Oral Anticancer Agents and Related Costs in Older Adults with Metastatic Renal Cell Carcinoma in the United States

BACKGROUND

Substantial racial and socioeconomic disparities in metastatic RCC (mRCC) have persisted following the introduction of targeted oral anticancer agents (OAAs). The relationship between patient characteristics and OAA access and costs that may underlie persistent disparities in mRCC outcomes have not been examined in a nationally representative patient population.

METHODS

Retrospective SEER-Medicare analysis of patients diagnosed with mRCC between 2007-2015 over age 65 with Medicare part D prescription drug coverage. Associations between patient characteristics, OAA receipt, and associated costs were analyzed in the 12 months following mRCC diagnosis and adjusted to 2015 dollars.

RESULTS

2,792 patients met inclusion criteria, of which 32.4%received an OAA. Most patients received sunitinib (57%) or pazopanib (28%) as their first oral therapy. Receipt of OAA did not differ by race/ethnicity or socioeconomic indicators. Patients of advanced age (> 80 years), unmarried patients, and patients residing in the Southern US were less likely to receive OAAs. The mean inflation-adjusted 30-day cost to Medicare of a patient's first OAA prescription nearly doubled from $3864 in 2007 to $7482 in 2015, while patient out-of-pocket cost decreased from $2409 to $1477.

CONCLUSION

Race, ethnicity, and socioeconomic status were not associated with decreased OAA receipt in patients with mRCC; however, residing in the Southern United States was, as was marital status. Surprisingly, the cost to Medicare of an initial OAA prescription nearly doubled from 2007 to 2015, while patient out-of-pocket costs decreased substantially. Shifts in OAA costs may have significant economic implications in the era of personalized medicine.

Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma

87

Background: While several patient-level factors have been associated with oral anti-cancer agent (OAA) initiation and adherence for metastatic renal cell carcinoma (mRCC) and other cancers, few provider-level factors have been examined, despite providers being a key component driving OAA access. We examined provider and patient characteristics associated with OAA initiation and adherence among individuals with mRCC. Methods: We used linked North Carolina state cancer registry data and multi-payer claims data to identify mRCC patients diagnosed in 2004-2015. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. Provider-level variables included specialty, sex, race/ethnicity, years in practice, provider’s RCC patient volume, and practice location. Patient-level control variables of interest included: age at metastatic diagnosis, sex, race/ethnicity, rural location, insurance coverage at metastatic index date, histology, stage at initial diagnosis, radical/partial nephrectomy in the prior year, number of comorbidities at baseline, and frailty. OAA initiation within the 12 months following the patient’s metastatic index date was identified from prescription drug files and pharmacy claims. Adherence to OAAs was defined as having ≥80% proportion of days covered (PDC) for the 90 consecutive days following an initial OAA claim that patients had access to any OAA days’ supply. We estimated risk ratios (RR) and corresponding 95% confidence limits (CL) using modified Poisson regression to evaluate patient- and provider-level factors associated with OAA initiation and adherence. Results: Of the 687 patients in our sample, 37% initiated an OAA following mRCC diagnosis. Patients with a modal provider specializing in hematology/medical oncology were more likely to initiate OAAs than those seen by other specialties (i.e., urology/urological surgery, internal medicine, and other). Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing in urban areas only more likely to initiate OAAs (RR = 1.37; 95%CL:1.09,1.73). Patients who were older, with more comorbid conditions, stage I at initial diagnosis, and greater frailty were less likely to initiate OAAs. Among the 207 patients who initiated an OAA and survived the following 90 days, the median PDC was 0.91. No provider-level factors were associated with OAA adherence. However, Medicare-insured patients were less likely to be adherent (RR = 0.61; 95%CL:0.42,0.87) than those with private insurance. Conclusions: Our results suggest that provider- and patient-level factors are associated with OAA initiation but only patient-level factors are associated with adherence.

Patient- and provider-level predictors of mortality among patients with metastatic renal cell carcinoma receiving oral anticancer agents

116

Background: It is important to understand how emerging new therapies, such as oral anti-cancer agents (OAAs), diffuse across and can improve outcomes within real-world populations, which include age groups and racial groups not well-represented in clinical trials, such as people older than age 65 and Black patients. Our objectives were to examine whether disparities in mortality persist among patients with metastatic renal cell carcinoma (mRCC) receiving OAAs and whether these disparities may be partially explained by patient’s clinical characteristics or provider-level factors. Methods: We used linked state cancer registry data and multi-payer claims data to identify patients with mRCC who were diagnosed in 2004 through 2015 and had initiated an OAA and survived ≥ 90 days after initiating. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox proportional hazard models to evaluate which patient demographics, patient clinical characteristics, and provider-level factors were associated with 2-year all-cause mortality. Results: The cohort included 207 patients with mRCC. In unadjusted analyses, public insurance (Medicaid or Medicare), de novo metastatic diagnosis, frailty, polypharmacy, and a visit to a skilled nursing facility were associated with increased all-cause mortality. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, Medicare-insured patients continued to have higher all-cause mortality compared to privately insured patients (HR: 2.35, 95% CL: 1.32-4.18). None of the provider-level covariates (i.e., specialization, experience, volume, or practice location) investigated were associated with all-cause mortality. Conclusions: Even when adjusting for age, frailty, and comorbidities, Medicare-insured patient had lower overall survival than privately-insured patients. Patient survival did not differ based on modal provider’s characteristics.

Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma

Background

Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC).

Methods

We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence.

Results

Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87).

Conclusions

Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.

Patterns and Predictors of Oral Anticancer Agent Use in Diverse Patients With Metastatic Renal Cell Carcinoma

PURPOSE

Availability of targeted oral anticancer agents (OAAs) has transformed care for patients with metastatic renal cell carcinoma (mRCC). Our objective was to identify patterns and predictors of OAA use within 12 months after mRCC was detected to understand real-world adoption of OAAs.

METHODS

We used a novel, North Carolina cancer registry-linked multipayer claims data resource to examine patterns of use of five oral therapies among patients with mRCC diagnosed in 2006-2015, with claims through 2016. Patients were required to have 12 months of continuous enrollment before metastatic index date. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences in OAA use.

RESULTS

Our population-based study of 713 patients demonstrated low (37%) OAA use during the first year after metastatic index date among both publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Compared with patients age 18-49 years, patients age 70-74 years were half likely to use OAAs (95% confidence limit [CL], 0.34 to 0.78) and patients age 80+ years were 71% less likely to use OAAs (95% CL, 0.17 to 0.50). Patients with two comorbidities (RR, 0.73; 95% CL, 0.55 to 0.98) and those with 3+ comorbidities (RR, 0.68; 95% CL, 0.50 to 0.91) were less likely to receive OAA than those without comorbidities. Patients with higher frailty also had lower OAA utilization (RR, 0.67; 95% CL, 0.52 to 0.85).

CONCLUSION

These findings suggest a need to better understand the system-level and provider-level drivers of OAA underuse, as well as OAA adherence and associated survival.

Management of Chronic Rhinosinusitis Prior to Otolaryngology Referral: An Opportunity for Quality Improvement

OBJECTIVE

The management of chronic rhinosinusitis (CRS) by a nonotolaryngologist prior to otolaryngology referral is an important component of the patient care pathway. The purpose of this study is to characterize CRS management during this period and to identify areas of quality improvement.

STUDY DESIGN

Retrospective review of a national claims database.

SETTING

Academic institution.

METHODS

Data were analyzed from the IBM Health MarketScan Research Databases (2013-2017). Patients with 3-year enrollment data were identified who were initially diagnosed with CRS by a nonotolaryngologist and subsequently seen by an otolaryngologist. Management of CRS by the nonotolaryngologist was assessed in terms of duration, demographics, health care resource utilization, and health care expenditure.

RESULTS

A total of 51,273 patients met inclusion criteria. The median length of the referral period was 142 days, with variations according to geography. Patients with a delayed referral period had higher health care resource utilization in terms of visits for CRS (mean, 1.8 vs 1.2), total visits (mean, 12.6 vs 3.9), and medication prescriptions (especially antibiotics; mean, 5.8 vs 2.1). Health care expenditure was almost twice as high for the delayed referral group (mean, $986 vs $571), mainly due to CRS-related medication costs (mean, $578 vs $214).

CONCLUSION

Our findings suggest that there are wide variations in how CRS is managed prior to referral to an otolaryngologist. The dissemination of clinical practice guidelines to primary care providers may help to increase efficiency of CRS care and offers a unique opportunity for quality improvement that extends beyond the bounds of our own specialty.

Strategies for research participant engagement: A synthetic review and conceptual framework

BACKGROUND

Research participant engagement, which we define as recruitment and retention in clinical trials, is a costly and challenging issue in clinical research. Research teams have leveraged a variety of strategies to increase research participant engagement in clinical trials, although a framework and evidence for effective participant engagement strategies are lacking. We (1) developed a novel conceptual framework for strategies used to recruit and retain participants in clinical trials based on their underlying behavioral principles and (2) categorized empirically tested recruitment and retention strategies in this novel framework.

METHODS

We conducted a synthetic analysis of interventions tested in studies from two Cochrane reviews on clinical trial recruitment and retention, which included studies from 1986 to 2015. We developed a conceptual framework of behavioral strategies for increasing research participant engagement using deductive and inductive approaches with the studies included in the Cochrane reviews. Reviewed interventions were then categorized using this framework. We examined the results of reviewed interventions and categorized the effects on clinical trial recruitment and retention as significantly positive, null, or significantly negative; summary statistics are presented for the frequency and effects of each behavioral strategy type.

RESULTS

We analyzed 141 unique interventions across 96 studies: 91 interventions targeted clinical trial research participant recruitment and 50 targeted retention. Our framework included 14 behavioral strategies to improve research participant engagement grouped into four general approaches: changing attitudes by appealing to social motivators, changing attitudes by targeting individual psychology, reducing barriers and cognitive burdens, and providing incentives. The majority of interventions (54%) aimed to reduce barriers or cognitive burdens, with improving comprehension (27%) as the most common specific strategy identified. For recruitment, the most common behavioral strategies tested were building legitimacy or trust (38%) and framing risks and benefits (32%), while financial or material incentives (32%) and reducing financial, time, and social barriers (32%) were most common for retention interventions. Among interventions tested in randomized controlled trials, 51% had a null effect on research participant engagement, and 30% had a statistically significant positive effect.

DISCUSSION

Clinical researchers have tested a wide range of interventions that leverage distinct behavioral strategies to achieve improved research participant recruitment and retention. Common behavioral strategies include building legitimacy or trust between research teams and participants, as well as improving participant comprehension of trial objectives and procedures. The high frequency of null effects among tested interventions suggests challenges in selecting the optimal interventions for increasing research participant engagement, although the proposed behavioral strategy categories can serve as a conceptual framework for developing and testing future interventions.

Geographic Variations in Healthcare Utilization and Expenditure for Chronic Rhinosinusitis: A Population-Based Approach

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis (CRS) is a common and costly health problem in the United States. A better understanding of healthcare resource utilization (HCRU) and healthcare expenditure (HCE) pertaining to CRS is required. The objective of this study is to investigate geographic variations in HCRU and HCE for CRS.

STUDY TYPE/DESIGN

Retrospective study of administrative database.

METHODS

Patients meeting pre-defined diagnostic criteria for CRS with continuous 1-year pre-index and 2-year post-index data were identified on IBM® Marketscan Research Databases over a 5-year period (2013-2017). Data pertaining to demographics, HCRU, and HCE were analyzed according to geographic region. Multivariable generalized linear models accounted for age, sex, baseline medication utilization, and co-morbidities.

RESULTS

About 237,969 patients were included. Antibiotics were the most commonly prescribed medication (95%). Surgery rate (11%), immunotherapy (9.2%), oral steroid use (66%), and antibiotic utilization (mean 6.3 prescriptions) were highest in the South. However, visits with an otolaryngologist were considerably higher in the Northeast (62%). The Northeast region had the highest mean HCE ($2,449), which was 13% greater than HCE for the North Central region ($2,172). HCRU and HCE were higher in urban areas across all metrics, with 2-year HCE being 18% greater in urban areas ($2,374 vs. $2,019). Significant geographic variation in HCE was observed even after adjusting for covariates.

CONCLUSION

Significant geographic variations in HCRU and HCE exist for CRS even after adjusting for covariates. Future studies are needed to help direct quality improvement and cost-saving efforts as well as efficient resource allocation in an era of value-based care.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Feasibility and efficacy of a decision aid for emergency department patients with suspected ureterolithiasis: protocol for an adaptive randomized controlled trial

Background

Approximately 2 million patients present to emergency departments in the USA annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization.

Methods

This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention—a decision aid (“Kidney Stone Choice”)—on patient-centered outcomes, compared with usual care. Patients age 18–55 presenting to the emergency department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization.

Discussion

We hypothesize that this study will demonstrate that “Kidney Stone Choice,” the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy.

Trial registration

ClinicalTrials.gov NCT04234035. Registered on 21 January 2020 – Retrospectively Registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05140-9.

Oral anticancer agent (OAA) adherence and survival in elderly patients with metastatic renal cell carcinoma (mRCC)

280

Background: Multiple effective oral anticancer agents (OAAs) are now approved for the treatment of patients with advanced or metastatic renal cell carcinoma (mRCC) based on improvement in overall and progression-free survival in randomized clinical trials. However, real-world adherence and outcomes associated with OAA use in the general mRCC patient population have not been previously investigated. Methods: Retrospective analysis of SEER-Medicare patients with mRCC who received treatment with an OAA between 2007 and 2015. Adherence was assessed as proportion of days covered (PDC) within 3 months of OAA initiation with PDC > 50% categorized as adherent. The impact of initial OAA adherence on overall and disease-specific survival was analyzed landmarked at 3 months after OAA initiation. Results: A total of 905 patients met study criteria, of which 577 (63.8%) were categorized as adherent to initial OAA treatment. Multivariable analysis adjusting for clinical and demographic factors revealed that living within an impoverished neighborhood was associated with a 20% lower likelihood of adherence (OR 0.80, CI 0.68 – 0.93). No association was observed between adherence and race, ethnicity, marital status, or number of comorbidities. In survival analyses OAA adherence was associated with a significant reduction in both overall (HR 0.71, CI 0.58 – 0.87) and RCC-specific mortality (HR 0.68, CI 0.57 – 0.86). Receipt of sunitinib was associated with a significant reduction in overall and disease specific mortality compared with sorafenib. Post-hoc analysis of patients taking pazopanib as their initial OAA (N = 252) demonstrated reduced all-cause mortality if they received the minimum effective dose of 800 mg daily (HR 0.50, CI 0.35 – 0.72) and decreased adherence associated with initial higher out-of-pocket payments (χ2 test, p = 0.003). Conclusions: Socioeconomic factors predict poor adherence to OAA therapy in Medicare beneficiaries with metastatic RCC, which is in turn associated with poor overall and disease-specific survival. Efforts to improve outcomes and mitigate disparities in the general mRCC population should incorporate considerations of OAA adherence and economic factors. Sunitinib and pazopanib appear associated with favorable survival and remain the most commonly used OAAs in this over 65 year old patient population.

Patterns and predictors of oral anticancer agent utilization in diverse metastatic renal cell carcinoma patients

279

Background: Availability of targeted oral anti-cancer agents (OAA) has transformed care delivery for metastatic renal cell carcinoma (RCC) patients. Our objective was to identify patterns and predictors of OAA use within the 12 months after metastatic RCC was detected to understand the extent of real-world adoption of these treatment advances. Methods: We used a novel, North Carolina, registry-linked multi-payer claims data resource to examine patterns of use of sorafenib, sunitinib, pazopanib, everolimus, axitinib, cabozantinib, and levantinib in a cohort of metastatic RCC patients diagnosed over 10 years (2006-2015, with claims through 2016). Patients were required to have 12 months of pre- and post-metastatic-index-date continuous enrollment. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) and 95% confidence limits (CLs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences (RD) in OAA use. Results: Our population-based study of 713 patients demonstrated relatively low (37%) OAA use at any time during the 12 months post-metastatic-index date among publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Lower OAA use was observed among patients who were older, frailer, and with greater comorbidity burden. Other patient-level characteristics, such as sex, race, rurality and type of insurance were not significant predictors of OAA use. Conclusions: These data underscore the importance of distinguishing clinically appropriate from potentially poor-quality care and warrant additional studies to understand in more depth the system, provider and patient level drivers of these patterns.

Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling

INTRODUCTION

Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.

OBJECTIVES

This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences.

STUDY DESIGN

Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well.

RESULTS

We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable.

DISCUSSION

In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.

Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design

Background: Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. Materials and Methods: We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. Results: The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. Conclusion: STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial

RATIONALE & OBJECTIVE

Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake.

STUDY DESIGN

We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants.

SETTING & PARTICIPANTS

Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake.

INTERVENTIONS

All participants receive usual care and a smart water bottle with smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions.

OUTCOMES

The primary end point is recurrence of a symptomatic stone during 24 months of follow-up. Secondary end points include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms.

LIMITATIONS

Periodic 24-hour urine volumes may not fully reflect daily behavior.

CONCLUSIONS

With its highly novel features, the PUSH Study will address an important health care problem.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT03244189.

Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults

BACKGROUND

Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. Alpha-blockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain.  OBJECTIVES: To assess the effects of alpha-blockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020.

SELECTION CRITERIA

We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an alpha-blocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE.

MAIN RESULTS

We included 40 studies with 4793 participants randomized to usual care and an alpha-blocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used alpha-blocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin.  Alpha-blockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an alpha-blocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. Alpha-blockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, alpha-blockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. Alpha-blockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; alpha-blockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with alpha-blocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. Alpha-blockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of alpha-blocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session.

AUTHORS' CONCLUSIONS

Based on low certainty evidence, adjuvant alpha-blocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

Development and Performance of a Clinical Decision Support Tool to Inform Resource Utilization for Elective Operations

IMPORTANCE

Hospitals ceased most elective procedures during the height of coronavirus disease 2019 (COVID-19) infections. As hospitals begin to recommence elective procedures, it is necessary to have a means to assess how resource intensive a given case may be.

OBJECTIVE

To evaluate the development and performance of a clinical decision support tool to inform resource utilization for elective procedures.

DESIGN, SETTING, AND PARTICIPANTS

In this prognostic study, predictive modeling was used on retrospective electronic health records data from a large academic health system comprising 1 tertiary care hospital and 2 community hospitals of patients undergoing scheduled elective procedures from January 1, 2017, to March 1, 2020. Electronic health records data on case type, patient demographic characteristics, service utilization history, comorbidities, and medications were and abstracted and analyzed. Data were analyzed from April to June 2020.

MAIN OUTCOMES AND MEASURES

Predicitons of hospital length of stay, intensive care unit length of stay, need for mechanical ventilation, and need to be discharged to a skilled nursing facility. These predictions were generated using the random forests algorithm. Predicted probabilities were turned into risk classifications designed to give assessments of resource utilization risk.

RESULTS

Data from the electronic health records of 42 199 patients from 3 hospitals were abstracted for analysis. The median length of stay was 2.3 days (range, 1.3-4.2 days), 6416 patients (15.2%) were admitted to the intensive care unit, 1624 (3.8%) received mechanical ventilation, and 2843 (6.7%) were discharged to a skilled nursing facility. Predictive performance was strong with an area under the receiver operator characteristic ranging from 0.76 to 0.93. Sensitivity of the high-risk and medium-risk groupings was set at 95%. The negative predictive value of the low-risk grouping was 99%. We integrated the models into a daily refreshing Tableau dashboard to guide decision-making.

CONCLUSIONS AND RELEVANCE

The clinical decision support tool is currently being used by surgical leadership to inform case scheduling. This work shows the importance of a learning health care environment in surgical care, using quantitative modeling to guide decision-making.