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109 MOVING TOWARDS BEST PRACTICES FOR EARLY-STAGE BLADDER CANCER
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
THE JOURNAL OF UROLOGY姞
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III Podium 5 Sunday, May 30, 2010
8:00 AM-10:00 AM
109 MOVING TOWARDS BEST PRACTICES FOR EARLY-STAGE BLADDER CANCER John M. Hollingsworth*, Sean Zhang, Zaojun Ye, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: While contemporary practice guidelines for nonmuscle-invasive bladder cancer favor aggressive surveillance and treatment, recent findings reveal no added benefit for patients managed by high- vs. low-intensity providers, suggesting that more care does not always translate into improved outcomes. However, it is possible that some care processes are of higher value than others. Motivated by this, we used cancer registry data to help define best practices for urologists who manage early-stage bladder cancer. METHODS: Using SEER-Medicare data (1992 – 2007), we identified patients with low-grade Ta disease. We established the provider responsible for a patient’s care in the first 2 years following diagnosis. We determined the frequency with which a patient received certain surveillance- and treatment-directed care processes during this time. After fitting 2-level generalized linear mixed models, we generated reliability-adjusted measures for provider use of these care processes, allowing us to sort providers into intensity quartiles. Finally, we used multivariable Cox proportional hazards regression to examine the relationship between a patient’s overall risk of death and his provider’s intensity quartile for a given care process. RESULTS: In total, 5152 patients with low-grade Ta bladder cancer were cared for by 1627 providers. On average, each urologist managed 3.2 (standard deviation [SD], 3.5) patients during the study interval. Stratified by care process, the corresponding provider means for each intensity quartile are displayed below. As the Table shows, patients exposed to the highest users of endoscopic surveillance (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86 – 1.06), urine cytology (HR, 0.99; 95% CI, 0.89 – 1.10), and intravesical therapy (HR, 0.99; 95% CI, 0.89 – 1.11) had overall survival outcomes that were comparable to those managed by the lowest intensity providers. CONCLUSIONS: Among those patients with the most common form of nonmuscle-invasive bladder cancer, exposure to increasing provider treatment intensity for each of the care processes examined was not associated with improved survival. These data serve to inform best practices in the care of patients with early-stage disease; however, future well-designed clinical trials are still needed.
e45
110 NEOADJUVANT CHEMOTHERAPY AS A PREDICTOR OF COST, READMISSION, AND LENGTH OF STAY IN RADICAL CYSTECTOMY PATIENTS Deep Trivedi*, Jennifer Gordetsky, Guan Wu, Changyong Feng, Susan Messing, Nathaniel Robbins, Thomas Pashalides, Ingrid Mikk, Hani Rashid, Dragan Golijanin, Katia Noyes, Edward Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: There is evidence that receiving neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) results in improved survival over surgery alone in patients with high-stage, muscle invasive bladder cancer. NAC may be underutilized, however, due to reported concerns of increased perioperative complications. Little data exist on whether NAC affects post-operative hospitalization cost, length of stay (LOS), or readmission rate in this group of patients. METHODS: Retrospective billing record and medical chart review of 150 consecutive patients who underwent RC from 1/2006 to 12/2008 was conducted to assess the association between receipt of NAC and initial post-surgical LOS, American Society of Anesthesiologists (ASA) score (when available), intraoperative parameters, and patient demographics. To adjust for the effect of outliers, adjusted LOS was calculated as the mean of LOS values excluding the top 10%. Association between the above variables of interest and use of NAC was examined using Student t-test. Pearson’chi-squared test was used to explore the association between NAC receipt and 90-day readmission status. RESULTS: Two-sample t-tests showed a significant difference in operative time, but no difference in age, mean ASA score, estimated blood loss (EBL), LOS, adjusted LOS, or total post-surgical hospitalization cost between recipents and non-recipents of NAC. Pearson’s chi-square test showed no difference in readmission rate (30.23% vs. 25.00%, p⫽0.63) between these groups. (See table) CONCLUSIONS: In this series, NAC predicts increased operative time but has no significant impact on the readmission rate, duration or cost of initial hospitalization in patients undergoing RC. NeoAdjⴝNo Mean SD 70.26 9.09
N 20
NeoAdjⴝYes Mean SD 66.65 13.39
Variable Age
N 129
ASA
102
2.59
EBL (mL)
123
1381.70
2027.05
19
2071.05
3574.26
Op Time (min) 111
460.24
104.58
17
512.53
93.89
0.637 17
2.57
0.712
P-value 0.13 0.11 0.21 0.02*
Median LOS
127
8
-
20
11
-
Adj. LOS
115
9
3.91
18
10.9
4.49
0.05
10.17
20
21.85
7.69
0.48
20 48,850.00 17,146.00
0.94
Overall LOS
127
Total cost ($)
129 $48,469.00 36,198.00
11.46
-
Source of Funding: None
111 ACCURATELY CHARACTERIZING THE MORBIDITY OF RADICAL CYSTECTOMY: DISPOSITION, READMISSION, AND DEATH WITHIN 90 DAYS Michael Porter*, John Gore, Hunter Wessells, Jonathan Wright, Seattle, WA
Source of Funding: Robert Wood Johnson Foundation Clinical Scholars
INTRODUCTION AND OBJECTIVES: The perioperative morbidity associated with radical cystectomy (RC) has generally been defined by single institution series and analyses of administrative data that yield estimates of in hospital complications and death. Our goal was to describe patient disposition and intermediate term outcomes associated with radical cystectomy using longitudinal population based data. METHODS: Data from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) was analyzed. The CHARS database includes all hospital discharges in Washington State and is linked at the patient level allowing for longitudinal analysis of future hospital admissions. The study cohort was assembled using
THE JOURNAL OF UROLOGY姞
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III Podium 5 Sunday, May 30, 2010
8:00 AM-10:00 AM
109 MOVING TOWARDS BEST PRACTICES FOR EARLY-STAGE BLADDER CANCER John M. Hollingsworth*, Sean Zhang, Zaojun Ye, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: While contemporary practice guidelines for nonmuscle-invasive bladder cancer favor aggressive surveillance and treatment, recent findings reveal no added benefit for patients managed by high- vs. low-intensity providers, suggesting that more care does not always translate into improved outcomes. However, it is possible that some care processes are of higher value than others. Motivated by this, we used cancer registry data to help define best practices for urologists who manage early-stage bladder cancer. METHODS: Using SEER-Medicare data (1992 – 2007), we identified patients with low-grade Ta disease. We established the provider responsible for a patient’s care in the first 2 years following diagnosis. We determined the frequency with which a patient received certain surveillance- and treatment-directed care processes during this time. After fitting 2-level generalized linear mixed models, we generated reliability-adjusted measures for provider use of these care processes, allowing us to sort providers into intensity quartiles. Finally, we used multivariable Cox proportional hazards regression to examine the relationship between a patient’s overall risk of death and his provider’s intensity quartile for a given care process. RESULTS: In total, 5152 patients with low-grade Ta bladder cancer were cared for by 1627 providers. On average, each urologist managed 3.2 (standard deviation [SD], 3.5) patients during the study interval. Stratified by care process, the corresponding provider means for each intensity quartile are displayed below. As the Table shows, patients exposed to the highest users of endoscopic surveillance (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86 – 1.06), urine cytology (HR, 0.99; 95% CI, 0.89 – 1.10), and intravesical therapy (HR, 0.99; 95% CI, 0.89 – 1.11) had overall survival outcomes that were comparable to those managed by the lowest intensity providers. CONCLUSIONS: Among those patients with the most common form of nonmuscle-invasive bladder cancer, exposure to increasing provider treatment intensity for each of the care processes examined was not associated with improved survival. These data serve to inform best practices in the care of patients with early-stage disease; however, future well-designed clinical trials are still needed.
e45
110 NEOADJUVANT CHEMOTHERAPY AS A PREDICTOR OF COST, READMISSION, AND LENGTH OF STAY IN RADICAL CYSTECTOMY PATIENTS Deep Trivedi*, Jennifer Gordetsky, Guan Wu, Changyong Feng, Susan Messing, Nathaniel Robbins, Thomas Pashalides, Ingrid Mikk, Hani Rashid, Dragan Golijanin, Katia Noyes, Edward Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: There is evidence that receiving neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) results in improved survival over surgery alone in patients with high-stage, muscle invasive bladder cancer. NAC may be underutilized, however, due to reported concerns of increased perioperative complications. Little data exist on whether NAC affects post-operative hospitalization cost, length of stay (LOS), or readmission rate in this group of patients. METHODS: Retrospective billing record and medical chart review of 150 consecutive patients who underwent RC from 1/2006 to 12/2008 was conducted to assess the association between receipt of NAC and initial post-surgical LOS, American Society of Anesthesiologists (ASA) score (when available), intraoperative parameters, and patient demographics. To adjust for the effect of outliers, adjusted LOS was calculated as the mean of LOS values excluding the top 10%. Association between the above variables of interest and use of NAC was examined using Student t-test. Pearson’chi-squared test was used to explore the association between NAC receipt and 90-day readmission status. RESULTS: Two-sample t-tests showed a significant difference in operative time, but no difference in age, mean ASA score, estimated blood loss (EBL), LOS, adjusted LOS, or total post-surgical hospitalization cost between recipents and non-recipents of NAC. Pearson’s chi-square test showed no difference in readmission rate (30.23% vs. 25.00%, p⫽0.63) between these groups. (See table) CONCLUSIONS: In this series, NAC predicts increased operative time but has no significant impact on the readmission rate, duration or cost of initial hospitalization in patients undergoing RC. NeoAdjⴝNo Mean SD 70.26 9.09
N 20
NeoAdjⴝYes Mean SD 66.65 13.39
Variable Age
N 129
ASA
102
2.59
EBL (mL)
123
1381.70
2027.05
19
2071.05
3574.26
Op Time (min) 111
460.24
104.58
17
512.53
93.89
0.637 17
2.57
0.712
P-value 0.13 0.11 0.21 0.02*
Median LOS
127
8
-
20
11
-
Adj. LOS
115
9
3.91
18
10.9
4.49
0.05
10.17
20
21.85
7.69
0.48
20 48,850.00 17,146.00
0.94
Overall LOS
127
Total cost ($)
129 $48,469.00 36,198.00
11.46
-
Source of Funding: None
111 ACCURATELY CHARACTERIZING THE MORBIDITY OF RADICAL CYSTECTOMY: DISPOSITION, READMISSION, AND DEATH WITHIN 90 DAYS Michael Porter*, John Gore, Hunter Wessells, Jonathan Wright, Seattle, WA
Source of Funding: Robert Wood Johnson Foundation Clinical Scholars
INTRODUCTION AND OBJECTIVES: The perioperative morbidity associated with radical cystectomy (RC) has generally been defined by single institution series and analyses of administrative data that yield estimates of in hospital complications and death. Our goal was to describe patient disposition and intermediate term outcomes associated with radical cystectomy using longitudinal population based data. METHODS: Data from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) was analyzed. The CHARS database includes all hospital discharges in Washington State and is linked at the patient level allowing for longitudinal analysis of future hospital admissions. The study cohort was assembled using