- Email: [email protected]
132 COST-EFFECTIVENESS ANALYSIS OF PERCUTANEOUS RENAL MASS BIOPSY TO GUIDE THE SURGICAL MANAGEMENT OF SMALL RENAL MASSES
e54
THE JOURNAL OF UROLOGY姞
practitioners has actually declined slightly (less than 1%) and solo practice has increased by nearly 2%. Overall, urologists in group practice are almost 9 years younger than urologists in solo practice. CONCLUSIONS: Many unclassified, solo, and two-physician practice urologic surgeons likely made the move to group practice during the past decade. The growth of group practice among urologic surgeons may provide benefits for sub-specialization call coverage and leverage in coping with ongoing consolidation among provider organizations. These consolidated organizations will need to consider how they will grow without further isolating rural urology practice.
Source of Funding: American College of Surgeons Health Policy Research Institute (ACS HPRI)
131 CERTIFICATE OF NEED LAWS AND THE DIFFUSION OF INTENSITY-MODULATED RADIOTHERAPY Bruce L. Jacobs*, Yun Zhang, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Intensity-modulated radiotherapy (IMRT) has disseminated rapidly, largely due to its purported improvements in cancer control and toxicity profile. While IMRT requires a substantial initial investment, it also creates opportunities for significant reimbursement, which raises the concern for overutilization. In this context, some states have implemented certificate of need laws (CONs), which have varying degrees of stringency, to curb the adoption of expensive, yet unproven services. How CONs affect the use of IMRT is unknown. We examined the dissemination of IMRT in markets with differing levels of CON stringency. METHODS: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who underwent treatment with radiation (n⫽ 57,749), of which 23,545 had IMRT. We aggregated these data to Hospital Service Areas (HSAs), which represent local healthcare markets for hospital care. Information on CONs was obtained from the National Directory of Health Planning, Policy, and Regulatory Agencies. We categorized HSAs as markets having no CONs, lowstringency CONs (i.e., equipment threshold ⬎$1.5 million), or highstringency CONs (i.e., equipment threshold ⬍$1.5 million). This cutoff was chosen due to the approximate cost of IMRT equipment. Our primary outcome was the adjusted proportion of IMRT among those patients receiving radiation in a given market. RESULTS: After excluding markets with ⬍10 patients treated with radiation in a given year, we identified 684 markets. The overall proportion of IMRT utilization was 35%, 44%, and 46% for no CON, low-stringency CON, and high-stringency CON markets, respectively (p⬍0.01). Over time, the adjusted proportion of patients treated with IMRT increased dramatically, regardless of CON regulation. For each year, markets with any form of CONs (i.e., high or low stringency) had similar use of IMRT, however both of these markets demonstrated higher utilization of IMRT than markets without CONs (p⬍0.01). CONCLUSIONS: Any level of CON regulation, regardless of stringency, does not appear to inhibit the use of IMRT. Given IMRT’s
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
unproven benefits and favorable reimbursement, the failure of CONs to curb utilization raises concerns for overtreatment.
Source of Funding: Bruce Jacobs is supported in part by the American Cancer Society Postdoctoral Fellowship Grant (121805-PF-12-008-01-CPHPS) and by the National Institutes of Health T32 Training Grant NIH 5 T32 DK007782-12. Brent Hollenbeck is supported by the American Cancer Society Pennsylvania Division—Dr. William and Rita Conrady Mentored Research Scholar Grant (MSRG-07-006-01-CPHPS).
132 COST-EFFECTIVENESS ANALYSIS OF PERCUTANEOUS RENAL MASS BIOPSY TO GUIDE THE SURGICAL MANAGEMENT OF SMALL RENAL MASSES Steven Chang*, Toni Choueiri, Michelle Hirsch, Stuart Silverman, Boston, MA INTRODUCTION AND OBJECTIVES: The majority of localized solid renal tumors are small renal masses (SRM, ⱕ4cm) of which 20%-30% are benign. Percutaneous renal mass biopsy (RMB) is an optional pre-operative evaluation that potentially identifies benign lesions avoiding unnecessary treatment. We performed a cost-effectiveness analysis to determine the utility of RMB to guide management decisions for SRM. METHODS: We developed a decision-analytic model estimating the costs and benefits of RMB, compared to immediate therapies, to inform the decision for the following treatments: percutaneous/ laparoscopic ablation, open/laparoscopic partial nephrectomy (PN), and open/laparoscopic radical nephrectomy (RN). Using published literature, we used a 15% non-diagnostic rate, 97.5% sensitivity, 91.2% specificity and 0.01% complication rate. RMB showing malignancy or a non-diagnostic biopsy led to treatment; the finding of a non-malignant SRM led to active surveillance. Our base case was a healthy 65-year old patient with an asymptomatic unilateral 3cm SRM. Outcomes were measured in quality-adjusted life-years (QALY) and 2008 US$, respectively. We used a societal perspective, lifetime horizon, 3% discount rate, 3-month cycle length, and a $50,000/QALY willingness-to-pay threshold. Alternative clinical scenarios were assessed with sensitivity analysis. RESULTS: In the base case scenario, RMB was the costeffective strategy for all patients considering RN options, while it was not cost-effective to guide the management for patients considering PN or ablative options. The open and laparoscopic approaches for PN and RN did not impact the utility for RMB. For RN, sensitivity analyses showed that RMB remained cost-effective across a wide range of tumor sizes, patient ages, and healthy states. RMB prior to PN and laparoscopic ablation became the cost-effective strategy for smaller tumors (⬍2.5cm), younger patients (⬍60 years), or less healthy individuals (⬎5% risk of peri-operative mortality). For patients planning for percutaneous ablation, RMB was only cost-effective among younger patients
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
(⬍60 years) with SRM ⬍2cm in size. The results were primarily driven by the risks for procedural complications and post-operative chronic kidney disease. CONCLUSIONS: For all patients with a SRM considering RN, RMB is recommended. Among patients with a SRM planning for PN or laparoscopic ablation, RMB is recommended for patients ⬍60-years old, with SRM ⬍2.5cm, or poor health. For patients electing for percutaneous ablation, RMB is only recommended for patients ⬍60-years old with a SRM ⬍2cm. Source of Funding: Kidney Cancer Association & DF/HCC Kidney Cancer SPORE 5P50CA101942-07
133 COST VARIATIONS OF PEDIATRIC PYELOPLASTY AND VESICOURETERAL REIMPLANTS FROM THE UNIVERSITY HEALTH CONSORTIUM DATABASE Ruthie Su*, Paul Merguerian, Seattle, WA INTRODUCTION AND OBJECTIVES: Variation in health care costs is known to exist in the United States but there is limited information on the extent to which these differences occur in the pediatric urology community. We examine cost variations in the United States for pyeloplasties and vesicoureteral reimplants in the pediatric population and ask whether differences in cost were associated with hospital case volume, co-morbidities, complications, or geographic regions. METHODS: Data was analyzed from the University Health Consortium (UHC) database. Hospitals reporting costs for pyeloplasty or reimplant procedures on patients less than 17 years old between January 2010 to January 2011were included. Case volume, direct cost, direct cost index (observed costs/ expected costs), case mix index (CMI), length of stay (LOS), and complications were evaluated amongst all university hospitals. These characteristics were examined between Western, New England, Mid-Atlantic, Mid-west, and Southeastern regions. Freestanding children’s hospitals were compared to non children’s hospitals. RESULTS: Data was available for a total of 58 hospitals, 14 of which were free standing chidren’s hospitals. Variation in direct costs ranged from $2,363 to $14,136 for pyeloplasty and $2,305 to $11,206 for reimplantation. The overall average direct cost index for the pyeloplasty procedure was 1.13 (range 0.44-2.38) and 1.00 (range 0.311.98) for reimplants. For reimplants we did not find statistically significant cost variation. Hospitals that performed greater than 20 pyeloplasties in a year had a higher average direct cost index compared to hospitals that performed less than 20 pyeloplasties in a year (1.41 vs 1.08, p⬍0.05). There were no differences in CMI, LOS, complications, or between children’s and non children’s hospitals. The Western region had a significantly higher direct cost index (1.44) compared to other regions; the New England region had the second highest (1.21). CONCLUSIONS: There is significant cost variation for a pyeloplasty, but not a reimplant procedure. The higher cost hospitals included those that performed more than 20 pyeloplasties per year and were concentrated in the Western and New England regions. Further studies are needed to elucidate why these cost variations exist and whether increased costs can be justified with better health outcomes. Source of Funding: None
134 COST-EFFECTIVENESS OF SHOCK WAVE FREQUENCIES OF 60 VERSUS 120 SHOCKS PER MINUTE FOR TREATMENT OF UPPER URETERAL STONES: ECONOMIC ANALYSIS OF A RANDOMIZED, DOUBLE-BLIND TRIAL Zachary Klinghoffer*, Vincent Tu, Hamilton, Canada; Kenneth Pace, Toronto, Canada INTRODUCTION AND OBJECTIVES: Increasing evidence suggests that lower shockwave frequencies may improve stone frag-
THE JOURNAL OF UROLOGY姞
e55
mentation rates at the expense of longer operative times. The purpose of our study was to compare the cost-effectiveness of shockwave frequencies of 60 and 120 shocks per minute for primary treatment of upper ureteral stones. METHODS: A decision analysis model was developed to estimate the costs and stone-free rates associated with treatment at shockwave frequencies of 60 and 120 shocks per minute. Stone-free rates and probabilities of requiring ancillary procedures, including shockwave lithotripsy re-treatment, ureteroscopy with laser lithotripsy and percutaneous nephrolithotomy, following primary treatment were derived from our previously published randomized, double-blind trial. Costs of shockwave lithotripsy at 60 and 120 shocks per minute were obtained from our institutional data. Costs of ancillary procedures were obtained from the Ontario Case Costing Initiative. Univariate and probabilistic sensitivity analyses were performed to determine which parameters affected the outcome of our model. RESULTS: Primary treatment of upper ureteral stones with shockwave lithotripsy at 60 shocks per minute was the more costeffective treatment strategy, rendering one patient stone-free for $1,925 Canadian dollars (CAD). Shockwave lithotripsy at 120 shocks per minute rendered one patient stone-free for $2,178 CAD. Univariate sensitivity analysis demonstrated our model to be robust to changes to key parameters. Probabilistic sensitivity analysis reinforced shockwave lithotripsy at 60 shocks per minute as the more cost-effective treatment strategy compared to 120 shocks per minute across all willingness-topay thresholds. CONCLUSIONS: Primary treatment of upper ureteral stones with shockwave lithotripsy at 60 shocks per minute is more costeffective than treatment at 120 shocks per minute. Our study demonstrates that although the cost of initial treatment at 60 shocks per minute exceeds that of treatment at 120 shocks per minute due to increased operative times, treatment at 60 shocks per minute is more cost-effective due to the decreased need for ancillary treatments.
Source of Funding: None
135 COST-ANALYSIS OF PCA3 VERSUS PSA IN THE DETECTION OF PROSTATE CANCER IN MEN WITH A PRIOR NEGATIVE BIOPSY Kenneth Nepple*, Seth Strope, St. Louis, MO; Adam Kibel, Boston, MA; Gundarshan Sandhu, Lucas Wiegand, Steven Kymes, St. Louis, MO INTRODUCTION AND OBJECTIVES: The objective of this study was to perform a cost-analysis of PCA3 versus PSA in men with a prior negative prostate biopsy by assessing both the cost of testing and the costs of prostate biopsy and complications. METHODS: A cost-analysis model was used to evaluate the cost in US dollars associated with testing and prostate biopsy. Base case was a male with a history of a negative prostate biopsy tested by PCA3 or PSA to evaluate for prostate cancer. Primary analysis was performed from the healthcare payer perspective. Model probabilities were derived from published data including ROC curves in the placebo arm of the REDUCE trial of men who had both PCA3 and PSA testing. PCA3 and PSA were compared at points on the ROC curves with equal sensitivity (cancer detection) but different specificity. Sensitivity analysis of the model was performed.
THE JOURNAL OF UROLOGY姞
practitioners has actually declined slightly (less than 1%) and solo practice has increased by nearly 2%. Overall, urologists in group practice are almost 9 years younger than urologists in solo practice. CONCLUSIONS: Many unclassified, solo, and two-physician practice urologic surgeons likely made the move to group practice during the past decade. The growth of group practice among urologic surgeons may provide benefits for sub-specialization call coverage and leverage in coping with ongoing consolidation among provider organizations. These consolidated organizations will need to consider how they will grow without further isolating rural urology practice.
Source of Funding: American College of Surgeons Health Policy Research Institute (ACS HPRI)
131 CERTIFICATE OF NEED LAWS AND THE DIFFUSION OF INTENSITY-MODULATED RADIOTHERAPY Bruce L. Jacobs*, Yun Zhang, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Intensity-modulated radiotherapy (IMRT) has disseminated rapidly, largely due to its purported improvements in cancer control and toxicity profile. While IMRT requires a substantial initial investment, it also creates opportunities for significant reimbursement, which raises the concern for overutilization. In this context, some states have implemented certificate of need laws (CONs), which have varying degrees of stringency, to curb the adoption of expensive, yet unproven services. How CONs affect the use of IMRT is unknown. We examined the dissemination of IMRT in markets with differing levels of CON stringency. METHODS: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who underwent treatment with radiation (n⫽ 57,749), of which 23,545 had IMRT. We aggregated these data to Hospital Service Areas (HSAs), which represent local healthcare markets for hospital care. Information on CONs was obtained from the National Directory of Health Planning, Policy, and Regulatory Agencies. We categorized HSAs as markets having no CONs, lowstringency CONs (i.e., equipment threshold ⬎$1.5 million), or highstringency CONs (i.e., equipment threshold ⬍$1.5 million). This cutoff was chosen due to the approximate cost of IMRT equipment. Our primary outcome was the adjusted proportion of IMRT among those patients receiving radiation in a given market. RESULTS: After excluding markets with ⬍10 patients treated with radiation in a given year, we identified 684 markets. The overall proportion of IMRT utilization was 35%, 44%, and 46% for no CON, low-stringency CON, and high-stringency CON markets, respectively (p⬍0.01). Over time, the adjusted proportion of patients treated with IMRT increased dramatically, regardless of CON regulation. For each year, markets with any form of CONs (i.e., high or low stringency) had similar use of IMRT, however both of these markets demonstrated higher utilization of IMRT than markets without CONs (p⬍0.01). CONCLUSIONS: Any level of CON regulation, regardless of stringency, does not appear to inhibit the use of IMRT. Given IMRT’s
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
unproven benefits and favorable reimbursement, the failure of CONs to curb utilization raises concerns for overtreatment.
Source of Funding: Bruce Jacobs is supported in part by the American Cancer Society Postdoctoral Fellowship Grant (121805-PF-12-008-01-CPHPS) and by the National Institutes of Health T32 Training Grant NIH 5 T32 DK007782-12. Brent Hollenbeck is supported by the American Cancer Society Pennsylvania Division—Dr. William and Rita Conrady Mentored Research Scholar Grant (MSRG-07-006-01-CPHPS).
132 COST-EFFECTIVENESS ANALYSIS OF PERCUTANEOUS RENAL MASS BIOPSY TO GUIDE THE SURGICAL MANAGEMENT OF SMALL RENAL MASSES Steven Chang*, Toni Choueiri, Michelle Hirsch, Stuart Silverman, Boston, MA INTRODUCTION AND OBJECTIVES: The majority of localized solid renal tumors are small renal masses (SRM, ⱕ4cm) of which 20%-30% are benign. Percutaneous renal mass biopsy (RMB) is an optional pre-operative evaluation that potentially identifies benign lesions avoiding unnecessary treatment. We performed a cost-effectiveness analysis to determine the utility of RMB to guide management decisions for SRM. METHODS: We developed a decision-analytic model estimating the costs and benefits of RMB, compared to immediate therapies, to inform the decision for the following treatments: percutaneous/ laparoscopic ablation, open/laparoscopic partial nephrectomy (PN), and open/laparoscopic radical nephrectomy (RN). Using published literature, we used a 15% non-diagnostic rate, 97.5% sensitivity, 91.2% specificity and 0.01% complication rate. RMB showing malignancy or a non-diagnostic biopsy led to treatment; the finding of a non-malignant SRM led to active surveillance. Our base case was a healthy 65-year old patient with an asymptomatic unilateral 3cm SRM. Outcomes were measured in quality-adjusted life-years (QALY) and 2008 US$, respectively. We used a societal perspective, lifetime horizon, 3% discount rate, 3-month cycle length, and a $50,000/QALY willingness-to-pay threshold. Alternative clinical scenarios were assessed with sensitivity analysis. RESULTS: In the base case scenario, RMB was the costeffective strategy for all patients considering RN options, while it was not cost-effective to guide the management for patients considering PN or ablative options. The open and laparoscopic approaches for PN and RN did not impact the utility for RMB. For RN, sensitivity analyses showed that RMB remained cost-effective across a wide range of tumor sizes, patient ages, and healthy states. RMB prior to PN and laparoscopic ablation became the cost-effective strategy for smaller tumors (⬍2.5cm), younger patients (⬍60 years), or less healthy individuals (⬎5% risk of peri-operative mortality). For patients planning for percutaneous ablation, RMB was only cost-effective among younger patients
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
(⬍60 years) with SRM ⬍2cm in size. The results were primarily driven by the risks for procedural complications and post-operative chronic kidney disease. CONCLUSIONS: For all patients with a SRM considering RN, RMB is recommended. Among patients with a SRM planning for PN or laparoscopic ablation, RMB is recommended for patients ⬍60-years old, with SRM ⬍2.5cm, or poor health. For patients electing for percutaneous ablation, RMB is only recommended for patients ⬍60-years old with a SRM ⬍2cm. Source of Funding: Kidney Cancer Association & DF/HCC Kidney Cancer SPORE 5P50CA101942-07
133 COST VARIATIONS OF PEDIATRIC PYELOPLASTY AND VESICOURETERAL REIMPLANTS FROM THE UNIVERSITY HEALTH CONSORTIUM DATABASE Ruthie Su*, Paul Merguerian, Seattle, WA INTRODUCTION AND OBJECTIVES: Variation in health care costs is known to exist in the United States but there is limited information on the extent to which these differences occur in the pediatric urology community. We examine cost variations in the United States for pyeloplasties and vesicoureteral reimplants in the pediatric population and ask whether differences in cost were associated with hospital case volume, co-morbidities, complications, or geographic regions. METHODS: Data was analyzed from the University Health Consortium (UHC) database. Hospitals reporting costs for pyeloplasty or reimplant procedures on patients less than 17 years old between January 2010 to January 2011were included. Case volume, direct cost, direct cost index (observed costs/ expected costs), case mix index (CMI), length of stay (LOS), and complications were evaluated amongst all university hospitals. These characteristics were examined between Western, New England, Mid-Atlantic, Mid-west, and Southeastern regions. Freestanding children’s hospitals were compared to non children’s hospitals. RESULTS: Data was available for a total of 58 hospitals, 14 of which were free standing chidren’s hospitals. Variation in direct costs ranged from $2,363 to $14,136 for pyeloplasty and $2,305 to $11,206 for reimplantation. The overall average direct cost index for the pyeloplasty procedure was 1.13 (range 0.44-2.38) and 1.00 (range 0.311.98) for reimplants. For reimplants we did not find statistically significant cost variation. Hospitals that performed greater than 20 pyeloplasties in a year had a higher average direct cost index compared to hospitals that performed less than 20 pyeloplasties in a year (1.41 vs 1.08, p⬍0.05). There were no differences in CMI, LOS, complications, or between children’s and non children’s hospitals. The Western region had a significantly higher direct cost index (1.44) compared to other regions; the New England region had the second highest (1.21). CONCLUSIONS: There is significant cost variation for a pyeloplasty, but not a reimplant procedure. The higher cost hospitals included those that performed more than 20 pyeloplasties per year and were concentrated in the Western and New England regions. Further studies are needed to elucidate why these cost variations exist and whether increased costs can be justified with better health outcomes. Source of Funding: None
134 COST-EFFECTIVENESS OF SHOCK WAVE FREQUENCIES OF 60 VERSUS 120 SHOCKS PER MINUTE FOR TREATMENT OF UPPER URETERAL STONES: ECONOMIC ANALYSIS OF A RANDOMIZED, DOUBLE-BLIND TRIAL Zachary Klinghoffer*, Vincent Tu, Hamilton, Canada; Kenneth Pace, Toronto, Canada INTRODUCTION AND OBJECTIVES: Increasing evidence suggests that lower shockwave frequencies may improve stone frag-
THE JOURNAL OF UROLOGY姞
e55
mentation rates at the expense of longer operative times. The purpose of our study was to compare the cost-effectiveness of shockwave frequencies of 60 and 120 shocks per minute for primary treatment of upper ureteral stones. METHODS: A decision analysis model was developed to estimate the costs and stone-free rates associated with treatment at shockwave frequencies of 60 and 120 shocks per minute. Stone-free rates and probabilities of requiring ancillary procedures, including shockwave lithotripsy re-treatment, ureteroscopy with laser lithotripsy and percutaneous nephrolithotomy, following primary treatment were derived from our previously published randomized, double-blind trial. Costs of shockwave lithotripsy at 60 and 120 shocks per minute were obtained from our institutional data. Costs of ancillary procedures were obtained from the Ontario Case Costing Initiative. Univariate and probabilistic sensitivity analyses were performed to determine which parameters affected the outcome of our model. RESULTS: Primary treatment of upper ureteral stones with shockwave lithotripsy at 60 shocks per minute was the more costeffective treatment strategy, rendering one patient stone-free for $1,925 Canadian dollars (CAD). Shockwave lithotripsy at 120 shocks per minute rendered one patient stone-free for $2,178 CAD. Univariate sensitivity analysis demonstrated our model to be robust to changes to key parameters. Probabilistic sensitivity analysis reinforced shockwave lithotripsy at 60 shocks per minute as the more cost-effective treatment strategy compared to 120 shocks per minute across all willingness-topay thresholds. CONCLUSIONS: Primary treatment of upper ureteral stones with shockwave lithotripsy at 60 shocks per minute is more costeffective than treatment at 120 shocks per minute. Our study demonstrates that although the cost of initial treatment at 60 shocks per minute exceeds that of treatment at 120 shocks per minute due to increased operative times, treatment at 60 shocks per minute is more cost-effective due to the decreased need for ancillary treatments.
Source of Funding: None
135 COST-ANALYSIS OF PCA3 VERSUS PSA IN THE DETECTION OF PROSTATE CANCER IN MEN WITH A PRIOR NEGATIVE BIOPSY Kenneth Nepple*, Seth Strope, St. Louis, MO; Adam Kibel, Boston, MA; Gundarshan Sandhu, Lucas Wiegand, Steven Kymes, St. Louis, MO INTRODUCTION AND OBJECTIVES: The objective of this study was to perform a cost-analysis of PCA3 versus PSA in men with a prior negative prostate biopsy by assessing both the cost of testing and the costs of prostate biopsy and complications. METHODS: A cost-analysis model was used to evaluate the cost in US dollars associated with testing and prostate biopsy. Base case was a male with a history of a negative prostate biopsy tested by PCA3 or PSA to evaluate for prostate cancer. Primary analysis was performed from the healthcare payer perspective. Model probabilities were derived from published data including ROC curves in the placebo arm of the REDUCE trial of men who had both PCA3 and PSA testing. PCA3 and PSA were compared at points on the ROC curves with equal sensitivity (cancer detection) but different specificity. Sensitivity analysis of the model was performed.