- Email: [email protected]
MP04-05 DECLINING USE OF CONTINENT DIVERSIONS FOR BLADDER CANCER
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
e29
MP04-04 CHARACTERIZING THE COSTS OF COMPLICATIONS AFTER CYSTECTOMY: CAN WE TARGET THE PRIMARY DRIVERS? Matthew Mossanen*, Ross E. Krasnow, Matthew D. Ingham, Mark A. Preston, Quoc D. Trinh, Adam S. Kibel, Boston, MA; Steven I. Chung, Stanford, CA; Steven L. Chang, Boston, MA
Source of Funding: Ajmera Family Chair in Urologic Oncology
MP04-03 NON-MUSCLE INVASIVE BLADDER CANCER IS ASSOCIATED WITH DECREASED PHYSICAL HEALTHRELATED QUALITY OF LIFE Wayne Brisbane*, Sarah Holt, Brian Winters, John Gore, Atreya Dash, Michael Porter, Jonathan Wright, George Schade, Seattle, WA INTRODUCTION AND OBJECTIVES: The effect of non-muscle invasive bladder cancer (NMIBC) on health-related quality of life (HRQOL) is poorly understood. We evaluated changes in HRQOL in patients with a new diagnosis of NMIBC compared with the general population using the Surveillance Epidemiology and End Results (SEER) Medicare Health Outcomes Survey (MHOS) database. METHODS: We identified 325 Medicare beneficiaries diagnosed with NMIBC between initial and 2-year follow-up using SEERMHOS data (1998-2013). NMIBC patients who underwent cystoscopy with biopsy or transurethral resection of bladder tumor(s) for bladder cancer were propensity matched 1:5 to non-cancer controls (n¼1685). Changes from baseline in the physical component score (PCS) and mental component score (MCS), which are normalized to between 0-100, where 50 represents the US population mean, were compared between NMIBC patients and non-cancer controls with c2 testing and multivariate linear regression analysis. We secondarily assessed differences in urinary symptoms on post-diagnosis surveys with univariate and multivariate models. RESULTS: Pre-diagnosis, mean PCS (39.94 vs 39.54, p ¼ 0.71) and mean MCS (52.03 vs 52.17, p ¼ 0.82) scores were similar between NMIBC patients and matched non-cancer controls. Postdiagnosis, NMIBC patients had a significantly greater decrease in PCS compared with controls (-2.87 (95% CI -3.87, -1.86) vs. -1.47 (95% CI -1.93, -1.02), p ¼ 0.02). Conversely, mean MCS change did not vary between groups (-1.79 (95% CI -2.76, -0.81) vs. -0.72 (95% CI -1.21, -0.23), p ¼ 0.09). With respect to urinary function, NMIBC pts were more likely to have worsening of urinary leakage (38.0 % vs 18.7 %, p¼ < 0.01), require physician intervention for urinary symptoms (33.9 % vs 13.7 %, p¼ <0.01 ), and receive treatment for urine leakage (31.6 % vs 12.0 %, p¼ <0.01 ) compared with non-cancer controls (p ¼ <0.01). CONCLUSIONS: The diagnosis of NMIBC is associated with a significant decrease in physical HRQOL, including a significant impact on urinary symptoms and leakage. Further efforts to prospectively evaluate HRQOL in patients with NMIBC should be pursued to inform and improve patient counseling. Source of Funding: none
INTRODUCTION AND OBJECTIVES: Radical Cystectomy (RC) is subject to substantial morbidity and patients face complication rates as high as 64% at 90-days. Understanding the costs of complications after RC is essential to improving care. We studied the financial costs of different categories of complications after RC in order to identify drivers of expenditures. METHODS: Using the Premier Hospital Database we identified adult patients who underwent RC for bladder cancer from over 600 hospitals across the United States between 2003-2013. Ninety-day complications were captured using ICD9 codes. Complications were categorized according to Agency for Healthcare Research and Quality Clinical Classification Software. The primary outcome was cost of complication and secondary outcomes were mortality, length of stay (LOS), and discharge disposition. A generalized liner model conforming to a gamma distribution was used to evaluate cost data. Analyses were survey weighted, and all models were adjusted for patient (age, race, obesity, marital status, payer), hospital (bed size, teaching affiliation, rural, region), and surgery characteristics (lymphadenectomy, continent diversion, robotic, operative time, transfusion, surgeon volume, hospital volume) and clustered by hospital. RESULTS: We identified 9,137 RC patients, representing a weighting population of 57,553 patients. The top four most costly complications were venous thromboembolism (VTE $17547), soft tissue ($13523), gastrointestinal (GI $8663), and infectious (non-wound, i.e. sepsis, $7930) (p<0.001 for each). Pharmacy related costs were the primary driver of VTE costs. LOS was increased in each complication by 1.7 days for infectious, 4.5 days for soft tissue, 3.5 days for GI, and 3 days for VTE (p<0.001 for each). Being married, having fewer comorbidities, larger hospitals, teaching hospitals, shorter operations, lack of transfusions, high volume hospitals, and high volume surgeons were associated with statistically significantly lower costs of complications after cystectomy. CONCLUSIONS: VTE, soft tissue, and GI complications are the most expensive complications after cystectomy, and thereby highlight potential candidates for future quality improvement initiatives. Source of Funding: None
MP04-05 DECLINING USE OF CONTINENT DIVERSIONS FOR BLADDER CANCER Nicholas Farber*, Izak Faiena, Viktor Dombrovskiy, Alexandra Tabakin, Brian Shinder, Rutveej Patel, Sammy Elsamra, Thomas Jang, Eric Singer, Robert Weiss, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: Radical cystectomy with urinary diversion is a standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. Continent diversions (CD) may allow better quality of life and body image perceptions over ileal conduits (IC) in selected patients. Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing radical cystectomy. METHODS: Using ICD-9 codes, we identified in the National Inpatient Sample (NIS) from 2001-2012 all patients with the principal diagnosis of malignant neoplasm of bladder (188.x, 233.7) who underwent radical cystectomy (57.71) followed by either ileal conduit (56.61) or orthotopic neobladder/continent diversion (57.87). Patient sociodemographics, comorbidities and in-hospital complications,
e30
THE JOURNAL OF UROLOGYâ
mortality, length of stay (LOS), and total cost after radical cystectomy with IC vs CD were compared. Chi square test and multivariable logistic regression were used to analyze patient and hospital characteristics. Student’s t-test and Wilcoxon rank sum test were used to evaluate continuous variables. RESULTS: Between 2001-2012, an estimated 69,049 ICs and 6,991 CDs were performed. The total number of CDs increased from 2001 to 2012 (p < 0.0001), but peaked in 2008 and subsequently declined every year thereafter. Patients of all ages received ICs at a higher rate than CDs (Table 1), including younger age groups (40-59 and 60-69). Males and Caucasians were more likely to have CD compared to females (p<0.001) and African Americans (p<0.0001), respectively. The rate of CDs was highest in the West (12.1%, p<0.001), at urban teaching centers (10.85%, p<0.001), and in large hospitals (9.71%, p<0.001). On logistic regression analysis, when accounting for age, gender, comorbidities, and hospital characteristics, ICs were associated with higher rates of overall (OR 1.06, p¼0.0185) and infectious (OR 1.13, p¼0.002) complications and in-hospital mortality (OR 1.87, p<0.0001). There was no difference in LOS between the two groups. CONCLUSIONS: The number of CDs performed has declined since 2008. Patients of all ages, including young patients, are more likely to receive IC than CD. Gender, socioeconomic factors, and geographic location may influence diversion type. CDs are associated with comparable rates of complications and in-hospital mortality. Potential causes for declining incidence of continent diversions may include physician reimbursement, length of surgical time, and higher incidence of robotic surgery. These factors should be the subject for further study.
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
RESULTS: Our decision support tool generates a forecasted probability of readmission as well as suggested follow-up frequencies. Sample screenshots from the tool are presented in the Figure. After inputting the date of hospital discharge and other patient characteristics, the app tracks the status of the patient, suggests an optimal follow-up strategy, provides patients with the ability to contact their provider by phone, and tracks future appointments. CONCLUSIONS: We integrated a delay-time analysis methodology into a software tool that can run on personal computers, iPads and iPhones to improve follow-up of patients after radical cystectomy. This software generates real-time predictions of the likelihood of readmission and indicates when future follow-up should be performed, so as to identify clinical deterioration in a timely manner. Through further customization and pilot testing, this decision support tool will enable personalized follow-up to help prevent hospital readmission after radical cystectomy.
Source of Funding: none Source of Funding: None
MP04-06
MP04-07
PERSONALIZED DECISION SUPPORT TOOL TO PREVENT HOSPITAL READMISSION FOR PATIENTS TREATED WITH RADICAL CYSTECTOMY
PROGNOSTIC IMPACT OF IMMUNOHISTOCHEMICAL CLASSIFICATION OF BLADDER CANCER ACCORDING TO LUMINAL (UROPLAKIN III) AND BASAL (CYTOKERATIN 5/6) MARKERS
Sarah Finley, Shivani Joshi*, Tudor Borza, Xiang Liu, Ted A. Skolarus, Ann Arbor, MI; Bruce L. Jacobs, Pittsuburgh, PA; Benjamin Y. Li, Ann Arbor, MI; Heather Jim, Scott M. Gilbert, Tampa, FL; Zhitong Xie, Ann Arbor, MI; Jonathan E. Helm, Bloomington, IN; Mariel S. Lavieri, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: To create a userfriendly, personalized decision support tool that can display the likelihood of readmission after radical cystectomy, as well as recommendations for optimal follow-up based on published data. METHODS: We developed the “REACT: Readmission Elimination App for Cystectomy Treatment” using Apple’s Xcode. This tool uses delay-time analysis models to determine the optimal timing of office visits and phone calls in order to maximize the probability of detecting radical cystectomy patients susceptible to readmission. We calibrated and validated the tool using radical cystectomy patient data from the 2009-2010 Healthcare Cost and Utilization Project State Inpatient Databases, and our institution’s bladder cancer database from 2007 to 2011, as published in J Urol. 2016 May;195(5):1362-7.
Tetsutaro Hayashi*, Kazuhiro Sentani, Shinji Kakumoto, Hiroshima, Japan; Htoo Zarni Oo, Vancouver, Canada; Naoya Sakamoto, Hiroshima, Japan; Kazuaki Mutaguchi, Nakatsu, Japan; Kohei Kobatake, Keisuke Goto, Shogo Inoue, Jun Teishima, Hiroshima, Japan; Peter Black, Vancouver, Canada; Akio Matsubara, Hiroshima, Japan INTRODUCTION AND OBJECTIVES: Recent genomic studies suggest that urothelial carcinoma (UC) can be grouped into luminal and basal subtypes. Basal bladder cancers are enriched with squamous features and are associated with worse prognosis. Previously, we reported that Desmocollin2 (DSC2) is an immunohistochemical (IHC) marker of squamous differentiation (SD) in UC, that correlates significantly with advanced tumor stage and poor prognosis. Here, we examined the subtype classification of bladder cancer based on Uroplakin III (UPK3) and Cytokeratin 5/6 (CK5/6) expression. METHODS: Expression of UPK3, CK5/6 and DSC2 was measured by IHC in 57 cases of bladder cancer treated with cystectomy
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
e29
MP04-04 CHARACTERIZING THE COSTS OF COMPLICATIONS AFTER CYSTECTOMY: CAN WE TARGET THE PRIMARY DRIVERS? Matthew Mossanen*, Ross E. Krasnow, Matthew D. Ingham, Mark A. Preston, Quoc D. Trinh, Adam S. Kibel, Boston, MA; Steven I. Chung, Stanford, CA; Steven L. Chang, Boston, MA
Source of Funding: Ajmera Family Chair in Urologic Oncology
MP04-03 NON-MUSCLE INVASIVE BLADDER CANCER IS ASSOCIATED WITH DECREASED PHYSICAL HEALTHRELATED QUALITY OF LIFE Wayne Brisbane*, Sarah Holt, Brian Winters, John Gore, Atreya Dash, Michael Porter, Jonathan Wright, George Schade, Seattle, WA INTRODUCTION AND OBJECTIVES: The effect of non-muscle invasive bladder cancer (NMIBC) on health-related quality of life (HRQOL) is poorly understood. We evaluated changes in HRQOL in patients with a new diagnosis of NMIBC compared with the general population using the Surveillance Epidemiology and End Results (SEER) Medicare Health Outcomes Survey (MHOS) database. METHODS: We identified 325 Medicare beneficiaries diagnosed with NMIBC between initial and 2-year follow-up using SEERMHOS data (1998-2013). NMIBC patients who underwent cystoscopy with biopsy or transurethral resection of bladder tumor(s) for bladder cancer were propensity matched 1:5 to non-cancer controls (n¼1685). Changes from baseline in the physical component score (PCS) and mental component score (MCS), which are normalized to between 0-100, where 50 represents the US population mean, were compared between NMIBC patients and non-cancer controls with c2 testing and multivariate linear regression analysis. We secondarily assessed differences in urinary symptoms on post-diagnosis surveys with univariate and multivariate models. RESULTS: Pre-diagnosis, mean PCS (39.94 vs 39.54, p ¼ 0.71) and mean MCS (52.03 vs 52.17, p ¼ 0.82) scores were similar between NMIBC patients and matched non-cancer controls. Postdiagnosis, NMIBC patients had a significantly greater decrease in PCS compared with controls (-2.87 (95% CI -3.87, -1.86) vs. -1.47 (95% CI -1.93, -1.02), p ¼ 0.02). Conversely, mean MCS change did not vary between groups (-1.79 (95% CI -2.76, -0.81) vs. -0.72 (95% CI -1.21, -0.23), p ¼ 0.09). With respect to urinary function, NMIBC pts were more likely to have worsening of urinary leakage (38.0 % vs 18.7 %, p¼ < 0.01), require physician intervention for urinary symptoms (33.9 % vs 13.7 %, p¼ <0.01 ), and receive treatment for urine leakage (31.6 % vs 12.0 %, p¼ <0.01 ) compared with non-cancer controls (p ¼ <0.01). CONCLUSIONS: The diagnosis of NMIBC is associated with a significant decrease in physical HRQOL, including a significant impact on urinary symptoms and leakage. Further efforts to prospectively evaluate HRQOL in patients with NMIBC should be pursued to inform and improve patient counseling. Source of Funding: none
INTRODUCTION AND OBJECTIVES: Radical Cystectomy (RC) is subject to substantial morbidity and patients face complication rates as high as 64% at 90-days. Understanding the costs of complications after RC is essential to improving care. We studied the financial costs of different categories of complications after RC in order to identify drivers of expenditures. METHODS: Using the Premier Hospital Database we identified adult patients who underwent RC for bladder cancer from over 600 hospitals across the United States between 2003-2013. Ninety-day complications were captured using ICD9 codes. Complications were categorized according to Agency for Healthcare Research and Quality Clinical Classification Software. The primary outcome was cost of complication and secondary outcomes were mortality, length of stay (LOS), and discharge disposition. A generalized liner model conforming to a gamma distribution was used to evaluate cost data. Analyses were survey weighted, and all models were adjusted for patient (age, race, obesity, marital status, payer), hospital (bed size, teaching affiliation, rural, region), and surgery characteristics (lymphadenectomy, continent diversion, robotic, operative time, transfusion, surgeon volume, hospital volume) and clustered by hospital. RESULTS: We identified 9,137 RC patients, representing a weighting population of 57,553 patients. The top four most costly complications were venous thromboembolism (VTE $17547), soft tissue ($13523), gastrointestinal (GI $8663), and infectious (non-wound, i.e. sepsis, $7930) (p<0.001 for each). Pharmacy related costs were the primary driver of VTE costs. LOS was increased in each complication by 1.7 days for infectious, 4.5 days for soft tissue, 3.5 days for GI, and 3 days for VTE (p<0.001 for each). Being married, having fewer comorbidities, larger hospitals, teaching hospitals, shorter operations, lack of transfusions, high volume hospitals, and high volume surgeons were associated with statistically significantly lower costs of complications after cystectomy. CONCLUSIONS: VTE, soft tissue, and GI complications are the most expensive complications after cystectomy, and thereby highlight potential candidates for future quality improvement initiatives. Source of Funding: None
MP04-05 DECLINING USE OF CONTINENT DIVERSIONS FOR BLADDER CANCER Nicholas Farber*, Izak Faiena, Viktor Dombrovskiy, Alexandra Tabakin, Brian Shinder, Rutveej Patel, Sammy Elsamra, Thomas Jang, Eric Singer, Robert Weiss, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: Radical cystectomy with urinary diversion is a standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. Continent diversions (CD) may allow better quality of life and body image perceptions over ileal conduits (IC) in selected patients. Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing radical cystectomy. METHODS: Using ICD-9 codes, we identified in the National Inpatient Sample (NIS) from 2001-2012 all patients with the principal diagnosis of malignant neoplasm of bladder (188.x, 233.7) who underwent radical cystectomy (57.71) followed by either ileal conduit (56.61) or orthotopic neobladder/continent diversion (57.87). Patient sociodemographics, comorbidities and in-hospital complications,
e30
THE JOURNAL OF UROLOGYâ
mortality, length of stay (LOS), and total cost after radical cystectomy with IC vs CD were compared. Chi square test and multivariable logistic regression were used to analyze patient and hospital characteristics. Student’s t-test and Wilcoxon rank sum test were used to evaluate continuous variables. RESULTS: Between 2001-2012, an estimated 69,049 ICs and 6,991 CDs were performed. The total number of CDs increased from 2001 to 2012 (p < 0.0001), but peaked in 2008 and subsequently declined every year thereafter. Patients of all ages received ICs at a higher rate than CDs (Table 1), including younger age groups (40-59 and 60-69). Males and Caucasians were more likely to have CD compared to females (p<0.001) and African Americans (p<0.0001), respectively. The rate of CDs was highest in the West (12.1%, p<0.001), at urban teaching centers (10.85%, p<0.001), and in large hospitals (9.71%, p<0.001). On logistic regression analysis, when accounting for age, gender, comorbidities, and hospital characteristics, ICs were associated with higher rates of overall (OR 1.06, p¼0.0185) and infectious (OR 1.13, p¼0.002) complications and in-hospital mortality (OR 1.87, p<0.0001). There was no difference in LOS between the two groups. CONCLUSIONS: The number of CDs performed has declined since 2008. Patients of all ages, including young patients, are more likely to receive IC than CD. Gender, socioeconomic factors, and geographic location may influence diversion type. CDs are associated with comparable rates of complications and in-hospital mortality. Potential causes for declining incidence of continent diversions may include physician reimbursement, length of surgical time, and higher incidence of robotic surgery. These factors should be the subject for further study.
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
RESULTS: Our decision support tool generates a forecasted probability of readmission as well as suggested follow-up frequencies. Sample screenshots from the tool are presented in the Figure. After inputting the date of hospital discharge and other patient characteristics, the app tracks the status of the patient, suggests an optimal follow-up strategy, provides patients with the ability to contact their provider by phone, and tracks future appointments. CONCLUSIONS: We integrated a delay-time analysis methodology into a software tool that can run on personal computers, iPads and iPhones to improve follow-up of patients after radical cystectomy. This software generates real-time predictions of the likelihood of readmission and indicates when future follow-up should be performed, so as to identify clinical deterioration in a timely manner. Through further customization and pilot testing, this decision support tool will enable personalized follow-up to help prevent hospital readmission after radical cystectomy.
Source of Funding: none Source of Funding: None
MP04-06
MP04-07
PERSONALIZED DECISION SUPPORT TOOL TO PREVENT HOSPITAL READMISSION FOR PATIENTS TREATED WITH RADICAL CYSTECTOMY
PROGNOSTIC IMPACT OF IMMUNOHISTOCHEMICAL CLASSIFICATION OF BLADDER CANCER ACCORDING TO LUMINAL (UROPLAKIN III) AND BASAL (CYTOKERATIN 5/6) MARKERS
Sarah Finley, Shivani Joshi*, Tudor Borza, Xiang Liu, Ted A. Skolarus, Ann Arbor, MI; Bruce L. Jacobs, Pittsuburgh, PA; Benjamin Y. Li, Ann Arbor, MI; Heather Jim, Scott M. Gilbert, Tampa, FL; Zhitong Xie, Ann Arbor, MI; Jonathan E. Helm, Bloomington, IN; Mariel S. Lavieri, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: To create a userfriendly, personalized decision support tool that can display the likelihood of readmission after radical cystectomy, as well as recommendations for optimal follow-up based on published data. METHODS: We developed the “REACT: Readmission Elimination App for Cystectomy Treatment” using Apple’s Xcode. This tool uses delay-time analysis models to determine the optimal timing of office visits and phone calls in order to maximize the probability of detecting radical cystectomy patients susceptible to readmission. We calibrated and validated the tool using radical cystectomy patient data from the 2009-2010 Healthcare Cost and Utilization Project State Inpatient Databases, and our institution’s bladder cancer database from 2007 to 2011, as published in J Urol. 2016 May;195(5):1362-7.
Tetsutaro Hayashi*, Kazuhiro Sentani, Shinji Kakumoto, Hiroshima, Japan; Htoo Zarni Oo, Vancouver, Canada; Naoya Sakamoto, Hiroshima, Japan; Kazuaki Mutaguchi, Nakatsu, Japan; Kohei Kobatake, Keisuke Goto, Shogo Inoue, Jun Teishima, Hiroshima, Japan; Peter Black, Vancouver, Canada; Akio Matsubara, Hiroshima, Japan INTRODUCTION AND OBJECTIVES: Recent genomic studies suggest that urothelial carcinoma (UC) can be grouped into luminal and basal subtypes. Basal bladder cancers are enriched with squamous features and are associated with worse prognosis. Previously, we reported that Desmocollin2 (DSC2) is an immunohistochemical (IHC) marker of squamous differentiation (SD) in UC, that correlates significantly with advanced tumor stage and poor prognosis. Here, we examined the subtype classification of bladder cancer based on Uroplakin III (UPK3) and Cytokeratin 5/6 (CK5/6) expression. METHODS: Expression of UPK3, CK5/6 and DSC2 was measured by IHC in 57 cases of bladder cancer treated with cystectomy