- Email: [email protected]
PD02-01 THE IMPACT OF FRAILTY ON COMPLICATIONS IN PATIENTS UNDERGOING COMMON UROLOGIC PROCEDURES; A STUDY FROM THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT DATABASE
e50
THE JOURNAL OF UROLOGYâ
desire (r ¼ -0.78), capacity (r ¼ -0.71). Urethrolysis was performed a mean 47 months (IQR 12-62) after prior AI procedure. After urethrolysis the majority of urinary symptoms improved (stress 8%, urge 36% and mixed 12% incontinence) with spontaneous voiding achieved in 23 (92%) women. CONCLUSIONS: Urethral pressure profilometry improves the diagnostic utility of UDS in women with BOO following an AI procedure. Source of Funding: None
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
General & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I Podium Friday, May 6, 2016
8:00 AM-10:00 AM
PD01-12 A FLUID-STRUCTURE INTERACTION SIMULATION OF FECAL INCONTINENCE Yun Peng, Leila Neshatian, Rose Khavari, Timothy Boone, Yingchun Zhang*, Houston, TX INTRODUCTION AND OBJECTIVES: Fecal incontinence (FI) is a common symptom with a prevalence of 7-15%. We employed a computational modeling approach to study the mechanism of fecal continence, which has not been fully understood yet. METHODS: A previous subject specific pelvic model was employed, while the internal and external anal sphincters (IAS/EAS) were newly included by revisiting the magnetic resonance images (Fig 1a). The sphincters and other soft tissues were modeled as elastic solids in the model, and the gravity was applied. Biomechanical analysis were conducted using Abaqus (Providence, Rhode Island) Explicit Solver. The motion of the stool was described using the smoothed particle hydrodynamics (SPH) method, which is based on a clever discretization technique. The “particles” shown in Fig 1 should be interpreted as displayed interpolation points of a continuum medium rather than isolated mass points. SPH is a well-established computational technique in many hydrodynamics applications, and can be used to accurately describe the fluid nature of the stool that can be difficult using traditional computation approaches. Three tests were performed in this study. Test 1: only the effect of gravity was considered; Test 2: the resting anorectal status was simulated by applying a pressure of 88 mmHg on the surface of the IAS. Test 3: based on test 2, a Valsalva maneuver was simulated by further applying an intraabdominal pressure (IAP) of 100cmH2O to the bodyfill. Incontinence was confirmed if the stool reached to the outer anus opening. RESULTS: In test 1, the stool leaked due to gravity as no closing pressure was applied (Fig 1b). In test 2, the anus was closed because of the closing pressure applied on the IAS. Continence was successfully maintained (Fig 1c). In test 3, the pelvic floor deformations were obvious because of the increased IAP. The incontinence was again seen as the closing pressure was not enough to hold the stool under the increased IAP (Fig 1d), indicating that additional closing pressure from EAS may be necessary for maintaining continence during Valsalva maneuver. CONCLUSIONS: Computational modeling is a useful tool for studying FI. The stool-anorectum interaction can be well described by the SPH method. Future studies will consider the efforts of the EAS and the puborectalis muscle.
Source of Funding: NIH DK082644, the University of Houston.
PD02-01 THE IMPACT OF FRAILTY ON COMPLICATIONS IN PATIENTS UNDERGOING COMMON UROLOGIC PROCEDURES; A STUDY FROM THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT DATABASE Anne M Suskind*, Louise C Walter, Chengshi Jin, John Boscardin, Saunak Sen, Matthew R Cooperberg, Emily Finlayson, San Francisco, CA INTRODUCTION AND OBJECTIVES: Frailty, a measure of diminished physiologic reserve, results in increased susceptibility to disability from stressors such as surgery. The objective of this project is to evaluate the association of frailty with both major and minor surgical complications among patients undergoing urologic surgery. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2007 to 2013, we identified all urologic cases that appeared more than 1000 times in the dataset among patients age 40 and older. Frailty was measured using the NSQIP Frailty Index (FI), a validated measure that includes 11 impairments such as decreased functional status and impaired sensorium. We created multivariable logistic regression models using the NSQIP Frailty Index to assess major and minor complications after surgery. RESULTS: We identified 95,108 urologic cases representing 21 urologic procedures. The average frequency of complications per individual was 11.7%, with the most common complications being hospital readmission (6.2%), blood transfusion (4.6%), and urinary tract infection (3.1%). Major and minor complications increased with increasing NSQIP-FI. Frailty remained strongly associated with complications after adjustment for year, age, race, smoking status, and method of anesthesia [adjusted OR 1.74 (95% CI 1.64, 1.85) NSQIP-FI 0.18+]. Increasing NSQIP-FI was associated with increasing frequency of complications within age groups (by decade) up to age 81 and across procedures (Figure), with the exception of cystectomy and prostatectomy with extended lymph node dissection. CONCLUSIONS: Frailty strongly correlates with risk of postoperative complications among patients undergoing urologic surgery. This finding is true within most age groups and across most urologic procedures.
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Dr. Suskind’s time is funded by the K12 Urologic Research (KURe) Career Development Program (NIDDK K12 DK83021-07)
e51
PD02-03 UNDERLYING REASONS ASSOCIATED WITH HOSPITAL READMISSION FOLLOWING UROLOGIC SURGERY IN THE U.S. Mark Tyson*, Sam Chang, Nashville, TN
PD02-02 ENHANCED RECOVERY AFTER SURGERY AND CARE COORDINATION PATHWAY AT CITY OF HOPE: DECREASED LENGTH OF STAY, READMISSIONS, AND COMPLICATIONS Steven V. Kardos, M.D.*, Kevin G. Chan, M.D., Bertram Yuh, M.D., Jonathan Yamzon, M.D., Nora H. Ruel, Finly Zachariah, M.D., Clayton S. Lau, M.D., Laura Crocitto, M.D., Duarte, CA INTRODUCTION AND OBJECTIVES: Bladder cancer is the second most common urologic malignancy with over 73,350 new cases diagnosed annually of which the incidence is increasing in the elderly. Radical cystectomy (RC), the gold standard for muscle invasive disease, carries a particularly high risk of morbidity and mortality, as well as a protracted length of stay (LOS) and increased readmission rates. Furthermore, in 2013, the Institute of Medicine (IOM) declared cancer care in the US a national crisis with a priority to improve quality of care through care coordination. Simultaneously, enhanced recovery after surgery (ERAS) protocols have surfaced as coordinated, evidencebased models designed to standardize medical care, improve outcomes, and lower healthcare costs. At City of Hope (COH), we evaluated our ERAS and care coordination pathway. METHODS: In April of 2014, an ERAS and care coordination pathway for bladder cancer was launched at COH with an emphasis on the perioperative care of patients (pts) from a multi-disciplinary team perspective. Preoperatively, pts undergo orientation on stoma education, goals of care, and treatment expectations. The pathway clinically focuses on avoidance of bowel preparation, early feeding and mobilization, minimizing narcotic pain management, and u-opioid antagonists. On discharge, pts are closely monitored via scheduled phone calls as well as clinic visits. Quality metrics including LOS, complications, and readmissions are reported as median and interquartile range (IQR) along with descriptive statistics including chi-square and Wilcoxon rank-sum tests. RESULTS: Table 1 illustrates the demographic and clinical characteristics of the cohorts. Since implementation, the median LOS was statistically significant between cohorts with 6 days for pts on pathway compared to 8 days for those preceding the pathway (p¼0.0007). Furthermore, the complication and readmission rates have decreased from 67.5% to 50% and from 35% to 30%, respectively. Dehydration and urinary tract infection (UTI) accounted for 17.9% and 21.4% of readmissions for those prior to the pathway, while UTI occurred in 5% of pts readmitted after adhering to the pathway. CONCLUSIONS: Our ERAS and care coordination pathway has reduced LOS without an increase in complication nor readmission rates.
INTRODUCTION AND OBJECTIVES: Financial penalties for readmission have been expanded beyond medical complications to now include surgical complications. While hospitals are working to reduce readmissions, more information is needed about the reasons for readmission after urologic surgery. METHODS: Using NSQIP data, we studied patients undergoing urologic surgery during 2013. Readmissions rates and reasons for readmission were assessed for a full-spectrum of urological procedures. Multivariable logistic regression analysis using a forward selection process was performed to identify variables associated with unplanned readmission. The proportion of variation in outcome attributable to one of four categories of variables generally considered to be explanatory for readmission was assessed using McKelvey & Zavoina’s R2 for multilevel logistic regression models (complications during index hospitalization, patient comorbidity, patient demographics, and discharge destination). RESULTS: We identified 52,643 urologic surgeries with an unplanned readmission rate of 5.8% (n¼3,040). For individual procedures, the readmission rate ranged from 1.4% for urethroplasty to 21.6% for radical cystectomy. The most common reason for unplanned readmission was surgical site infection or urinary tract infections (22%), ileus/bowel obstruction (9%), sepsis (6%), and bleeding/anemia (5%). Increasing age (OR: 1.01 [95% CI: 1.00, 1.01]; P<0.01), male gender (1.23 [1.12, 1.34]; p<0.01), black race (1.26 [1.10, 1.45]; p<0.01), increasing ASA class (1.63 [1.35, 1.97]; p<0.01), underweight BMI (1.24 [1.01, 1.53]; p¼0.04), CHF (1.76 [1.20, 2.58]; p<0.01), disseminated cancer (1.52 [1.28, 1.81]; p<0.01), bleeding disorder (1.31 [1.08, 1.60]; p<0.01), steroid use (1.68 [1.41, 2.00]; p<0.01), and index hospital complications (p<0.01 for each) was associated with unplanned readmission after urologic surgery. Discharge to a skilled care facility was protective (0.60 [0.48, 0.75]; p<0.01). Complications during the index hospitalization accounted for most of the variation in risk of unplanned readmission (R2¼0.16). CONCLUSIONS: Unplanned readmission after urologic surgery was most closely associated with complications from the index hospitalization as compared to patient comorbidity, demographics, and discharge destination. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission. Source of Funding: This work was supported in part by a grant from the U.S. National Cancer Institute 5T32CA106183 (Mark Tyson).
PD02-04 HOSPITAL BUT NOT SURGICAL VOLUME PREDICTS 30- AND 90-DAY COMPLICATIONS IN RADICAL CYSTECTOMY (RC) e RESULTS FROM THE PROSPECTIVE MULTICENTER RADICAL CYSTECTOMY SERIES (PROMETRICS 2011) STUDY GROUP Christian Meyer*, Sami-Ramzi Ley-Bannurah, Malte Vetterlein, Hamburg, Germany; Roman Mayr, Michael Gierth, Hans-Martin Fritsche, Maximilian Burger, Regensburg, Germany; Bastian Keck, Bernd Wullich, Erlangen, Germany; Thomas Martini, Christian Bolenz, Ulm, Germany; Armin Pycha, Bolzano, Italy; Julian Hanske, Florian Roghman, Joachim Noldus, Herne, Germany; Christian Gilfrich, Matthias May, Straubing, Germany; Patrick Bastian, €sseldorf, Germany; Michael Rink, Felix Chun, Roland Dahlem, Du Margit Fisch, Atiqullah Aziz, Hamburg, Germany
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Volume-outcome relationships have been described to define oncologic and perioperative outcomes in RC. However, most of these studies were limited by their administrative data structure. Additionally, few studies have investigated the effect of case volume on quality of care criteria (QCC) in bladder cancer (BCa). We sought to address these shortcomings in the
THE JOURNAL OF UROLOGYâ
desire (r ¼ -0.78), capacity (r ¼ -0.71). Urethrolysis was performed a mean 47 months (IQR 12-62) after prior AI procedure. After urethrolysis the majority of urinary symptoms improved (stress 8%, urge 36% and mixed 12% incontinence) with spontaneous voiding achieved in 23 (92%) women. CONCLUSIONS: Urethral pressure profilometry improves the diagnostic utility of UDS in women with BOO following an AI procedure. Source of Funding: None
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
General & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I Podium Friday, May 6, 2016
8:00 AM-10:00 AM
PD01-12 A FLUID-STRUCTURE INTERACTION SIMULATION OF FECAL INCONTINENCE Yun Peng, Leila Neshatian, Rose Khavari, Timothy Boone, Yingchun Zhang*, Houston, TX INTRODUCTION AND OBJECTIVES: Fecal incontinence (FI) is a common symptom with a prevalence of 7-15%. We employed a computational modeling approach to study the mechanism of fecal continence, which has not been fully understood yet. METHODS: A previous subject specific pelvic model was employed, while the internal and external anal sphincters (IAS/EAS) were newly included by revisiting the magnetic resonance images (Fig 1a). The sphincters and other soft tissues were modeled as elastic solids in the model, and the gravity was applied. Biomechanical analysis were conducted using Abaqus (Providence, Rhode Island) Explicit Solver. The motion of the stool was described using the smoothed particle hydrodynamics (SPH) method, which is based on a clever discretization technique. The “particles” shown in Fig 1 should be interpreted as displayed interpolation points of a continuum medium rather than isolated mass points. SPH is a well-established computational technique in many hydrodynamics applications, and can be used to accurately describe the fluid nature of the stool that can be difficult using traditional computation approaches. Three tests were performed in this study. Test 1: only the effect of gravity was considered; Test 2: the resting anorectal status was simulated by applying a pressure of 88 mmHg on the surface of the IAS. Test 3: based on test 2, a Valsalva maneuver was simulated by further applying an intraabdominal pressure (IAP) of 100cmH2O to the bodyfill. Incontinence was confirmed if the stool reached to the outer anus opening. RESULTS: In test 1, the stool leaked due to gravity as no closing pressure was applied (Fig 1b). In test 2, the anus was closed because of the closing pressure applied on the IAS. Continence was successfully maintained (Fig 1c). In test 3, the pelvic floor deformations were obvious because of the increased IAP. The incontinence was again seen as the closing pressure was not enough to hold the stool under the increased IAP (Fig 1d), indicating that additional closing pressure from EAS may be necessary for maintaining continence during Valsalva maneuver. CONCLUSIONS: Computational modeling is a useful tool for studying FI. The stool-anorectum interaction can be well described by the SPH method. Future studies will consider the efforts of the EAS and the puborectalis muscle.
Source of Funding: NIH DK082644, the University of Houston.
PD02-01 THE IMPACT OF FRAILTY ON COMPLICATIONS IN PATIENTS UNDERGOING COMMON UROLOGIC PROCEDURES; A STUDY FROM THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT DATABASE Anne M Suskind*, Louise C Walter, Chengshi Jin, John Boscardin, Saunak Sen, Matthew R Cooperberg, Emily Finlayson, San Francisco, CA INTRODUCTION AND OBJECTIVES: Frailty, a measure of diminished physiologic reserve, results in increased susceptibility to disability from stressors such as surgery. The objective of this project is to evaluate the association of frailty with both major and minor surgical complications among patients undergoing urologic surgery. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2007 to 2013, we identified all urologic cases that appeared more than 1000 times in the dataset among patients age 40 and older. Frailty was measured using the NSQIP Frailty Index (FI), a validated measure that includes 11 impairments such as decreased functional status and impaired sensorium. We created multivariable logistic regression models using the NSQIP Frailty Index to assess major and minor complications after surgery. RESULTS: We identified 95,108 urologic cases representing 21 urologic procedures. The average frequency of complications per individual was 11.7%, with the most common complications being hospital readmission (6.2%), blood transfusion (4.6%), and urinary tract infection (3.1%). Major and minor complications increased with increasing NSQIP-FI. Frailty remained strongly associated with complications after adjustment for year, age, race, smoking status, and method of anesthesia [adjusted OR 1.74 (95% CI 1.64, 1.85) NSQIP-FI 0.18+]. Increasing NSQIP-FI was associated with increasing frequency of complications within age groups (by decade) up to age 81 and across procedures (Figure), with the exception of cystectomy and prostatectomy with extended lymph node dissection. CONCLUSIONS: Frailty strongly correlates with risk of postoperative complications among patients undergoing urologic surgery. This finding is true within most age groups and across most urologic procedures.
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Dr. Suskind’s time is funded by the K12 Urologic Research (KURe) Career Development Program (NIDDK K12 DK83021-07)
e51
PD02-03 UNDERLYING REASONS ASSOCIATED WITH HOSPITAL READMISSION FOLLOWING UROLOGIC SURGERY IN THE U.S. Mark Tyson*, Sam Chang, Nashville, TN
PD02-02 ENHANCED RECOVERY AFTER SURGERY AND CARE COORDINATION PATHWAY AT CITY OF HOPE: DECREASED LENGTH OF STAY, READMISSIONS, AND COMPLICATIONS Steven V. Kardos, M.D.*, Kevin G. Chan, M.D., Bertram Yuh, M.D., Jonathan Yamzon, M.D., Nora H. Ruel, Finly Zachariah, M.D., Clayton S. Lau, M.D., Laura Crocitto, M.D., Duarte, CA INTRODUCTION AND OBJECTIVES: Bladder cancer is the second most common urologic malignancy with over 73,350 new cases diagnosed annually of which the incidence is increasing in the elderly. Radical cystectomy (RC), the gold standard for muscle invasive disease, carries a particularly high risk of morbidity and mortality, as well as a protracted length of stay (LOS) and increased readmission rates. Furthermore, in 2013, the Institute of Medicine (IOM) declared cancer care in the US a national crisis with a priority to improve quality of care through care coordination. Simultaneously, enhanced recovery after surgery (ERAS) protocols have surfaced as coordinated, evidencebased models designed to standardize medical care, improve outcomes, and lower healthcare costs. At City of Hope (COH), we evaluated our ERAS and care coordination pathway. METHODS: In April of 2014, an ERAS and care coordination pathway for bladder cancer was launched at COH with an emphasis on the perioperative care of patients (pts) from a multi-disciplinary team perspective. Preoperatively, pts undergo orientation on stoma education, goals of care, and treatment expectations. The pathway clinically focuses on avoidance of bowel preparation, early feeding and mobilization, minimizing narcotic pain management, and u-opioid antagonists. On discharge, pts are closely monitored via scheduled phone calls as well as clinic visits. Quality metrics including LOS, complications, and readmissions are reported as median and interquartile range (IQR) along with descriptive statistics including chi-square and Wilcoxon rank-sum tests. RESULTS: Table 1 illustrates the demographic and clinical characteristics of the cohorts. Since implementation, the median LOS was statistically significant between cohorts with 6 days for pts on pathway compared to 8 days for those preceding the pathway (p¼0.0007). Furthermore, the complication and readmission rates have decreased from 67.5% to 50% and from 35% to 30%, respectively. Dehydration and urinary tract infection (UTI) accounted for 17.9% and 21.4% of readmissions for those prior to the pathway, while UTI occurred in 5% of pts readmitted after adhering to the pathway. CONCLUSIONS: Our ERAS and care coordination pathway has reduced LOS without an increase in complication nor readmission rates.
INTRODUCTION AND OBJECTIVES: Financial penalties for readmission have been expanded beyond medical complications to now include surgical complications. While hospitals are working to reduce readmissions, more information is needed about the reasons for readmission after urologic surgery. METHODS: Using NSQIP data, we studied patients undergoing urologic surgery during 2013. Readmissions rates and reasons for readmission were assessed for a full-spectrum of urological procedures. Multivariable logistic regression analysis using a forward selection process was performed to identify variables associated with unplanned readmission. The proportion of variation in outcome attributable to one of four categories of variables generally considered to be explanatory for readmission was assessed using McKelvey & Zavoina’s R2 for multilevel logistic regression models (complications during index hospitalization, patient comorbidity, patient demographics, and discharge destination). RESULTS: We identified 52,643 urologic surgeries with an unplanned readmission rate of 5.8% (n¼3,040). For individual procedures, the readmission rate ranged from 1.4% for urethroplasty to 21.6% for radical cystectomy. The most common reason for unplanned readmission was surgical site infection or urinary tract infections (22%), ileus/bowel obstruction (9%), sepsis (6%), and bleeding/anemia (5%). Increasing age (OR: 1.01 [95% CI: 1.00, 1.01]; P<0.01), male gender (1.23 [1.12, 1.34]; p<0.01), black race (1.26 [1.10, 1.45]; p<0.01), increasing ASA class (1.63 [1.35, 1.97]; p<0.01), underweight BMI (1.24 [1.01, 1.53]; p¼0.04), CHF (1.76 [1.20, 2.58]; p<0.01), disseminated cancer (1.52 [1.28, 1.81]; p<0.01), bleeding disorder (1.31 [1.08, 1.60]; p<0.01), steroid use (1.68 [1.41, 2.00]; p<0.01), and index hospital complications (p<0.01 for each) was associated with unplanned readmission after urologic surgery. Discharge to a skilled care facility was protective (0.60 [0.48, 0.75]; p<0.01). Complications during the index hospitalization accounted for most of the variation in risk of unplanned readmission (R2¼0.16). CONCLUSIONS: Unplanned readmission after urologic surgery was most closely associated with complications from the index hospitalization as compared to patient comorbidity, demographics, and discharge destination. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission. Source of Funding: This work was supported in part by a grant from the U.S. National Cancer Institute 5T32CA106183 (Mark Tyson).
PD02-04 HOSPITAL BUT NOT SURGICAL VOLUME PREDICTS 30- AND 90-DAY COMPLICATIONS IN RADICAL CYSTECTOMY (RC) e RESULTS FROM THE PROSPECTIVE MULTICENTER RADICAL CYSTECTOMY SERIES (PROMETRICS 2011) STUDY GROUP Christian Meyer*, Sami-Ramzi Ley-Bannurah, Malte Vetterlein, Hamburg, Germany; Roman Mayr, Michael Gierth, Hans-Martin Fritsche, Maximilian Burger, Regensburg, Germany; Bastian Keck, Bernd Wullich, Erlangen, Germany; Thomas Martini, Christian Bolenz, Ulm, Germany; Armin Pycha, Bolzano, Italy; Julian Hanske, Florian Roghman, Joachim Noldus, Herne, Germany; Christian Gilfrich, Matthias May, Straubing, Germany; Patrick Bastian, €sseldorf, Germany; Michael Rink, Felix Chun, Roland Dahlem, Du Margit Fisch, Atiqullah Aziz, Hamburg, Germany
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Volume-outcome relationships have been described to define oncologic and perioperative outcomes in RC. However, most of these studies were limited by their administrative data structure. Additionally, few studies have investigated the effect of case volume on quality of care criteria (QCC) in bladder cancer (BCa). We sought to address these shortcomings in the