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PD10-06 PATIENT FRAILTY PREDICTS FOR SERIOUS COMPLICATIONS AFTER RENAL CANCER SURGERY– ANALYSIS FROM NSQIP
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Blue Cross and Blue Shield of Michigan and grant 1T32-CA180984 from the National Cancer Institute.
PD10-06 PATIENT FRAILTY PREDICTS FOR SERIOUS COMPLICATIONS AFTER RENAL CANCER SURGERYe ANALYSIS FROM NSQIP Jessica Hoffen*, Natalie Fahey, ChiHsiung Wang, Sangtae Park, Evanston, IL INTRODUCTION AND OBJECTIVES: Payers are increasingly focusing on preventable complications and hospital readmissions as they seek greater value for healthcare dollars. Many renal cancer patients are older, have multiple comorbidities, and are at increased risk for such complications. Measures of patient frailty have been validated in other fields as useful tools that simply and objectively identify patients at risk for complications and readmissions. This study evaluated the predictive value of a frailty index in identifying renal cancer patients at risk for postoperative Clavien III, IV or V complications. METHODS: We identified all patients diagnosed with renal cancer after undergoing open or minimally invasive radical or partial nephrectomy between 2005 and 2013 in the National Surgical Quality Improvement Program database. The modified frailty index (mFI) was calculated for each patient by scoring the presence /absence of comorbid conditions (Table 1). Univariate and multivariable regression analyses were performed to determine whether mFI and other clinical variables could independently predict serious complications. RESULTS: N¼11,755 patients underwent renal cancer surgery and 35.4% had mFI score ¼ 0, 52.5% had mFI¼1, 9.1% had mFI¼2, 2% had mFI¼3, and 0.7% had mFI4. Univariate analysis showed that higher mFI scores were associated with four-fold increased risk of sustaining a Clavien III, IV or V complication (p<0.0001). Higher mFI also predicted for suffering more than one of the 12 measured Clavien 3 complications (p <0.0001). Multivariable regression (Table 2) showed that patients with a frailty index of 1, 2, 3 and 4 had a monotonically increasing odds of suffering a Clavien 3 complication. Prolonged OR time, lower preoperative serum albumin and older age also predicted for increased risk of serious complications and readmissions. CONCLUSIONS: The modified Frailty Index is a simple and objective measure that independently predicts Clavien 3 complications and readmissions in renal cancer patients undergoing open or minimally invasive surgery.
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PD10-07 FASTER CARE FOR LESS? COST MODEL OF HEMATURIA CARE REDESIGN Tony T. Chen*, Wendy Webster, Mohammad Shahsahebi, Michael E. Lipkin, Glenn M. Preminger, Sharon K. Hull, Charles D. Scales Jr, Durham, NC INTRODUCTION AND OBJECTIVES: Asymptomatic microhematuria (AMH) is a common incidental finding. Evaluation often involves two patient encounters (consultation and subsequent procedure), which increases time from referral to workup conclusion, is burdensome to patients and may increase costs of care. Using the health system perspective, we compared costs of our traditional twovisit evaluation process with those of a planned single-encounter process. METHODS: We created a cost identification model to compare overall costs of the traditional and single-encounter pathways. First, a multidisciplinary team of primary care and urology providers and administrative leaders developed care process maps of the delivery value chain for microhematuria. Using the novel strategy of timedriven activity-based costing (TDABC), we then estimated indirect costs; direct costs were based on Medicare fees for the appropriate encounters. Using time-motion studies, we measured operational costs and process times to calculate personnel capacity costs. Finally, direct and indirect costs of each pathway were combined to calculate total cycle costs. RESULTS: In the traditional evaluation cycle, the average total costs were $400; 75% were direct costs and 25% were indirect costs. By comparison, the single episode-based encounter reduced total costs by 15%. The majority of the savings accrued from lower indirect costs involved in the second visit of the traditional pathway. A number of modifiable personnel factors influence indirect costs. Assistance of resident physicians in the evaluation & management visit reduced indirect costs by 18%. Use of certified medical assistants in patient care reduced indirect costs incurred by registered nurses by 65%. From the patient perspective, projected time savings are substantial, including elimination of at least one office visit and the associated travel and opportunity costs. CONCLUSIONS: Using the novel costing approach of TDABC, we estimate that the cost of hematuria evaluation may be reduced by 15% through an innovative care delivery pathway. The new pathway may also improve value by freeing up additional return appointment slots. Additionally, variation in personnel can drive indirect costs. As the new pathway is implemented, future studies will assess actual costs, referral to completion time, patient satisfaction and clinical outcomes. Source of Funding: None
PD10-08 COMPLIANCE AND METABOLIC STONE DISEASE. DOES DISTANCE TO CARE MATTER? Maxx Gallegos*, Julie Riley, Albuquerque, NM
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Due to a dry climate and unique patient demographic, metabolic stone disease is prevalent in New Mexico. University of New Mexico Hospital is the only tertiary referral center for urologic disease in the state, therefore, comprehensive stone surveillance and treatment is crucial. It has been anecdotally suggested that distance from a care center is a factor in patient noncompliance. Our study aims to show this phenomenon. METHODS: All upper tract stone diagnoses of the last 5 years were reviewed, including patients who received medical expulsive therapy, ureteroscopy or percutaneous nephrolithotomy. Of those, only patients who submitted a 24-hour urine for metabolic stone surveillance were analyzed. This yielded 225 unique patients for final review. Compliance with follow up was determined by chart review. Patients
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Blue Cross and Blue Shield of Michigan and grant 1T32-CA180984 from the National Cancer Institute.
PD10-06 PATIENT FRAILTY PREDICTS FOR SERIOUS COMPLICATIONS AFTER RENAL CANCER SURGERYe ANALYSIS FROM NSQIP Jessica Hoffen*, Natalie Fahey, ChiHsiung Wang, Sangtae Park, Evanston, IL INTRODUCTION AND OBJECTIVES: Payers are increasingly focusing on preventable complications and hospital readmissions as they seek greater value for healthcare dollars. Many renal cancer patients are older, have multiple comorbidities, and are at increased risk for such complications. Measures of patient frailty have been validated in other fields as useful tools that simply and objectively identify patients at risk for complications and readmissions. This study evaluated the predictive value of a frailty index in identifying renal cancer patients at risk for postoperative Clavien III, IV or V complications. METHODS: We identified all patients diagnosed with renal cancer after undergoing open or minimally invasive radical or partial nephrectomy between 2005 and 2013 in the National Surgical Quality Improvement Program database. The modified frailty index (mFI) was calculated for each patient by scoring the presence /absence of comorbid conditions (Table 1). Univariate and multivariable regression analyses were performed to determine whether mFI and other clinical variables could independently predict serious complications. RESULTS: N¼11,755 patients underwent renal cancer surgery and 35.4% had mFI score ¼ 0, 52.5% had mFI¼1, 9.1% had mFI¼2, 2% had mFI¼3, and 0.7% had mFI4. Univariate analysis showed that higher mFI scores were associated with four-fold increased risk of sustaining a Clavien III, IV or V complication (p<0.0001). Higher mFI also predicted for suffering more than one of the 12 measured Clavien 3 complications (p <0.0001). Multivariable regression (Table 2) showed that patients with a frailty index of 1, 2, 3 and 4 had a monotonically increasing odds of suffering a Clavien 3 complication. Prolonged OR time, lower preoperative serum albumin and older age also predicted for increased risk of serious complications and readmissions. CONCLUSIONS: The modified Frailty Index is a simple and objective measure that independently predicts Clavien 3 complications and readmissions in renal cancer patients undergoing open or minimally invasive surgery.
e241
PD10-07 FASTER CARE FOR LESS? COST MODEL OF HEMATURIA CARE REDESIGN Tony T. Chen*, Wendy Webster, Mohammad Shahsahebi, Michael E. Lipkin, Glenn M. Preminger, Sharon K. Hull, Charles D. Scales Jr, Durham, NC INTRODUCTION AND OBJECTIVES: Asymptomatic microhematuria (AMH) is a common incidental finding. Evaluation often involves two patient encounters (consultation and subsequent procedure), which increases time from referral to workup conclusion, is burdensome to patients and may increase costs of care. Using the health system perspective, we compared costs of our traditional twovisit evaluation process with those of a planned single-encounter process. METHODS: We created a cost identification model to compare overall costs of the traditional and single-encounter pathways. First, a multidisciplinary team of primary care and urology providers and administrative leaders developed care process maps of the delivery value chain for microhematuria. Using the novel strategy of timedriven activity-based costing (TDABC), we then estimated indirect costs; direct costs were based on Medicare fees for the appropriate encounters. Using time-motion studies, we measured operational costs and process times to calculate personnel capacity costs. Finally, direct and indirect costs of each pathway were combined to calculate total cycle costs. RESULTS: In the traditional evaluation cycle, the average total costs were $400; 75% were direct costs and 25% were indirect costs. By comparison, the single episode-based encounter reduced total costs by 15%. The majority of the savings accrued from lower indirect costs involved in the second visit of the traditional pathway. A number of modifiable personnel factors influence indirect costs. Assistance of resident physicians in the evaluation & management visit reduced indirect costs by 18%. Use of certified medical assistants in patient care reduced indirect costs incurred by registered nurses by 65%. From the patient perspective, projected time savings are substantial, including elimination of at least one office visit and the associated travel and opportunity costs. CONCLUSIONS: Using the novel costing approach of TDABC, we estimate that the cost of hematuria evaluation may be reduced by 15% through an innovative care delivery pathway. The new pathway may also improve value by freeing up additional return appointment slots. Additionally, variation in personnel can drive indirect costs. As the new pathway is implemented, future studies will assess actual costs, referral to completion time, patient satisfaction and clinical outcomes. Source of Funding: None
PD10-08 COMPLIANCE AND METABOLIC STONE DISEASE. DOES DISTANCE TO CARE MATTER? Maxx Gallegos*, Julie Riley, Albuquerque, NM
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Due to a dry climate and unique patient demographic, metabolic stone disease is prevalent in New Mexico. University of New Mexico Hospital is the only tertiary referral center for urologic disease in the state, therefore, comprehensive stone surveillance and treatment is crucial. It has been anecdotally suggested that distance from a care center is a factor in patient noncompliance. Our study aims to show this phenomenon. METHODS: All upper tract stone diagnoses of the last 5 years were reviewed, including patients who received medical expulsive therapy, ureteroscopy or percutaneous nephrolithotomy. Of those, only patients who submitted a 24-hour urine for metabolic stone surveillance were analyzed. This yielded 225 unique patients for final review. Compliance with follow up was determined by chart review. Patients