348 ASSOCIATION OF HEMATURIA ON MICROSCOPIC URINALYSIS AND RISK OF URINARY TRACT CANCER DEVELOPMENT

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THE JOURNAL OF UROLOGY姞

Vol. 183, No. 4, Supplement, Sunday, May 30, 2010

variability in the majority of the products surveyed. In other words, there were guesses ranging from $10 to $1,000 for a $100 product. There was no significant difference in the accuracy of the attending vs. resident physician perceived costs. CONCLUSIONS: At an academic urology practice, the median physician perceived cost of common urology and operative supplies was only accurate 32% of the time. In addition, there was no significant difference between the accuracy of attending vs. resident physician perceived costs. This poses a problem to resident education as it relates to the ACGME core competency of “systems-based practice.” Additional studies involving multiple academic and private institutions are needed. Source of Funding: None

347 SUPPLY COST SAVINGS FOR HIGH-VOLUME UROLOGIC PROCEDURES AT AN ACADEMIC MEDICAL CENTER James Dupree*, Arshia Wajid, Norm Smith, Chicago, IL INTRODUCTION AND OBJECTIVES: Over the past 20 years, there have been many efforts to reign in health care costs. Efforts are intensifying today, often focusing on hospital and physician costs. There is potential for surgeons to play a significant role in helping reduce supply costs while maintaining high quality patient care. We believe that increasing surgeons’ understanding of surgical supply cost may be one method to safely reduce costs. METHODS: We retrospectively reviewed the volume and supply cost data for all urologic procedures performed at our 897-bed, tertiary care academic medical center from September 2008 through August 2009. We identified the five highest volume urologic procedures and the five surgeons with the highest volume and median supply and disposable instrument cost for each of these procedures. We created a cost model to predict the supply cost saving that would occur if the profiled surgeons operated at the median supply cost. RESULTS: We analyzed 1,075 cases including 321 open radical prostatectomies (RRP), 264 holmium laser ureteroscopies (laser URS), 189 robotic-assisted laparoscopic prostatectomies (RALP), 178 cystoscopy/ureteroscopies (URS), and 123 transurethreal resections of prostates (TURP). Total yearly supply cost for these procedures was $1,162,068. Table 1 describes the costs and potential savings for each procedure. Potential supply cost savings ranged from $21/case and $5,541/year for laser ureteroscopy, to $128/case and $24,189/year for RALP. The total potential supply cost savings for these five procedures is $78,376/year, a saving of 6.7%. For RALP, RRP, and laser ureteroscopy, the highest volume surgeons had the lowest median supply costs (data not shown). CONCLUSIONS: Small reductions in supply costs can have a large impact on yearly cost savings. From a sample of the five highest volume procedures and five highest volume surgeons, we have shown that operating at a median supply cost could save $78,376 per year. This is an underestimate of department-wide potential cost savings as these cases represented only 32% of 3405 total cases performed by the department. As a retrospective study, we have the advantage of avoiding the Hawthorne effect, where the act of observing subjects alters their behaviors. The next step will be analyzing how supply costs change now that surgeons know this data. Table 1 – Description of supply costs and supply cost savings ($) Mean cost/ Median cost/ Cost savings/ Cost savings/ Procedure case case case year RRP 392 312 75 24,009 Laser URS

896

984

21

5,541

3,194

3196

128

24,189

URS

528

454

69

12,355

TURP

830

734

100

12,282

RALP

Source of Funding: None

348 ASSOCIATION OF HEMATURIA ON MICROSCOPIC URINALYSIS AND RISK OF URINARY TRACT CANCER DEVELOPMENT Howard Jung*, Joseph Gleason, Jeff Slezak, Ronald Loo, Hetal Patel, Gary Chien, Steven Jacobsen, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Detection of urinary tract cancer is of paramount importance during evaluation of hematuria. The American Urological Association (AUA) recommends evaluation of a patient with microscopic hematuria defined as 3 or more RBC/HPF from at least 2 urinalysis specimens. Meanwhile, the Canadian Urological Association (CUA) recommends evaluation within these parameters only if the patient is more than 40 years old. Currently, no large population study is available to validate either recommendation. The purpose of this study is to determine the incidence of urinary tract cancer in patients with hematuria, to stratify risk according to age, sex, and degree of hematuria, and to examine current best policy recommendations. METHODS: This is a retrospective cohort study including all members in a large health maintenance organization with hematuria diagnosed by microscopic urinalysis from January 1, 2004 to December 31, 2005. Members with recent hospitalization, pregnancy, urinary tract infection, or prior cancer diagnosis were excluded. The primary outcome was the diagnosis of malignancy associated with the upper or lower urinary tracts by the end of 2008. Further analysis according to age, gender, and degree of hematuria was performed. Logistic regression was used to model the probability of cancer detection. RESULTS: The cohort includes 309,402 members with at least one urinalysis in the defined time period. Of them, 156,691 demonstrated hematuria. There were 1,353 urinary tract cancers identified in the cohort at the end of 3 years. Of them, 1,071 demonstrated hematuria on at least one urinalysis. Urinary tract cancer rates were associated with older age (OR for ⬎40 ⫽17.0, 95% CI⫽11.2-25.7), degree of hematuria (OR for ⬎25 RBC/HPF ⫽4.0, CI⫽3.5-4.5), and male sex (OR ⫽4.8 CI⫽4.2-5.6). Using the AUA recommendations, we calculated a sensitivity of 50.2%, specificity of 83.8%, and positive predictive value (PPV) of 1.3%. Using the CUA recommendations, we calculated a sensitivity of 49.2%, specificity of 88.4%, and PPV of 1.8%. Using an alternative cutoff of ⬎25RBC/HPF in members ⬎40, we calculated a sensitivity of 50.4%, specificity of 92.2%, and PPV of 2.8%. CONCLUSIONS: Current recommendations for the evaluation of hematuria yield low rates of cancer detection. Meanwhile, certain populations, such as young age groups with low degrees of hematuria, may safely be spared full evaluation. These findings suggest the need for an alternative policy to improve identification of patients at risk of developing urinary tract cancer. Source of Funding: None

349 QUALITY AND INTENSITY OF EVALUATIVE CARE ARE ASSOCIATED WITH PROVISION OF BPH SURGERY Seth Strope*, St. Louis, MO; John Wei, Ann Arbor, MI; Timothy Wilt, Minneapolis, MN; Christopher Saigal, Los Angeles, CA; Sean Elliott, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Men undergo evaluation for BPH/LUTS with a variety of procedures and tests. To help standardize these evaluations, the AUA published best practice guidelines in 1998 and 2003. We sought to determine whether the intensity (expenditures) or quality (guideline adherence) of initial evaluation of BPH were associated with the likelihood of having surgery for BPH. METHODS: Using a 5% national sample of Medicare recipients from 1999 to 2007, we developed a cohort of patients who had not previously been seen by an urologist for BPH/LUTS. We developed indexes to measure urologists’ use of guideline recommended care (within 3 months of a new visit) by the 2003 AUA best practice guidelines, and the intensity (defined by time and geographic standardized Medicare expenditures within 1 year of initial visit to a urologist) of