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426 DISPARITIES IN THE UTILIZATION OF PARTIAL NEPHRECTOMY IN THE UNITED STATES A CASE FOR CONCERN?
Vol. 187, No. 4S, Supplement, Sunday, May 20, 2012
Source of Funding: Kidney Cancer Keystone Program
426 DISPARITIES IN THE UTILIZATION OF PARTIAL NEPHRECTOMY IN THE UNITED STATES: A CASE FOR CONCERN? Quoc-Dien Trinh*, Detroit, MI; Maxine Sun, Montreal, Canada; Jesse D Sammon, Khurshid R Ghani, Wooju Jeong, Detroit, MI; Marco Bianchi, Montreal, Canada; Jay Jhaveri, Shyam Sukumar, Ali Dabaja, Detroit, MI; Jens Hansen, Hamburg, Germany; Ariella Friedman, Michael Ehlert, Fred Muhletaler, Piyush K Agarwal, Craig G Rogers, James O Peabody, Detroit, MI; Shahrokh F Shariat, New York, NY; Mani Menon, Detroit, MI; Pierre I Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has several important advantages over radical nephrectomy (RN) in the management of renal cell carcinoma (RCC). Nonetheless, PN appears to be underutilized in North America. We examine specific patient and hospital characteristics that may be associated with the disparities underlying these previous observations. METHODS: The Nationwide Inpatient Sample was used to identify 375986 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2009. The utilization rates of PN and RN were assessed according to year of surgery, as well as patient and hospital characteristics. The determinants of PN were evaluated using logistic regression models. RESULTS: Overall, 63670 (16.9%) patients underwent PN between 1998 and 2009. PN use increased by nearly 5-fold over the study period: 5.9 to 27.1% (P⬍0.001). In multivariable logistic regression analysis, more advanced age and comorbidities was significantly associated with a lesser rate of PN (P⬍0.001). Medicaid, Medicare and uninsured patients were less likely to be treated with PN than their private insurance counterparts (Pⱕ0.002). Patients residing in the highest zip code income quartile were more likely to undergo PN (P⫽0.001). With regard to hospital characteristics, patients treated at high-volume (P⬍0.001), teaching institutions (P⬍0.001), as well as hospitals located in the Northeast region (all Pⱕ0.004) were significantly more likely to undergo a PN. CONCLUSIONS: On average, older, sicker, poorer, Medicare/ Medicaid/uninsured patients treated at non-teaching, rural, low-volume hospitals were less likely to be treated with PN. Efforts should be made to reduce the treatment disparities. Source of Funding: None
427 POPULATION BASED TRENDS IN SECONDARY PROCEDURES FOR MIDURETHRAL SLINGS Anne M. Suskind*, Samuel R. Kaufman, Rodney L. Dunn, John T. Stoffel, J. Quentin Clemens, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Over 1 million midurethral slings have been placed in women worldwide. Despite their
THE JOURNAL OF UROLOGY姞
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popularity, little is known regarding secondary procedures associated with slings. The purpose of this study was to investigate practice patterns and variation associated with sling removal/revision and urethrolysis on a population level. METHODS: We used CPT4 codes and the State Ambulatory Surgery Database to identify all ambulatory procedures for sling removal/ revision and urethrolysis from 2004-2009 in Florida. Next, we calculated age-adjusted rates of each procedure. We then measured variation in the use of each procedure by hospital service area. RESULTS: We identified 1,693 sling removal/revision procedures and 487 urethrolysis procedures during the time period examined. Age-adjusted rates of sling removal/revisions increased steadily from 2.33 to 5.11 procedures per 100,000 population between 2004 and 2009, while rates of urethrolysis procedures fluctuated up and down from 0.81 to 1.25 procedures per 100,000 population during the same period. Variation based on hospital service areas differed between the two groups, with urethrolysis procedures showing more regional variation than the sling removal/revision procedures, as shown by Figures A and B, respectively. CONCLUSIONS: Age-adjusted rates of sling removal/revision increase steadily with time as more slings are being placed. Uethrolysis procedures, on the other hand, seem to occur independently of rates of sling implantation, suggesting that their rates might be due to factors independent of the sling procedure itself. Regional variation reinforces these findings by showing that there is more variation, and likewise more medical uncertainty, associated with urethrolysis procedures compared to sling removal/revisions.
Source of Funding: None
428 ADOPTION OF LASER TECHNOLOGY IS ASSOCIATED WITH INCREASED BPH SURGERY RATES Florian R Schroeck*, John M Hollingsworth, Samuel R Kaufman, Rodney L Dunn, Brent K Hollenbeck, John T Wei, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Adoption of new laser technology may lead to increases in the number of patients receiving surgery for benign prostatic hyperplasia (BPH). We examined the association of laser technology adoption with BPH surgery rates. METHODS: We identified all patients undergoing surgery for BPH in Florida using data from the Healthcare Cost & Utilization Project for 2001-2009. We calculated BPH surgery rates for all regions (defined by Hospital Service Area) by year. Regions were split into 3 categories: 1) always offering, 2) never offering, or 3) initially not offering but adopting laser prostatectomy after 2001. We adjusted rates for regional factors using generalized estimating equation models. We included interaction terms in the models to examine differences in changes in surgery rate over time between region categories and to compare changes in rate before and after laser adoption. RESULTS: After adjusting for regional characteristics, time trends differed by region category (p⬍0.01). Regions always offering laser prostatectomy had high but decreasing rates of surgery (p⬍0.01, Figure), because they performed a stable number of procedures but had a rising population. Regions never offering laser surgery had much lower rates that remained stable (p⫽0.66, Figure). Regions adopting laser technology had increasing rates of surgery (from 103 to 128 per 100,000 men, p⬍0.01). In these regions, rates remained stable before adoption, but increased after adoption (p⬍0.01, Figure).
Source of Funding: Kidney Cancer Keystone Program
426 DISPARITIES IN THE UTILIZATION OF PARTIAL NEPHRECTOMY IN THE UNITED STATES: A CASE FOR CONCERN? Quoc-Dien Trinh*, Detroit, MI; Maxine Sun, Montreal, Canada; Jesse D Sammon, Khurshid R Ghani, Wooju Jeong, Detroit, MI; Marco Bianchi, Montreal, Canada; Jay Jhaveri, Shyam Sukumar, Ali Dabaja, Detroit, MI; Jens Hansen, Hamburg, Germany; Ariella Friedman, Michael Ehlert, Fred Muhletaler, Piyush K Agarwal, Craig G Rogers, James O Peabody, Detroit, MI; Shahrokh F Shariat, New York, NY; Mani Menon, Detroit, MI; Pierre I Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has several important advantages over radical nephrectomy (RN) in the management of renal cell carcinoma (RCC). Nonetheless, PN appears to be underutilized in North America. We examine specific patient and hospital characteristics that may be associated with the disparities underlying these previous observations. METHODS: The Nationwide Inpatient Sample was used to identify 375986 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2009. The utilization rates of PN and RN were assessed according to year of surgery, as well as patient and hospital characteristics. The determinants of PN were evaluated using logistic regression models. RESULTS: Overall, 63670 (16.9%) patients underwent PN between 1998 and 2009. PN use increased by nearly 5-fold over the study period: 5.9 to 27.1% (P⬍0.001). In multivariable logistic regression analysis, more advanced age and comorbidities was significantly associated with a lesser rate of PN (P⬍0.001). Medicaid, Medicare and uninsured patients were less likely to be treated with PN than their private insurance counterparts (Pⱕ0.002). Patients residing in the highest zip code income quartile were more likely to undergo PN (P⫽0.001). With regard to hospital characteristics, patients treated at high-volume (P⬍0.001), teaching institutions (P⬍0.001), as well as hospitals located in the Northeast region (all Pⱕ0.004) were significantly more likely to undergo a PN. CONCLUSIONS: On average, older, sicker, poorer, Medicare/ Medicaid/uninsured patients treated at non-teaching, rural, low-volume hospitals were less likely to be treated with PN. Efforts should be made to reduce the treatment disparities. Source of Funding: None
427 POPULATION BASED TRENDS IN SECONDARY PROCEDURES FOR MIDURETHRAL SLINGS Anne M. Suskind*, Samuel R. Kaufman, Rodney L. Dunn, John T. Stoffel, J. Quentin Clemens, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Over 1 million midurethral slings have been placed in women worldwide. Despite their
THE JOURNAL OF UROLOGY姞
e175
popularity, little is known regarding secondary procedures associated with slings. The purpose of this study was to investigate practice patterns and variation associated with sling removal/revision and urethrolysis on a population level. METHODS: We used CPT4 codes and the State Ambulatory Surgery Database to identify all ambulatory procedures for sling removal/ revision and urethrolysis from 2004-2009 in Florida. Next, we calculated age-adjusted rates of each procedure. We then measured variation in the use of each procedure by hospital service area. RESULTS: We identified 1,693 sling removal/revision procedures and 487 urethrolysis procedures during the time period examined. Age-adjusted rates of sling removal/revisions increased steadily from 2.33 to 5.11 procedures per 100,000 population between 2004 and 2009, while rates of urethrolysis procedures fluctuated up and down from 0.81 to 1.25 procedures per 100,000 population during the same period. Variation based on hospital service areas differed between the two groups, with urethrolysis procedures showing more regional variation than the sling removal/revision procedures, as shown by Figures A and B, respectively. CONCLUSIONS: Age-adjusted rates of sling removal/revision increase steadily with time as more slings are being placed. Uethrolysis procedures, on the other hand, seem to occur independently of rates of sling implantation, suggesting that their rates might be due to factors independent of the sling procedure itself. Regional variation reinforces these findings by showing that there is more variation, and likewise more medical uncertainty, associated with urethrolysis procedures compared to sling removal/revisions.
Source of Funding: None
428 ADOPTION OF LASER TECHNOLOGY IS ASSOCIATED WITH INCREASED BPH SURGERY RATES Florian R Schroeck*, John M Hollingsworth, Samuel R Kaufman, Rodney L Dunn, Brent K Hollenbeck, John T Wei, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Adoption of new laser technology may lead to increases in the number of patients receiving surgery for benign prostatic hyperplasia (BPH). We examined the association of laser technology adoption with BPH surgery rates. METHODS: We identified all patients undergoing surgery for BPH in Florida using data from the Healthcare Cost & Utilization Project for 2001-2009. We calculated BPH surgery rates for all regions (defined by Hospital Service Area) by year. Regions were split into 3 categories: 1) always offering, 2) never offering, or 3) initially not offering but adopting laser prostatectomy after 2001. We adjusted rates for regional factors using generalized estimating equation models. We included interaction terms in the models to examine differences in changes in surgery rate over time between region categories and to compare changes in rate before and after laser adoption. RESULTS: After adjusting for regional characteristics, time trends differed by region category (p⬍0.01). Regions always offering laser prostatectomy had high but decreasing rates of surgery (p⬍0.01, Figure), because they performed a stable number of procedures but had a rising population. Regions never offering laser surgery had much lower rates that remained stable (p⫽0.66, Figure). Regions adopting laser technology had increasing rates of surgery (from 103 to 128 per 100,000 men, p⬍0.01). In these regions, rates remained stable before adoption, but increased after adoption (p⬍0.01, Figure).