- Email: [email protected]
MP31-05 TRENDS IN INPATIENT UROLOGICAL SURGERY PRACTICE PATTERNS
THE JOURNAL OF UROLOGYâ
e420
urologists. Over 75% of US urologists are listed as receiving payments in 2014, while a minority of urology trainees are listed. This database is new and publicly available, and urologists should be familiar with the specific data contained within it. Source of Funding: None
MP31-03 CYSTINE STONE-FORMERS HAVE IMPAIRED HEALTH RELATED QUALITY OF LIFE COMPARED TO NON-CYSTINE STONE-FORMERS Necole M Streeper*, Hershey, PA; Margaret L Wertheim, Kristina L Penniston, Stephen Y Nakada, Madison, WI INTRODUCTION AND OBJECTIVES: Cystinuria is rare, comprising <1% of all stone formers with a median age of onset of 12 years and is known to have a high rate of stone recurrence due to poor compliance to medical therapy. The objective of this study is to compare the health-related quality of life (HRQOL) of patients with cystinuria to patients with other etiologies of stone formation using the diseasespecific Wisconsin Stone Quality of Life (WiSQoL) questionnaire. METHODS: With IRB approval, we identified 35 patients with cystinuria through our stone clinics and performed a matched casecontrol study of non-cystine stone-formers, who were matched according to gender, age, and co-morbidities. Patients were asked to complete the WiSQoL questionnaire and a medical/stone history form that included questions about disease age of onset, number of stone episodes, date of last stone episode and number of surgical interventions. RESULTS: Patients (n¼13, 3 male: 10 female) with an average age of 50.616.7 were control-matched with non-cystine stone-formers (n¼13, 3 male: 10 female) with an average age of 53.516.8. Cystine stone formers had more prior stone episodes and a greater number of surgical interventions. Cystine stone-formers had significantly lower total WiSQoL scores compared to non-cystine stone-formers, 95.631.8 vs. 124.59.3, respectively, (p<0.01). Compared to noncystine stone formers, cystine stone-formers reported significantly worse nocturia (p¼0.03), difficulty returning to sleep (p¼0.02), feeling tired or fatigued (p¼0.05), limited activity (p¼0.04), missed work or family time (p¼0.03), urinary frequency (p¼0.04), anxiety about the future (p¼0.02) and feeling more irritable than usual (p¼0.04). Cystine stone-formers with current stones (n¼6) were found to have significantly lower overall WiSQoL scores compared to non-cystine stoneformers with current stones (n¼5), 83.0 vs 120.8 respectively, (p¼0.03). CONCLUSIONS: Using a stone-specific questionnaire, patients who form cystine stones have lower HRQOL compared to non-cystine stone formers. Identifying and addressing specific areas of decrement in these patients may improve disease management and patients’ HRQOL. Source of Funding: none
MP31-04 WIDE VARIATION IN SURGEON PARTICIPATION IN EARLY MEDICARE ACCOUNTABLE CARE ORGANIZATIONS Lindsey Herrel*, Scott Hawken, Chandy Ellimoottil, Zaojun Ye, James Dupree, Brent Hollenbeck, David Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Despite rapid proliferation of Accountable Care Organizations (ACOs), the prevalence and impact of surgeon participation in this new healthcare delivery model remains poorly defined. We examined surgeon participation in Medicare Shared Savings Program (MSSP) ACOs, and compared characteristics and spending metrics for ACOs with low and high degrees of surgeon representation. METHODS: We estimated the percentage of surgeons nationwide participating in an MSSP ACO from April 2012 through December 2013, and compared this to other clinical domains (e.g., primary care) and across surgical subspecialties. We stratified ACOs into quartiles ranging from those with the least (1st quartile) to greatest (4th quartile) proportion of ACO participating physicians identified as surgeons. We
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
then evaluated characteristics and first-year spending metrics for ACOs with the least versus greatest degree of surgeon representation. RESULTS: ACO participation by surgical subspecialty ranged from 5.2% (plastic surgery) to 12.5% (CT surgery) (p<0.001). Across MSSP ACOs, surgeon representation varied widely from 0 to 53%, while 46 organizations had no surgeon participation (Figure). ACOs with the greatest surgeon representation had a larger and more diverse physician panel, and cared for more beneficiaries (18,997 vs 10,252, p<0.001). We noted no difference in annualized spending metrics, including savings ($154 vs $93 per beneficiary per year, p¼0.67). Nationally, surgeons participated in MSSP ACOs at a marginally lower rate than physicians from other clinical domains (8.8% of all surgeons vs 9.7% primary care physicians, p<0.001). CONCLUSIONS: Formal surgeon participation varies widely across MSSP ACOs. ACOs with the greatest surgeon representation were larger with broader physician involvement. Early results indicate that surgeon representation is not associated with lower expenditures; however, long-term studies will assess the ultimate impact of surgeon participation on ACO performance.
Source of Funding: This project was supported by funding from the National Institute of Diabetes, Digestive and Kidney Diseases (T-32-F025681 to LAH) the National Cancer Institute (1-R01-CA-174768-01-A1 to DCM) and the American Cancer Society (RSGI-13-323-01-CPHPS to BKH).
MP31-05 TRENDS IN INPATIENT UROLOGICAL SURGERY PRACTICE PATTERNS Scott Hawken*, Lindsey Herrel, Chandy Ellimoottil, Zaojun Ye, J. Quentin Clemens, David Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: As the nation’s population ages, and the number of practicing urologists per capita declines, characterization of practice patterns is essential to understand the current state of the urological workforce and anticipate future needs. Accordingly, we examined trends in adult inpatient urological surgery practice patterns over a five-year period. METHODS: We used the Nationwide Inpatient Sample (NIS) data from 2005 through 2009 to identify both surgeons and urological surgeries. We classified the latter into 1 of 7 clinical domains (Endourology & Stone Disease, Incontinence, Urogenital Reconstruction, Urologic Oncology, Benign Prostate, Renal Transplant, and Other Urological Procedures). For each urological surgeon, three parameters were determined for each year: 1) Case-diversity (the number of distinct urological clinical domains in which they performed 2 procedures/ year); 2) Subspecialty (the predominant clinical domain of cases that each surgeon performed); and 3) Subspecialty-focus (the proportion of a surgeon’s total urological cases/year that belonged to their assigned
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
clinical domain). We examined trends in these metrics over a five-year period, and compared results between urban and rural practice settings. RESULTS: We analyzed data for 2,237 individual surgeons performing 144,138 inpatient surgeries. Over time, urologist’s practice patterns evolved toward lower case-diversity (p<0.001) and greater subspecialty-focus (p<0.001) (Figure). These trends were more pronounced for surgeons practicing in urban versus rural practice settings (p-values <0.05) (Figure). CONCLUSIONS: At a national level, urologists’ inpatient surgical practice patterns are narrowing, with less case-diversity and higher subspecialty-focus. As more urological surgeons focus on treating only patients with specific conditions, there may be pressure to further sub-specialize. This could have implications for employment opportunities and increase the demand for fellowship training. It could also be an important step in meeting the growing demand for surgeons that meet specific volume thresholds for complex inpatient procedures.
e421
1.159-4.598; PN: OR 5.166, 95% CI 1.207-22.12), infectious complications (RN: OR 1.656, 95% CI 1.151-2.383; PN: OR 1.945, 95% CI 1.128-3.354) and pulmonary complications (RN: OR 3.040, 95% CI 2.125-4.349; OR 3.771, 95% CI 2.108-6.746). CONCLUSIONS: For patients undergoing RN or PN there is a significant association between receipt of PBT and 30-day post-operative outcomes, specifically overall morbidity, mortality, infectious complications, and pulmonary complications. The mechanism that underlies these effects has not been elucidated, but it most likely involves immunomodulation and acute lung injury. Future research should focus on formulating comprehensive transfusion guidelines for oncologicrelated nephrectomies.
Source of Funding: None
MP31-07 Source of Funding: This work was supported by funding from the National Cancer Institute (1-RO1-CA-174768 to DCM), the Agency for Healthcare Research and Quality (1F32HS024193-01 to CE), the National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK007782 to LAH), and the National Center for Advancing Translational Sciences (2UL1TR000433-06 to SRH).
MP31-06 PERIOPERATIVE BLOOD TRANSFUSION PREDICTS SHORTTERM MORBIDITY AND MORTALITY IN RADICAL AND PARTIAL NEPHRECTOMIES: EVIDENCE FROM NSQIP Wilson Sui*, Ifeanyi Onyeji, Justin T. Matulay, Marissa C. Velez, Maxwell B. James, G. Joel DeCastro, Sven Wenske, New York, NY INTRODUCTION AND OBJECTIVES: Perioperative blood transfusion (PBT), either during the operation or soon after, is used relatively frequently in both radical and partial nephrectomy with rates reported in the literature as high as 21%. PBT has been associated with increased risk of recurrence and poor survival after surgery for a variety of malignancies as well as most urologic cancers (i.e. bladder, prostate) however its effect on short-term outcomes has not been previously reported. Thus we sought to assess 30-day morbidity and mortality following partial nephrectomy (PN) and radical nephrectomy (RN) with relation to the administration of PBT. METHODS: The National Surgical Quality Improvement Program was queried for patients with malignant renal tumors (International Classification of Diseases Ninth Revision codes 189-189.2) who underwent RN (Current Procedure Terminology (CPT) codes 50220, 50225, 50230, 50234, 50236, 50545, 50546, 50548) or PN (CPT codes 50240, 50543) between 2005-2013. Patients were stratified by transfusion status and assessed for post-operative outcomes both separately and in composite, including morbidity, mortality, infectious complications, and pulmonary complications. Univariate and multivariate analyses were performed to identify significant independent predictors of these composite outcomes. RESULTS: The overall transfusion rates were 15.8% and 8.2% for RN and PN, respectively. On multivariate analysis, PBT was associated with increased morbidity (RN: OR 2.147, 95% CI 1.687-2.733; PN: OR 2.081, 95% CI 1.434-3.022), mortality (RN: OR 2.308, 95% CI
TELE-UROLOGY VERSUS FACE-TO-FACE CLINICS: A SURVEY OF PATIENT PREFERENCE Jeffrey Pearl*, Ilan Safir, Robert Gerhard, Irina Kirillova, James Baumgardner, Jennifer Lindelow, Christopher Filson, Muta M. Issa, Atlanta, GA INTRODUCTION AND OBJECTIVES: Patient satisfaction remains a key measure of quality care, and telemedicine clinics may improve the clinical experience by minimizing delays in receiving care. We compared satisfaction among patients seen in Tele-Urology (TU) versus conventional face-to-face (FTF) clinic encounters. METHODS: Patients who were seen via TU and FTF clinics participated in a post-encounter survey that addressed their clinical experience, satisfaction, and preference levels. The survey included 8 questions focused on efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism (linear visual scale 110) and 21 secondary “Yes/No” questions to delineate impact factors. Two questions asked whether patients would undergo similar encounters or recommend them for their family members and friends. Parametric chi-square and t-tests were used for statistical analysis, and p<0.05 was considered statistically significant. RESULTS: In total, 251 patients were surveyed (median age 63 years (range 25-91)). TU patients (n¼200) underwent timelier clinic access compared to FTF patients (n¼51) (median time to initial evaluation 13 day vs 72 days, p<0.001). TU patients had higher overall satisfaction (9.2 vs 7.8 FTF, p<0.001). This was also seen with efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism (all TU>FTF, all p<0.001). Patients reported preferring TU versus FTF clinics due to transportation issues (94.4%), provider communication and attention issues (76.5%), and clinic operational issues (59.8%). In particular, TU patients noted significantly more attention and better communication from their provider (89.0% vs 72.5% FTF, p¼0.002). Significantly more TU patients were willing to undergo similar evaluation if needed in the future (100% vs 75% FTF, p<0.001). Given the choice, the majority (82.0%) of FTF patients would choose TU over FTF in the future. CONCLUSIONS: Patients managed via Tele-Urology clinics report higher satisfaction and preference compared to those seen in conventional face-to-face clinic encounters, which seemed to center around concerns with transportation, clinical operations, and quality of
e420
urologists. Over 75% of US urologists are listed as receiving payments in 2014, while a minority of urology trainees are listed. This database is new and publicly available, and urologists should be familiar with the specific data contained within it. Source of Funding: None
MP31-03 CYSTINE STONE-FORMERS HAVE IMPAIRED HEALTH RELATED QUALITY OF LIFE COMPARED TO NON-CYSTINE STONE-FORMERS Necole M Streeper*, Hershey, PA; Margaret L Wertheim, Kristina L Penniston, Stephen Y Nakada, Madison, WI INTRODUCTION AND OBJECTIVES: Cystinuria is rare, comprising <1% of all stone formers with a median age of onset of 12 years and is known to have a high rate of stone recurrence due to poor compliance to medical therapy. The objective of this study is to compare the health-related quality of life (HRQOL) of patients with cystinuria to patients with other etiologies of stone formation using the diseasespecific Wisconsin Stone Quality of Life (WiSQoL) questionnaire. METHODS: With IRB approval, we identified 35 patients with cystinuria through our stone clinics and performed a matched casecontrol study of non-cystine stone-formers, who were matched according to gender, age, and co-morbidities. Patients were asked to complete the WiSQoL questionnaire and a medical/stone history form that included questions about disease age of onset, number of stone episodes, date of last stone episode and number of surgical interventions. RESULTS: Patients (n¼13, 3 male: 10 female) with an average age of 50.616.7 were control-matched with non-cystine stone-formers (n¼13, 3 male: 10 female) with an average age of 53.516.8. Cystine stone formers had more prior stone episodes and a greater number of surgical interventions. Cystine stone-formers had significantly lower total WiSQoL scores compared to non-cystine stone-formers, 95.631.8 vs. 124.59.3, respectively, (p<0.01). Compared to noncystine stone formers, cystine stone-formers reported significantly worse nocturia (p¼0.03), difficulty returning to sleep (p¼0.02), feeling tired or fatigued (p¼0.05), limited activity (p¼0.04), missed work or family time (p¼0.03), urinary frequency (p¼0.04), anxiety about the future (p¼0.02) and feeling more irritable than usual (p¼0.04). Cystine stone-formers with current stones (n¼6) were found to have significantly lower overall WiSQoL scores compared to non-cystine stoneformers with current stones (n¼5), 83.0 vs 120.8 respectively, (p¼0.03). CONCLUSIONS: Using a stone-specific questionnaire, patients who form cystine stones have lower HRQOL compared to non-cystine stone formers. Identifying and addressing specific areas of decrement in these patients may improve disease management and patients’ HRQOL. Source of Funding: none
MP31-04 WIDE VARIATION IN SURGEON PARTICIPATION IN EARLY MEDICARE ACCOUNTABLE CARE ORGANIZATIONS Lindsey Herrel*, Scott Hawken, Chandy Ellimoottil, Zaojun Ye, James Dupree, Brent Hollenbeck, David Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Despite rapid proliferation of Accountable Care Organizations (ACOs), the prevalence and impact of surgeon participation in this new healthcare delivery model remains poorly defined. We examined surgeon participation in Medicare Shared Savings Program (MSSP) ACOs, and compared characteristics and spending metrics for ACOs with low and high degrees of surgeon representation. METHODS: We estimated the percentage of surgeons nationwide participating in an MSSP ACO from April 2012 through December 2013, and compared this to other clinical domains (e.g., primary care) and across surgical subspecialties. We stratified ACOs into quartiles ranging from those with the least (1st quartile) to greatest (4th quartile) proportion of ACO participating physicians identified as surgeons. We
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
then evaluated characteristics and first-year spending metrics for ACOs with the least versus greatest degree of surgeon representation. RESULTS: ACO participation by surgical subspecialty ranged from 5.2% (plastic surgery) to 12.5% (CT surgery) (p<0.001). Across MSSP ACOs, surgeon representation varied widely from 0 to 53%, while 46 organizations had no surgeon participation (Figure). ACOs with the greatest surgeon representation had a larger and more diverse physician panel, and cared for more beneficiaries (18,997 vs 10,252, p<0.001). We noted no difference in annualized spending metrics, including savings ($154 vs $93 per beneficiary per year, p¼0.67). Nationally, surgeons participated in MSSP ACOs at a marginally lower rate than physicians from other clinical domains (8.8% of all surgeons vs 9.7% primary care physicians, p<0.001). CONCLUSIONS: Formal surgeon participation varies widely across MSSP ACOs. ACOs with the greatest surgeon representation were larger with broader physician involvement. Early results indicate that surgeon representation is not associated with lower expenditures; however, long-term studies will assess the ultimate impact of surgeon participation on ACO performance.
Source of Funding: This project was supported by funding from the National Institute of Diabetes, Digestive and Kidney Diseases (T-32-F025681 to LAH) the National Cancer Institute (1-R01-CA-174768-01-A1 to DCM) and the American Cancer Society (RSGI-13-323-01-CPHPS to BKH).
MP31-05 TRENDS IN INPATIENT UROLOGICAL SURGERY PRACTICE PATTERNS Scott Hawken*, Lindsey Herrel, Chandy Ellimoottil, Zaojun Ye, J. Quentin Clemens, David Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: As the nation’s population ages, and the number of practicing urologists per capita declines, characterization of practice patterns is essential to understand the current state of the urological workforce and anticipate future needs. Accordingly, we examined trends in adult inpatient urological surgery practice patterns over a five-year period. METHODS: We used the Nationwide Inpatient Sample (NIS) data from 2005 through 2009 to identify both surgeons and urological surgeries. We classified the latter into 1 of 7 clinical domains (Endourology & Stone Disease, Incontinence, Urogenital Reconstruction, Urologic Oncology, Benign Prostate, Renal Transplant, and Other Urological Procedures). For each urological surgeon, three parameters were determined for each year: 1) Case-diversity (the number of distinct urological clinical domains in which they performed 2 procedures/ year); 2) Subspecialty (the predominant clinical domain of cases that each surgeon performed); and 3) Subspecialty-focus (the proportion of a surgeon’s total urological cases/year that belonged to their assigned
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
clinical domain). We examined trends in these metrics over a five-year period, and compared results between urban and rural practice settings. RESULTS: We analyzed data for 2,237 individual surgeons performing 144,138 inpatient surgeries. Over time, urologist’s practice patterns evolved toward lower case-diversity (p<0.001) and greater subspecialty-focus (p<0.001) (Figure). These trends were more pronounced for surgeons practicing in urban versus rural practice settings (p-values <0.05) (Figure). CONCLUSIONS: At a national level, urologists’ inpatient surgical practice patterns are narrowing, with less case-diversity and higher subspecialty-focus. As more urological surgeons focus on treating only patients with specific conditions, there may be pressure to further sub-specialize. This could have implications for employment opportunities and increase the demand for fellowship training. It could also be an important step in meeting the growing demand for surgeons that meet specific volume thresholds for complex inpatient procedures.
e421
1.159-4.598; PN: OR 5.166, 95% CI 1.207-22.12), infectious complications (RN: OR 1.656, 95% CI 1.151-2.383; PN: OR 1.945, 95% CI 1.128-3.354) and pulmonary complications (RN: OR 3.040, 95% CI 2.125-4.349; OR 3.771, 95% CI 2.108-6.746). CONCLUSIONS: For patients undergoing RN or PN there is a significant association between receipt of PBT and 30-day post-operative outcomes, specifically overall morbidity, mortality, infectious complications, and pulmonary complications. The mechanism that underlies these effects has not been elucidated, but it most likely involves immunomodulation and acute lung injury. Future research should focus on formulating comprehensive transfusion guidelines for oncologicrelated nephrectomies.
Source of Funding: None
MP31-07 Source of Funding: This work was supported by funding from the National Cancer Institute (1-RO1-CA-174768 to DCM), the Agency for Healthcare Research and Quality (1F32HS024193-01 to CE), the National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK007782 to LAH), and the National Center for Advancing Translational Sciences (2UL1TR000433-06 to SRH).
MP31-06 PERIOPERATIVE BLOOD TRANSFUSION PREDICTS SHORTTERM MORBIDITY AND MORTALITY IN RADICAL AND PARTIAL NEPHRECTOMIES: EVIDENCE FROM NSQIP Wilson Sui*, Ifeanyi Onyeji, Justin T. Matulay, Marissa C. Velez, Maxwell B. James, G. Joel DeCastro, Sven Wenske, New York, NY INTRODUCTION AND OBJECTIVES: Perioperative blood transfusion (PBT), either during the operation or soon after, is used relatively frequently in both radical and partial nephrectomy with rates reported in the literature as high as 21%. PBT has been associated with increased risk of recurrence and poor survival after surgery for a variety of malignancies as well as most urologic cancers (i.e. bladder, prostate) however its effect on short-term outcomes has not been previously reported. Thus we sought to assess 30-day morbidity and mortality following partial nephrectomy (PN) and radical nephrectomy (RN) with relation to the administration of PBT. METHODS: The National Surgical Quality Improvement Program was queried for patients with malignant renal tumors (International Classification of Diseases Ninth Revision codes 189-189.2) who underwent RN (Current Procedure Terminology (CPT) codes 50220, 50225, 50230, 50234, 50236, 50545, 50546, 50548) or PN (CPT codes 50240, 50543) between 2005-2013. Patients were stratified by transfusion status and assessed for post-operative outcomes both separately and in composite, including morbidity, mortality, infectious complications, and pulmonary complications. Univariate and multivariate analyses were performed to identify significant independent predictors of these composite outcomes. RESULTS: The overall transfusion rates were 15.8% and 8.2% for RN and PN, respectively. On multivariate analysis, PBT was associated with increased morbidity (RN: OR 2.147, 95% CI 1.687-2.733; PN: OR 2.081, 95% CI 1.434-3.022), mortality (RN: OR 2.308, 95% CI
TELE-UROLOGY VERSUS FACE-TO-FACE CLINICS: A SURVEY OF PATIENT PREFERENCE Jeffrey Pearl*, Ilan Safir, Robert Gerhard, Irina Kirillova, James Baumgardner, Jennifer Lindelow, Christopher Filson, Muta M. Issa, Atlanta, GA INTRODUCTION AND OBJECTIVES: Patient satisfaction remains a key measure of quality care, and telemedicine clinics may improve the clinical experience by minimizing delays in receiving care. We compared satisfaction among patients seen in Tele-Urology (TU) versus conventional face-to-face (FTF) clinic encounters. METHODS: Patients who were seen via TU and FTF clinics participated in a post-encounter survey that addressed their clinical experience, satisfaction, and preference levels. The survey included 8 questions focused on efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism (linear visual scale 110) and 21 secondary “Yes/No” questions to delineate impact factors. Two questions asked whether patients would undergo similar encounters or recommend them for their family members and friends. Parametric chi-square and t-tests were used for statistical analysis, and p<0.05 was considered statistically significant. RESULTS: In total, 251 patients were surveyed (median age 63 years (range 25-91)). TU patients (n¼200) underwent timelier clinic access compared to FTF patients (n¼51) (median time to initial evaluation 13 day vs 72 days, p<0.001). TU patients had higher overall satisfaction (9.2 vs 7.8 FTF, p<0.001). This was also seen with efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism (all TU>FTF, all p<0.001). Patients reported preferring TU versus FTF clinics due to transportation issues (94.4%), provider communication and attention issues (76.5%), and clinic operational issues (59.8%). In particular, TU patients noted significantly more attention and better communication from their provider (89.0% vs 72.5% FTF, p¼0.002). Significantly more TU patients were willing to undergo similar evaluation if needed in the future (100% vs 75% FTF, p<0.001). Given the choice, the majority (82.0%) of FTF patients would choose TU over FTF in the future. CONCLUSIONS: Patients managed via Tele-Urology clinics report higher satisfaction and preference compared to those seen in conventional face-to-face clinic encounters, which seemed to center around concerns with transportation, clinical operations, and quality of