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MP37-08 MISATTRIBUTION ERRORS IN UROLOGIC PROCEDURES FROM THE PROPUBLICA SURGEON SCORECARD
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
MP37-06 DELAYED TREATMENT OF HIGH-RISK PROSTATE CANCER PATIENTS: IMPACT OF SOCIOECONOMIC BARRIERS AND USE OF ADVANCED TECHNOLOGIES R. Steven Gerhard*, Datta Patil, Yuan Liu, Kenneth Ogan, Mehrdad Alemozaffar, Ashesh Jani, Omer Kucuk, Viraj Master, Theresa Gillespie, Christopher Filson, Atlanta, GA INTRODUCTION AND OBJECTIVES: Though attention has been given to overtreatment of indolent prostate cancer, there has been less focus on potential undertreatment of men with high-risk tumors. To that end, we sought to characterize factors related to delayed or lack of treatment (DT) of high-risk prostate cancer patients, and to assess the impact on case volume and use of advanced technology on this outcome. METHODS: We identified patients with high-risk (i.e., Gleason 8+, PSA>20, cT3) localized (i.e., T1-3Nx-0Mx-0) prostate cancer in the National Cancer Database (2010-2012). Primary outcome was DT (i.e., no treatment within 6 months post-diagnosis). Exposures of interest were facility-level case volume (based on number of positive biopsies), robotic-assisted radical prostatectomy (RARP) volume, and intensitymodulated radiation therapy (IMRT) volume. Multivariable regression models, adjusted for clustering at the facility-level, estimated the association between facility volume factors (arranged in quartiles) and receipt of DT. The model adjusted for patient age, comorbidity, type of cancer center (academic vs comprehensive community vs community), and diagnosis year. Statistical tests were 2-sided and significant if p<0.05. RESULTS: Among 63439 prostate cancer patients with highrisk localized prostate tumors, 3690 (5.8%) received DT. Black patients (9.7% vs 4.9% White, OR 1.67, 95% CI 1.50-1.86), men with Medicaid or no insurance (12.6% vs 5% Private/HMO, OR 1.48, 95% CI 1.251.76), and those in the poorest census tracts (7.7% < $38,000 vs 5.2% $63,000+, OR 1.17, 95%CI: 1.02-1.34) were more likely to receive DT. Patients diagnosed at academic centers were more likely to receive DT (7.7% vs 5.7% community cancer centers, OR 1.48, 95% CI 1.06-2.08). Although facilities with the highest case volume had less delayed treatment (vs. lowest quartile, OR 0.35, 95% CI 0.23-0.52), centers with the highest RARP (OR 3.21, 95% CI 2.21-4.66) and IMRT volume (OR 1.45, 95% CI 1.15-1.83) had more frequent DT of high-risk prostate cancer patients. CONCLUSIONS: Black patients, underinsured men, and patients in the poorest census tracts were more likely to receive delayed treatment of high-risk prostate cancer, which may reflect impaired access to adequate cancer care. The unexpected finding of more delayed treatment at academic and high-volume RARP and IMRT centers may reflect barriers related to treatment capacity. Source of Funding: None
MP37-07 INDIVIDUAL PATIENT DATA ANALYSIS IN RANDOMIZED CLINICAL TRIALS: IMPACT OF RACE ON PROSTATE CANCER OUTCOMES Daniel Spratt*, Ann Arbor, MI; Yu-Wei Chen, Brandon Mahal, Boston, MA; Joseph Osborne, NYC, NY; Shuang Zhao, Todd Morgan, Ganesh Palapattu, Felix Feng, Ann Arbor, MI; Paul Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: Black men have a 2.5 fold higher mortality from prostate cancer compared to other racial ethnicities. However, it is unknown if this is due entirely from modifiable social disparities or tumor biology. Herein, we report the impact of black race on progression-free survival (PFS) and overall survival (OS) amongst men with prostate cancer enrolled on randomized controlled trials. METHODS: Individual patient data from six randomized controlled trials were used to calculate adjusted hazard ratios to
e499
compare black vs white race on PFS and OS. Subgroup analyses of metastatic castration resistant prostate cancer (mCRPC) trials were performed based on the control arm treatments (mitoxantrone or docetaxel), and disease state (localized or mCRPC). Relevant co-variates were used for adjustment in all analyses. RESULTS: A total of 3192 patients were included, of which 265 were black (8.3%). There were no significant differences between black and white men’s baseline characteristics in regards to age, performance status, or pre-treatment PSA. The pooled hazard ratio for black race for OS and PFS was 0.98 (95%CI 0.85-1.13) and 1.29 (95%CI 0.95-1.76), respectively. The median OS for black compared to white men treated with mitoxantrone was 254 days vs 238 days (p¼0.92), and for docetaxel was 581 days vs 546 days (p¼0.53). For men with localized prostate cancer, the median OS was 97% for both black and white men (p¼0.32). CONCLUSIONS: In the context of randomized clinical trials where patients receive generally uniform treatment, a significant difference in OS for black men could not be detected in either localized or mCRPC. The confidence interval for PFS suggests the possibility of worse outcome for black men implicating either intrinsic biologic differences or uncorrected social disparities that warrant further investigation. Source of Funding: Prostate Cancer Foundation
MP37-08 MISATTRIBUTION ERRORS IN UROLOGIC PROCEDURES FROM THE PROPUBLICA SURGEON SCORECARD Young Suk Kwon*, Seonghyun Kang, Wei Wang, Nicholas Farber, Kushan Radadia, Paul Lee, Jongmyung Kim, Jeong Hee Hong, Isaac Kim, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: The ProPublica published a surgeon scorecard displaying adjusted complication rates of nearly 17000 surgeons in the United States after analyzing Medicare billing data of eight surgical procedures. While methodological issues are controversial and the accuracy of this online tool remains to be determined, a growing number of people rely on the information presented in this publically available database. We have examined the surgeon scorecard to evaluate its accuracy and consistency with respect to urologists and urologic procedures. METHODS: Data from 2009 through 2013 were queried from the ProPublica surgeon scorecard (https://projects.propublica.org/ surgeons). The surgeons were categorized into two groups based on the number of performed cases (# of case 20 vs. <20) as presented in the scorecard. The specialties of providers who performed prostatectomy in the scorecard were verified using affiliated hospital homepage, Healthgrades (http://www.healthgrades.com), and Vitals (http://www.vitals.com). Any identified non-urologists were confirmed using at least two different sources. Similarly, all surgical procedures performed by the list of urologists provided by the scorecard were reviewed. RESULTS: The total number of providers performing prostatectomy was 3040, including 972 who performed 20 cases, 2072 who performed <20 cases, and 4 providers who were erroneously counted twice in both categories. No errors were found for surgeons who performed 20 cases. However, for providers who performed <20 cases, 79 providers out of 2072 (3.81%) were non-urologists who performed prostatectomy while 38 out of 2702 (1.83%) were urologists performing non-urologic procedures based on the surgeon scorecard (table 1). CONCLUSIONS: While convenient and easily accessible, ProPublica surgeon scorecard contains some misattribution errors that may inevitably compromise overall reliability of the data. While the database is updated periodically, it is advisable for the public to take caution when interpreting data and selecting surgeons based on the ProPublica surgeon scorecard.
THE JOURNAL OF UROLOGYâ
e500
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
Internet searching often leads to poor estimates of survival, but nomograms can aid people in estimating survival rates. Clinicians should consider guiding patients to appropriate online health resources so that patients can obtain more accurate information and make informed decisions. Source of Funding: None
MP37-10 ADHESIVE BOWEL OBSTRUCTION FOLLOWING UROLOGIC SURGERY: IMPROVED OUTCOMES WITH EARLY INTERVENTION Arpeet Shah*, Robert Blackwell, Anai Kothari, Marcus Quek, Fred Luchette, Robert Flanigan, Paul Kuo, Gopa Gupta, Maywood, IL
Source of Funding: none
MP37-09 ABILITY OF THE GENERAL PUBLIC TO ACCURATELY ESTIMATE SURVIVAL RATES FOR GENITOURINARY CANCER USING UNRESTRICTED INTERNET SEARCHES AND ONLINE NOMOGRAMS. Lee Baumgarten, BS*, Philadelphia, PA; Lucas Labine, BS, Colby Dixon, MD, Isaac Palma, BS, Christopher Weight, MD, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Accurately communicating risk is an integral part of effective cancer care and decisionmaking. In the past, patients have relied almost exclusively on physicians for cancer information, but research suggests that most adults use online resources as the first source of health information. We evaluated whether US adults can properly estimate survival for hypothetical genitourinary cancer patients using unrestricted Internet searching, followed by using a nomogram, the gold standard of predicting cancer prognosis. METHODS: Adults over 18 years old were recruited at the Minnesota State Fair to complete a survey. Participants were randomly selected to see a pathology report from either a kidney (n¼114) or prostatectomy (n¼129) cancer specimen. Using the report, participants were first asked to estimate the percent chance that the patient would be alive in 10 or 15 years respectively by unrestricted Internet searching. Afterwards, they were asked to re-estimate this value by using a freely available, validated, kidney or prostate cancer nomogram. Participants’ answers were then compared to the true estimate (i.e. proper use of the nomogram) as well as a ‘ballpark estimate’ +/- 10 percentage points of the true estimate. RESULTS: Of the 270 participants who took the survey, 243 (90%) correctly completed both questions and met inclusion criteria. Participants were 69% female (n¼167), and educated, with 90% (n¼119) earning a bachelor’s degree or higher and were on average 47 years (SD 15.6). Based on unrestricted Internet searching, only 33% (95% CI 28-39) of adults were in the ‘ballpark’. When using the nomogram only 14% (95% CI 11%-19%) of participants used it properly, but nearly half were in the ‘ballpark’, (44%, 95% CI 38%-51%). CONCLUSIONS: Even in amongst a highly educated population, estimates of cancer specific survival for genitourinary cancer patients using unrestricted Internet searching are quite inaccurate. When using a validated online nomogram, most participants were unable to use the tool correctly, but estimates using the nomogram were closer to the true estimate than Internet search only. These findings suggest that unrestricted
INTRODUCTION AND OBJECTIVES: Early surgical management for adhesive bowel obstruction is recommended in the general surgery literature. We describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (years 2006-2011) were used to identify radical cystectomy, radical prostatectomy, and kidney surgery (radical/partial nephrectomy, nephroureterectomy) patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, UTI, DVT, pneumonia), major complications (MI, PE, sepsis), death, and postoperative length-of-stay were assessed. RESULTS: Major urologic surgery was performed on 104,400 patients, and the subsequent 5-year cumulative incidence of adhesive bowel obstruction admission was 12.4% following cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. On adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18% vs 30%, p¼0.001), major complications (10% vs 19%, p¼0.002), and median postoperative length of stay (8 vs 11 days, p<0.001). On multivariate analysis early surgery decreased the odds of minor/moderate complications by 43% (p¼0.01), major complications by 45% (p¼0.03), and postoperative length of stay by 3.1 days (p¼0.01). CONCLUSIONS: Adhesive bowel obstruction is a significant long-term sequela of urologic surgery. Early surgical management of adhesive bowel obstruction is associated with improved perioperative outcomes.
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
MP37-06 DELAYED TREATMENT OF HIGH-RISK PROSTATE CANCER PATIENTS: IMPACT OF SOCIOECONOMIC BARRIERS AND USE OF ADVANCED TECHNOLOGIES R. Steven Gerhard*, Datta Patil, Yuan Liu, Kenneth Ogan, Mehrdad Alemozaffar, Ashesh Jani, Omer Kucuk, Viraj Master, Theresa Gillespie, Christopher Filson, Atlanta, GA INTRODUCTION AND OBJECTIVES: Though attention has been given to overtreatment of indolent prostate cancer, there has been less focus on potential undertreatment of men with high-risk tumors. To that end, we sought to characterize factors related to delayed or lack of treatment (DT) of high-risk prostate cancer patients, and to assess the impact on case volume and use of advanced technology on this outcome. METHODS: We identified patients with high-risk (i.e., Gleason 8+, PSA>20, cT3) localized (i.e., T1-3Nx-0Mx-0) prostate cancer in the National Cancer Database (2010-2012). Primary outcome was DT (i.e., no treatment within 6 months post-diagnosis). Exposures of interest were facility-level case volume (based on number of positive biopsies), robotic-assisted radical prostatectomy (RARP) volume, and intensitymodulated radiation therapy (IMRT) volume. Multivariable regression models, adjusted for clustering at the facility-level, estimated the association between facility volume factors (arranged in quartiles) and receipt of DT. The model adjusted for patient age, comorbidity, type of cancer center (academic vs comprehensive community vs community), and diagnosis year. Statistical tests were 2-sided and significant if p<0.05. RESULTS: Among 63439 prostate cancer patients with highrisk localized prostate tumors, 3690 (5.8%) received DT. Black patients (9.7% vs 4.9% White, OR 1.67, 95% CI 1.50-1.86), men with Medicaid or no insurance (12.6% vs 5% Private/HMO, OR 1.48, 95% CI 1.251.76), and those in the poorest census tracts (7.7% < $38,000 vs 5.2% $63,000+, OR 1.17, 95%CI: 1.02-1.34) were more likely to receive DT. Patients diagnosed at academic centers were more likely to receive DT (7.7% vs 5.7% community cancer centers, OR 1.48, 95% CI 1.06-2.08). Although facilities with the highest case volume had less delayed treatment (vs. lowest quartile, OR 0.35, 95% CI 0.23-0.52), centers with the highest RARP (OR 3.21, 95% CI 2.21-4.66) and IMRT volume (OR 1.45, 95% CI 1.15-1.83) had more frequent DT of high-risk prostate cancer patients. CONCLUSIONS: Black patients, underinsured men, and patients in the poorest census tracts were more likely to receive delayed treatment of high-risk prostate cancer, which may reflect impaired access to adequate cancer care. The unexpected finding of more delayed treatment at academic and high-volume RARP and IMRT centers may reflect barriers related to treatment capacity. Source of Funding: None
MP37-07 INDIVIDUAL PATIENT DATA ANALYSIS IN RANDOMIZED CLINICAL TRIALS: IMPACT OF RACE ON PROSTATE CANCER OUTCOMES Daniel Spratt*, Ann Arbor, MI; Yu-Wei Chen, Brandon Mahal, Boston, MA; Joseph Osborne, NYC, NY; Shuang Zhao, Todd Morgan, Ganesh Palapattu, Felix Feng, Ann Arbor, MI; Paul Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: Black men have a 2.5 fold higher mortality from prostate cancer compared to other racial ethnicities. However, it is unknown if this is due entirely from modifiable social disparities or tumor biology. Herein, we report the impact of black race on progression-free survival (PFS) and overall survival (OS) amongst men with prostate cancer enrolled on randomized controlled trials. METHODS: Individual patient data from six randomized controlled trials were used to calculate adjusted hazard ratios to
e499
compare black vs white race on PFS and OS. Subgroup analyses of metastatic castration resistant prostate cancer (mCRPC) trials were performed based on the control arm treatments (mitoxantrone or docetaxel), and disease state (localized or mCRPC). Relevant co-variates were used for adjustment in all analyses. RESULTS: A total of 3192 patients were included, of which 265 were black (8.3%). There were no significant differences between black and white men’s baseline characteristics in regards to age, performance status, or pre-treatment PSA. The pooled hazard ratio for black race for OS and PFS was 0.98 (95%CI 0.85-1.13) and 1.29 (95%CI 0.95-1.76), respectively. The median OS for black compared to white men treated with mitoxantrone was 254 days vs 238 days (p¼0.92), and for docetaxel was 581 days vs 546 days (p¼0.53). For men with localized prostate cancer, the median OS was 97% for both black and white men (p¼0.32). CONCLUSIONS: In the context of randomized clinical trials where patients receive generally uniform treatment, a significant difference in OS for black men could not be detected in either localized or mCRPC. The confidence interval for PFS suggests the possibility of worse outcome for black men implicating either intrinsic biologic differences or uncorrected social disparities that warrant further investigation. Source of Funding: Prostate Cancer Foundation
MP37-08 MISATTRIBUTION ERRORS IN UROLOGIC PROCEDURES FROM THE PROPUBLICA SURGEON SCORECARD Young Suk Kwon*, Seonghyun Kang, Wei Wang, Nicholas Farber, Kushan Radadia, Paul Lee, Jongmyung Kim, Jeong Hee Hong, Isaac Kim, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: The ProPublica published a surgeon scorecard displaying adjusted complication rates of nearly 17000 surgeons in the United States after analyzing Medicare billing data of eight surgical procedures. While methodological issues are controversial and the accuracy of this online tool remains to be determined, a growing number of people rely on the information presented in this publically available database. We have examined the surgeon scorecard to evaluate its accuracy and consistency with respect to urologists and urologic procedures. METHODS: Data from 2009 through 2013 were queried from the ProPublica surgeon scorecard (https://projects.propublica.org/ surgeons). The surgeons were categorized into two groups based on the number of performed cases (# of case 20 vs. <20) as presented in the scorecard. The specialties of providers who performed prostatectomy in the scorecard were verified using affiliated hospital homepage, Healthgrades (http://www.healthgrades.com), and Vitals (http://www.vitals.com). Any identified non-urologists were confirmed using at least two different sources. Similarly, all surgical procedures performed by the list of urologists provided by the scorecard were reviewed. RESULTS: The total number of providers performing prostatectomy was 3040, including 972 who performed 20 cases, 2072 who performed <20 cases, and 4 providers who were erroneously counted twice in both categories. No errors were found for surgeons who performed 20 cases. However, for providers who performed <20 cases, 79 providers out of 2072 (3.81%) were non-urologists who performed prostatectomy while 38 out of 2702 (1.83%) were urologists performing non-urologic procedures based on the surgeon scorecard (table 1). CONCLUSIONS: While convenient and easily accessible, ProPublica surgeon scorecard contains some misattribution errors that may inevitably compromise overall reliability of the data. While the database is updated periodically, it is advisable for the public to take caution when interpreting data and selecting surgeons based on the ProPublica surgeon scorecard.
THE JOURNAL OF UROLOGYâ
e500
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
Internet searching often leads to poor estimates of survival, but nomograms can aid people in estimating survival rates. Clinicians should consider guiding patients to appropriate online health resources so that patients can obtain more accurate information and make informed decisions. Source of Funding: None
MP37-10 ADHESIVE BOWEL OBSTRUCTION FOLLOWING UROLOGIC SURGERY: IMPROVED OUTCOMES WITH EARLY INTERVENTION Arpeet Shah*, Robert Blackwell, Anai Kothari, Marcus Quek, Fred Luchette, Robert Flanigan, Paul Kuo, Gopa Gupta, Maywood, IL
Source of Funding: none
MP37-09 ABILITY OF THE GENERAL PUBLIC TO ACCURATELY ESTIMATE SURVIVAL RATES FOR GENITOURINARY CANCER USING UNRESTRICTED INTERNET SEARCHES AND ONLINE NOMOGRAMS. Lee Baumgarten, BS*, Philadelphia, PA; Lucas Labine, BS, Colby Dixon, MD, Isaac Palma, BS, Christopher Weight, MD, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Accurately communicating risk is an integral part of effective cancer care and decisionmaking. In the past, patients have relied almost exclusively on physicians for cancer information, but research suggests that most adults use online resources as the first source of health information. We evaluated whether US adults can properly estimate survival for hypothetical genitourinary cancer patients using unrestricted Internet searching, followed by using a nomogram, the gold standard of predicting cancer prognosis. METHODS: Adults over 18 years old were recruited at the Minnesota State Fair to complete a survey. Participants were randomly selected to see a pathology report from either a kidney (n¼114) or prostatectomy (n¼129) cancer specimen. Using the report, participants were first asked to estimate the percent chance that the patient would be alive in 10 or 15 years respectively by unrestricted Internet searching. Afterwards, they were asked to re-estimate this value by using a freely available, validated, kidney or prostate cancer nomogram. Participants’ answers were then compared to the true estimate (i.e. proper use of the nomogram) as well as a ‘ballpark estimate’ +/- 10 percentage points of the true estimate. RESULTS: Of the 270 participants who took the survey, 243 (90%) correctly completed both questions and met inclusion criteria. Participants were 69% female (n¼167), and educated, with 90% (n¼119) earning a bachelor’s degree or higher and were on average 47 years (SD 15.6). Based on unrestricted Internet searching, only 33% (95% CI 28-39) of adults were in the ‘ballpark’. When using the nomogram only 14% (95% CI 11%-19%) of participants used it properly, but nearly half were in the ‘ballpark’, (44%, 95% CI 38%-51%). CONCLUSIONS: Even in amongst a highly educated population, estimates of cancer specific survival for genitourinary cancer patients using unrestricted Internet searching are quite inaccurate. When using a validated online nomogram, most participants were unable to use the tool correctly, but estimates using the nomogram were closer to the true estimate than Internet search only. These findings suggest that unrestricted
INTRODUCTION AND OBJECTIVES: Early surgical management for adhesive bowel obstruction is recommended in the general surgery literature. We describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (years 2006-2011) were used to identify radical cystectomy, radical prostatectomy, and kidney surgery (radical/partial nephrectomy, nephroureterectomy) patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, UTI, DVT, pneumonia), major complications (MI, PE, sepsis), death, and postoperative length-of-stay were assessed. RESULTS: Major urologic surgery was performed on 104,400 patients, and the subsequent 5-year cumulative incidence of adhesive bowel obstruction admission was 12.4% following cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. On adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18% vs 30%, p¼0.001), major complications (10% vs 19%, p¼0.002), and median postoperative length of stay (8 vs 11 days, p<0.001). On multivariate analysis early surgery decreased the odds of minor/moderate complications by 43% (p¼0.01), major complications by 45% (p¼0.03), and postoperative length of stay by 3.1 days (p¼0.01). CONCLUSIONS: Adhesive bowel obstruction is a significant long-term sequela of urologic surgery. Early surgical management of adhesive bowel obstruction is associated with improved perioperative outcomes.