Cross Blue Shield Of Michigan Research Articles

Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative.

We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study.

To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. Multicenter quality improvement consortium. Fifty-one hospitals in Michigan. None. Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.

Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study

BackgroundVasopressors are traditionally administered via central access, but newer data suggest peripheral administration may be safe and avoid delays and complications associated with central line placement. Research questionHow commonly are vasopressors initiated through peripheral IVs in routine practice? Is vasopressor initiation route associated with in-hospital mortality? Study design and methodsThis retrospective cohort study included adults hospitalized with sepsis (11/2020-9/2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. Results594 patients received vasopressors within 6 hours of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594, 67.3%). Patients with peripheral vs central initiation were similar; body mass index was the only patient factor independently associated with initiation route (aOR of peripheral initiation [per 1 kg/m2 increase]: 0.98, 95%CI: 0.97-1.00, p=0.015). Hospital had a large impact on initiation route (median OR: 2.19, 95%CI: 1.31-3.07). Compared to central, peripheral initiation was faster (median 2.5 vs 2.7 hours from hospital arrival, p=0.002) but associated with less initial norepinephrine use (84.3% vs 96.8%, p=0.001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%, aOR 0.66, 95%CI: 0.39-1.12). There was no documented tissue injury from peripheral vasopressors. Of patients with peripheral initiation, 135/400 (33.8%) never had a central line placed. InterpretationPeripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, there was wide practice variation not explained by patient case-mix and lower use of first-line norepinephrine with peripheral administration, suggesting additional standardization may be needed.

Lessons learned from the EACTS-MSTCVS quality fellowship: a call to action for continuous improvement of cardiothoracic surgery outcomes in Europe.

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings annually. It actively engages cardiac and general thoracic surgeons, data managers and researchers from all 32 non-federally funded cardiothoracic surgery sites across Michigan. Broadening its influence on joint learning and clinical outcomes, the MSTCVS-QC formed a strategic partnership with Blue Cross Blue Shield of Michigan, the state's largest private insurer, to further promote its initiatives. The MSTCVS-QC, operating from a dedicated QC centre employs an STS-associated database with additional aspects for data collection and analysis. The QC centre also organizes audits, facilitates collaborative meetings, disseminates surgical outcomes and champions the development and implementation of quality improvement initiatives related to cardiothoracic surgery in Michigan. Recognizing the MSTCVS-QC's successful efforts in advancing quality improvement, the European Association for Cardiothoracic Surgery (EACTS) introduced a fellowship program in 2018, facilitated through the EACTS Francis Fontan Fund (FFF). This program allows early-career academic physicians to spend 4-6 months with the MSTCVS-QC team in Ann Arbor. This article chronicles the evolution and functionality of the MSTCVS-QC, enriched by the experiences of the inaugural 4 EACTS/FFF fellows. Our objective is to emphasize the critical importance of fostering a culture of quality improvement and patient safety in the field of cardiothoracic surgery with open discussion of audited, high-quality data points. This principle, while implemented locally, has implications and value extending far beyond Europe, resonating globally.

1039-P: Examining Physician Case Studies on Success of Treatment Initiation in Patients with Type 2 Diabetes

Introduction: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a state-wide quality initiative supported by Blue Cross Blue Shield of Michigan that aims to improve the treatment of diabetes through three initiatives-encouraging increased prescribing of continuous glucose monitoring (CGM), SGLT2i/GLP-1RA medications, and low carbohydrate diet (LCD), defined as 80-130 total grams of carbohydrates per day, with patients on an SGLT2i instructed to stay &amp;gt;100g among 264 primary care practices. The aim of this study was to evaluate physician experience prescribing LCD through case studies. Methods: Each physician participating in MCT2D submitted a case study evaluating their experience implementing MCT2D initiatives. Close-ended questions were assessed using a 4-point scale (Yes, Somewhat, Too Early to Tell, No). Open-ended responses on intervention success were analyzed using a multi-step process of data immersion, generating initial codes, and reorganization. Results: Physicians prescribed a LCD either alone or in combination with CGM and/or SGLT2i/GLP-1RA in 375 of 970 case studies. More than half (51.5%) reported that the intervention(s) achieved the target outcome. Case studies incorporating all three interventions were associated with greater physician satisfaction with results, as compared to diet alone (p&amp;lt;0.01). Five major themes regarding intervention effectiveness were: glycemic control, weight loss, patient motivation, simplification of medications, and combined benefit of multiple interventions. Improvement of blood glucose was reported in 45.9% of LCD alone cases and in 69.1% of cases that involved all three interventions. An increase in patient motivation to achieve improvement in health was most frequently discussed in cases where diet and CGM were combined (67.3%). Conclusion: LCD may have a synergistic effect with the use of CGM and newer medications. These exploratory findings require confirmation through future investigations. Disclosure K.L.Khosrovaneh: None. H.L.Diez: None. C.R.Richardson: Other Relationship; Annals of Family Medicine, JMIR Diabetes, Research Support; Dexcom, Inc., Blue Cross Blue Shield of Michigan, Neilson Foundation. L.Oshman: Stock/Shareholder; Abbott, AbbVie Inc., Merck &amp; Co., Inc., Procter &amp; Gamble, Johnson &amp; Johnson, Eli Lilly and Company. N.Kim: None. J.Rau: None. J.Reiss: None. R.Hisamatsu: None. D.H.Griauzde: None. L.A.Young: None. J.Weisensel: None. J.E.Aikens: None.

1015-P: Impact of Social Vulnerability on Resources for CGM Initiation across Michigan Primary Care Practices

Objective: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a state-wide quality initiative supported by Blue Cross Blue Shield of Michigan. MCT2D aims to improve type 2 diabetes care by encouraging prescribing of continuous glucose monitoring (CGM), SGLT2i/GLP-1RA medications, and low carbohydrate diets. The study’s purpose was to describe clinic-level resources and barriers to CGM initiation in counties with high and low social vulnerabilities. Methods: We surveyed primary care practice providers about practice-level CGM patient education and barriers, and providers’ understanding of insurance coverage. 169 of 264 practices (64%) completed the survey. We classified practices as high vulnerability (HV; quartile 4), or low vulnerability (LV; quartiles 1-3) using the county-level CDC Social Vulnerability Index. Results: Among HV practices, the main CGM education was prescriber instruction (61.5%), while for LV it was printed material (69.8%). For both HV and LV practices the second most common educational resource was web links (53.9% and 51.6%, respectively). For both practice types, the most common barrier to CGM was patients’ lack of smartphone (60.5%, 62.4%, respectively), followed by patients’ lack of internet (55.3%) for HV practices and patients’ ability to use CGM (38.5%) for LV practices. Provider understanding of Michigan Medicaid CGM coverage policy was similar across practices with most reporting incorrectly that it was akin to Medicare (≥3 injections daily) (35.3% (HV) and 44.0% (LV)) or reporting lack of awareness of coverage (32.4% (HV) and 24.1% (LV)). Conclusions: There is a mismatch between practices’ educational approaches and patients’ access to technology. Improved transparency of CGM coverage criteria would enhance provider understanding and promote equitable access for patients. Limitations include that the data is county-level and further analysis evaluating other practice level social determinants of health is needed. Disclosure K.L.Khosrovaneh: None. R.Busui: Board Member; American Diabetes Association, Consultant; Averitas Pharma, Inc., Lexicon Pharmaceuticals, Inc., Nevro Corp., Novo Nordisk, Roche Diagnostics, Procter &amp; Gamble, Research Support; Novo Nordisk, Medtronic, National Institutes of Health. C.D.Jamison: None. C.R.Richardson: Other Relationship; Annals of Family Medicine, JMIR Diabetes, Research Support; Dexcom, Inc., Blue Cross Blue Shield of Michigan, Neilson Foundation. H.L.Diez: None. J.E.Aikens: None. L.Oshman: Stock/Shareholder; Abbott, AbbVie Inc., Merck &amp; Co., Inc., Procter &amp; Gamble, Johnson &amp; Johnson, Eli Lilly and Company. J.Rau: None. J.Reiss: None. L.A.Young: None. J.Weisensel: None. P.Okeke: None. K.R.Mizokami-stout: None.

1691-P: Weight Status, Longitudinal Weight Change, and Weight Loss Treatment Utilization among Primary Care Patients with Obesity

Background: Effective weight management treatments (WMTs) include nutrition counseling, very low-calorie (VLC) meal replacement, anti-obesity medications (AOMs), and bariatric surgery. Little is known about how these WMTs influence weight change among individual primary care patients and populations. Methods: This was a retrospective cohort study using medical record data from one academic health system. Participants were adults with primary care between October 2015 and March 2020. We used serial cross-sections to examine obesity prevalence and WMT use. We used a multistate model to investigate weight trajectories for patients with obesity and no WMT use prior to baseline. This is a time-to-event model with events representing transitions between 5 successive categories of weight change relative to baseline (i.e., ≥10% weight loss, 5-10% weight loss, baseline weight +/-5%, 5-10% weight gain, or ≥10% weight gain). The primary exposures were WMTs; controls were baseline age, BMI, and prior year primary care. Patients with WMT use were propensity matched 1:1 to controls. The primary outcome was the model-based probability of ≥5% weight loss at 1 year. Results: Among primary patients, the prevalence of obesity increased from 39.2% in 2017 to 40.7% in 2019 (n=138,632); WMT use increased from 2.8% to 8.9% (difference: 6.1%, 95% CI: 5.8-6.4%). In the multistate model (n=10,296), the one-year probability of ≥5% weight loss among patients without WMT exposure was 15.5% [95% CI: 14.8-16.1%]. In contrast, ≥5% weight loss was more likely for patients with year-long exposures to any WMT (nutrition counseling: 23.4%, 95% CI: 21.5-25.3%; VLC meal replacement: 56.4%, 95% CI: 48.7-62.8%; AOMs: 27.8%, 95% CI: 25.1-30.5%; bariatric surgery: 94.4%, 95% CI: 91.1-96.4%). Conclusions: Use of all WMTs increased the probability of achieving ≥5% weight loss at the individual-patient level but underutilization limits their ability to reduce weight at the population-level. Disclosure D.H.Griauzde: None. C.R.Richardson: Other Relationship; Annals of Family Medicine, JMIR Diabetes, Research Support; Dexcom, Inc., Blue Cross Blue Shield of Michigan, Neilson Foundation. J.M.Lee: Advisory Panel; GoodRx, Consultant; Tandem Diabetes Care, Inc. J.Henderson: None. A.P.Ehlers: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK123416)

Anticipating the End of Medicaid Continuous Enrollment and the Ramifications for Surgical Care.

*University of Michigan Medical School, Ann Arbor, Michigan †Department of Surgery, Michigan Medicine, Ann Arbor, Michigan ‡Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan Conflicts of Interest and Source of Funding: Luca Borah reported short-term funding from the National Institutes of Health. Victor Agbafe reported consulting payments for his fellowship with Third Culture Capital. Unrelated to the current work, Dr. Scott reported receiving funding from the Agency for Healthcare Research and Quality as principal investigator on grant K08-HS028672 and co-investigator on grant R01-HS027788 and reported receiving salary support from Blue Cross Blue Shield of Michigan through the initiative known as Michigan Social Health Interventions to Eliminate Disparities. No other disclosures were reported. [email protected]

MP80-10 MANAGEMENT OF BIOCHEMICAL RECURRENCE AFTER PROSTATECTOMY WITHIN THE MUSIC COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023MP80-10 MANAGEMENT OF BIOCHEMICAL RECURRENCE AFTER PROSTATECTOMY WITHIN THE MUSIC COLLABORATIVE David Gandham, Ji Qi, Stephanie Ferrante, Kevin Ginsburg, Brian Lane, Todd Morgan, Daniel Triner, Conrad Tobert, and Alice Semerjian David GandhamDavid Gandham More articles by this author , Ji QiJi Qi More articles by this author , Stephanie FerranteStephanie Ferrante More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Brian LaneBrian Lane More articles by this author , Todd MorganTodd Morgan More articles by this author , Daniel TrinerDaniel Triner More articles by this author , Conrad TobertConrad Tobert More articles by this author , and Alice SemerjianAlice Semerjian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although many men remain disease free following radical prostatectomy (RP), some men will develop biochemical recurrence (BCR). Treating (BCR) is challenging as various patient and cancer factors, balancing the oncological benefit, and potential morbidity of treatment must be considered. Herein, we evaluated the use of salvage therapy in men with BCR in diverse, real-world practices. METHODS: The MUSIC registry was queried for men undergoing RP between 3/2012 and 12/2021. Patients were included if they had an initial undetectable post-op PSA (<0.1) and then experienced BCR with PSA >=0.2. Time to salvage treatment after BCR and probability of undergoing treatment were estimated using the Kaplan-Meier method. Type of salvage therapy was summarized based on PSA value at time of treatment (0.1-0.19, 0.2-0.5, 0.51-1.0, and >1.0). Practice-level variation on time to salvage treatment was also assessed among those with at least ten patients. RESULTS: Of 17,755 patients who underwent RP in MUSIC, 2280 patients experienced BCR. Median time to BCR since RP was 9.0 months (IQR 1.7-23.8). Median length of follow up since BCR was 19.5 months (IQR 6.5-37.2). Probability of undergoing treatment sharply increased in the first 12 months following BCR, with 44% of patients getting treatment at 6 months, 52% at 12 months, and 61% at 24 months post-BCR (Figure 1). Among men receiving a salvage treatment, PSA before initiation of salvage therapy was 0.1-0.19 in 2.3% of patients, 0.2-0.5 in 58%, 0.51-1.0 in 15%, and >1.0 in 25%. Patients with higher PSA were more likely to receive systemic therapy (p<0.001). Significant practice-level variation was observed on time to salvage treatment after BCR, with the percent of patients undergoing treatment at 6 months ranging from 20% to 70% among 24 practices (p<0.001). CONCLUSIONS: The time from BCR and the PSA threshold used to trigger salvage treatment in men with BCR varies widely in MUSIC. This data may inform future quality improvement efforts aiming to decrease the variation in the PSA threshold used to initiate salvage therapy and the type of salvage therapy administered to men with BCR. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1155 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Gandham More articles by this author Ji Qi More articles by this author Stephanie Ferrante More articles by this author Kevin Ginsburg More articles by this author Brian Lane More articles by this author Todd Morgan More articles by this author Daniel Triner More articles by this author Conrad Tobert More articles by this author Alice Semerjian More articles by this author Expand All Advertisement PDF downloadLoading ...

MP54-07 STENTS AND SHOCKWAVE LITHOTRIPSY - THE WHO AND THE WHY: RESULTS FROM A STATEWIDE COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023MP54-07 STENTS AND SHOCKWAVE LITHOTRIPSY - THE WHO AND THE WHY: RESULTS FROM A STATEWIDE COLLABORATIVE Sami E. Majdalany, Monica van Til, Stephanie Daignault-Newton, David Leavitt, Khurshid Ghani, Casey Dauw, Naveen Kachroo, and Michigan Urological Surgery Improvement Collaborative Sami E. MajdalanySami E. Majdalany More articles by this author , Monica van TilMonica van Til More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , David LeavittDavid Leavitt More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Casey DauwCasey Dauw More articles by this author , Naveen KachrooNaveen Kachroo More articles by this author , and Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Shockwave lithotripsy (SWL) is a commonly performed stone procedure in the US. AUA guidelines do not recommend routine stent placement for SWL patients. We evaluated statewide practice patterns and predictors for stent placement at the time of SWL and whether stent placement affected stone free rates (SFR) and 30-day complication rates. METHODS: Adult patients undergoing SWL between 2016-2022 were identified using the MUSIC Reducing Operative Complications from Kidney Stones prospectively collected registry. We determined stent usage prior and during SWL across practices and collected demographic, clinical, stone and procedural factors. Outcomes included peri-operative management, complications and SFR. Multivariable logistic regression was used to identify predictors of stent placement at time of SWL. RESULTS: Among 13,063 cases identified from 35 practices (222 urologists), wide practice variation in stent placement patterns were noted ranging from 0-17% (Figure 1). Overall, 2.3% cases were stented at the time of SWL and 15.5% had a prior stent. Stent on a string was performed in 26 cases (9%) by 11 urologists (54% by 1 provider). Stented SWL patients (prior/time of SWL) were more likely to be older, have a higher Charlson comorbidity index, solitary kidney, 1st upper tract stone, ureteral stone, larger stone, hydronephrosis and positive urinalysis/urine culture (all p<0.01). Stented patients were more likely to have peri-op and post-op antibiotics and anticholinergics (p<0.001). Predictors of stent placement at time of SWL included ureteral stones (OR1.6, 95%CI 1.1-2.3, p=0.01), larger stones (OR1.2, 95%CI 1.216-1.23, p<0.001), African-American race (OR1.8, 95%CI 1.03-3.0, p=0.039) and hydronephrosis (OR1.8, 95%CI 1.3-2.6, p<0.001). There were no differences in emergency department (ED) visits between stented and unstented patients (5.3% vs 3.9%, p=0.21) or 60-day SFR (34% vs 40%, p=0.10). Stented patients had significantly higher infectious complications (3% vs 0.6%, p<0.001). CONCLUSIONS: Variation exists amongst urologists regarding stent usage with SWL, influenced by specific patient and stone factors as well as provider preference. Although ED visits and SFR did not differ, stented patients had a significantly increased post operative infection rate. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e756 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sami E. Majdalany More articles by this author Monica van Til More articles by this author Stephanie Daignault-Newton More articles by this author David Leavitt More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author Naveen Kachroo More articles by this author Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

PD40-03 PRACTICE AND SURGEON-LEVEL VARIATION IN THE SURGICAL MANAGEMENT OF T1A RENAL MASSES: RESULTS FROM A STATEWIDE COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023PD40-03 PRACTICE AND SURGEON-LEVEL VARIATION IN THE SURGICAL MANAGEMENT OF T1A RENAL MASSES: RESULTS FROM A STATEWIDE COLLABORATIVE Samantha Wilder, Mahmoud Hijazi, Ananya Vittal, Ji Qi, Mahin Mirza, Mohammad Jafri, Brian Lane, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Samantha WilderSamantha Wilder More articles by this author , Mahmoud HijaziMahmoud Hijazi More articles by this author , Ananya VittalAnanya Vittal More articles by this author , Ji QiJi Qi More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Mohammad JafriMohammad Jafri More articles by this author , Brian LaneBrian Lane More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003345.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current guidelines recommend prioritizing partial nephrectomy (PN) over radical nephrectomy (RN) in the management of cT1a renal masses (T1aRM). We examined variation in PN use for surgically treated T1aRM and identified factors associated with PN use in the MUSIC-KIDNEY collaborative. METHODS: All patients in the MUSIC-KIDNEY registry undergoing surgery for T1aRM between 5/2017 and 5/2022 were included. Practice- and surgeon-level variation in use of PN (vs RN) were evaluated among those who treated at least 5 patients surgically. Multivariable mixed-effects logistic regression model was performed to identify factors associated with PN use. Rates of prolonged hospitalization (>3 days for minimally invasive, >5 days for open), 30-day emergency department (ED) visits, and 30-day readmissions were compared between patients undergoing PN and RN, using Chi-squared test or Fisher’s exact test. RESULTS: 1014 surgically treated T1aRM patients from 14 practices and 68 surgeons were included. Among these, 843 (83%) underwent PN and 171 (17%) underwent RN. Rates of utilization of PN ranged from 50-93% across practices and 38-100% across surgeons (Figure 1). Low patient comorbidity, preoperative GFR>60, and low nephrometry score (RENL 4-6) were associated with increased use of PN (p<0.05). Postoperative ED visit rates were low for both RN and PN (3.5% vs 2.6%) and did not differ significantly (p>0.05). RN was associated with higher rates of prolonged hospitalization (19% vs 7.7%, p<0.05) and readmission (5.9% vs 2.9%, p<0.05). CONCLUSIONS: Over 80% of surgically treated T1aRM underwent PN in MUSIC-KIDNEY with variation across practices and surgeons. Association of high preoperative GFR with PN may be related to the high rates of surveillance (>50%) for T1aRM in MUSIC-KIDNEY for masses that may have otherwise undergone PN. Higher rates of prolonged hospitalization and readmission for RN may be related to higher baseline comorbidity. Quality improvement initiatives within MUSIC-KIDNEY include a PN video library and live peer-to-peer review sessions with the goal of increasing surgeon comfort and skill in PN. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1052 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha Wilder More articles by this author Mahmoud Hijazi More articles by this author Ananya Vittal More articles by this author Ji Qi More articles by this author Mahin Mirza More articles by this author Mohammad Jafri More articles by this author Brian Lane More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

PD45-11 DOES THE USE OF A URETERAL ACCESS SHEATH REDUCE INFECTION-RELATED HOSPITALIZATION? REAL-WORLD DATA FROM A SURGICAL COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023PD45-11 DOES THE USE OF A URETERAL ACCESS SHEATH REDUCE INFECTION-RELATED HOSPITALIZATION? REAL-WORLD DATA FROM A SURGICAL COLLABORATIVE Russelle. N. Becker, Andrew M. Higgins, Golena Fernandez Moncaleano, Sung Yong Cho, Mohammad Jafri, Jessica Phelps, Jeremy Konheim, Bronson Conrado, Monica S. Van Til, Stephanie Daignault-Newton, Casey A. Dauw, Khurshid R. Ghani, and For The Michigan Urological Surgery IMPROVEMENT Collaborative Russelle. N. BeckerRusselle. N. Becker More articles by this author , Andrew M. HigginsAndrew M. Higgins More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Sung Yong ChoSung Yong Cho More articles by this author , Mohammad JafriMohammad Jafri More articles by this author , Jessica PhelpsJessica Phelps More articles by this author , Jeremy KonheimJeremy Konheim More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Monica S. Van TilMonica S. Van Til More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003358.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Elevated intrarenal pressure during ureteroscopy (URS) may result in pyelovenous backflow, which is hypothesized to increase the risk of sepsis. When treating renal stones, the ureteral access sheath (UAS) is considered a pressure mitigation strategy, yet evidence on whether a UAS reduces infectious complications is unclear. Prior studies are limited by small cohorts, heterogenous inclusion criteria, ambiguous endpoints, or lack adequate risk adjustment. We examined UAS use when treating renal stones and its association with infection-related hospitalization in a statewide registry. METHODS: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all patients undergoing single-stage unilateral URS for renal stones, with or without the use of a UAS. We assessed variation in UAS in practices with>10 cases. We evaluated demographic differences between cases with or without UAS. A multivariable logistic regression model was constructed to examine the impact of UAS use and other patient, stone, and surgical factors on 30-day infection-related hospitalization. RESULTS: Among 6,142 patients undergoing URS by 233 urologists across 34 practices, 152 (2.5%) had an infection-related hospitalization within 30 days. Patients with UAS had significantly larger stones, more positive preoperative urine culture, and higher comorbidity. Overall 59% of cases utilized UAS, with significant variation between practices (4.1% to 99.5%, p<0.0001; Figure). Infection-related hospitalization rates were no different for cases with (2.6%) vs. without (2.3%) UAS use (p=0.5). On multivariable analysis, infection-related hospitalizations did not differ by UAS (OR 0.8; 95% CI 0.6 - 1.2; p=0.4), but were associated with higher Charlson Comorbidity Index (CCI 1 vs. 0, OR 1.9; 95% CI 1.2 - 2.9; CCI 2+ vs. 0, OR 2.3; 95% CI 1.4 - 3.6; p<0.001), history of recurrent UTI (OR 2.4; 95% CI 1.4 - 4.0; p<0.01), larger stones (OR per 5mm 1.1; 95% CI 1.0 - 1.3; p=0.04), and positive preoperative urine culture (OR 1.8; 95% CI 1.2 - 2.7; p<0.01). CONCLUSIONS: Utilization of UAS when treating renal stones varies widely across practices within Michigan. UAS did not reduce infection-related hospitalization following URS for renal stones. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1167 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russelle. N. Becker More articles by this author Andrew M. Higgins More articles by this author Golena Fernandez Moncaleano More articles by this author Sung Yong Cho More articles by this author Mohammad Jafri More articles by this author Jessica Phelps More articles by this author Jeremy Konheim More articles by this author Bronson Conrado More articles by this author Monica S. Van Til More articles by this author Stephanie Daignault-Newton More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS Samantha Wilder, Ji Qi, Mahin Mirza, Adam Gadzinski, Thomas Maatman, Brian Lane, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Samantha WilderSamantha Wilder More articles by this author , Ji QiJi Qi More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Adam GadzinskiAdam Gadzinski More articles by this author , Thomas MaatmanThomas Maatman More articles by this author , Brian LaneBrian Lane More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003231.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The prescription of opioids following surgery has played a role in the current opioid epidemic, both by increasing the risk of persistent opioid use and through diversion of unused pills into the community. We evaluated practice-level variation in opioid prescribing following surgery for cT1 renal masses (T1RM) and examined the relationships between opioid-free discharge and postoperative emergency department (ED) visits and readmissions. METHODS: We retrospectively examined all T1RM patients with data regarding prescription of postoperative opioids within the MUSIC-KIDNEY registry from April 2021 to August 2022. Patients were stratified into those who received opioids at discharge and those who had opioid-free discharge, and associations with patient, tumor, and surgical factors were evaluated. Practice-level variation was assessed. Rates of postoperative ED visits and readmissions within 30 days were compared between cohorts. RESULTS: Of 248 patients who underwent surgery for T1RM across 11 practices in MUSIC-KIDNEY, 24.2% underwent opioid-free discharge. Practice level variation in rates of opioid-free discharge ranged from 0% to 72.7% (Figure 1). For patients prescribed opioids, the median number of pills was 12 (IQR 8-12). Patients prescribed opioids at discharge had a higher median BMI than those with opioid-free discharge (31.7 vs 28.7, p=0.003). Other patient comorbidities, tumor factors, surgical approach (minimally invasive vs. open), and surgery type (partial vs. radical nephrectomy) did not differ between cohorts (p>0.05). The opioid-free group had at least comparable rates of 30 day ED visits (0% vs. 3.2%) and readmission (1.7% vs. 5.3%), although this did not reach statistical significance (P>0.05). CONCLUSIONS: MUSIC-KIDNEY data suggests that opioid-free discharge is not associated with increased rates of postoperative ED visits or readmissions. There exists wide practice-level variation in the prescription of opioids following surgery for T1RM in the state of Michigan. Further investigation into additional factors driving this variation is warranted. There is potential to learn from practices that are safely limiting the number of pills entering the community, and future QI initiatives may focus on this metric. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e161 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha Wilder More articles by this author Ji Qi More articles by this author Mahin Mirza More articles by this author Adam Gadzinski More articles by this author Thomas Maatman More articles by this author Brian Lane More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP48-01 THE EFFECT OF OPIATES ON PATIENT REPORTED OUTCOMES AFTER URETEROSCOPY

You have accessJournal of UrologyCME1 Apr 2023MP48-01 THE EFFECT OF OPIATES ON PATIENT REPORTED OUTCOMES AFTER URETEROSCOPY Andrew Higgins, Russell Becker, Stephanie Daignault-Newton, Golena Fernandez Moncaleano, John Ludlow, Hector Pimentel, Brian Seifman, David Wenzler, Bronson Conrado, Karla Witzke, and Khurshid Ghani Casey Dauw Andrew HigginsAndrew Higgins More articles by this author , Russell BeckerRussell Becker More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , John LudlowJohn Ludlow More articles by this author , Hector PimentelHector Pimentel More articles by this author , Brian SeifmanBrian Seifman More articles by this author , David WenzlerDavid Wenzler More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Karla WitzkeKarla Witzke More articles by this author , and Khurshid Ghani Casey DauwKhurshid Ghani Casey Dauw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The outcomes of kidney stone surgery have long been focused on stone-free rates and safety, yet patient reported outcomes (PRO) are often lacking. In 2018 the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) group initiated a pain optimization pathway using an opioid-free multi-modal pain regimen. This has resulted in a decline in opioid prescription rates after ureteroscopy (86 to 19%). We used a comprehensive PRO system to understand the initiative’s impact on patients’ experiences of treatment pain and satisfaction. METHODS: MUSIC ROCKS instituted its patient-reported outcomes (PRO) program in 2020 which included an assessment of patient pain (PROMIS Pain Intensity short form and Pain Interference short form) and overall treatment satisfaction (ICIQ-S). This system is automated and distributes questionnaires preoperatively and at 7-10 days and 4-6 weeks following ureteroscopy (URS). We compared patients who were prescribed opiates after URS to those who were not. After adjusting for observed demographic differences (age, gender, pre-stent status, stone location/size, and preoperative pain), we evaluated PRO pain intensity and interference with linear mixed models. A clinically meaningful difference in PROMIS scores is 2.5-3.5 points. Treatment satisfaction scores were compared with Wilcoxon rank tests. RESULTS: A total of 292 patients completed all questionnaires (258 non-opioid and 34 opioid). There was no significant difference between non-opioid and opioid cohorts with regards to age (60 vs 59 years), gender (50 vs 53% male), pre-stenting status (76 vs 65%), stone location (64 vs 59% ureteral), and stone size (8.0 vs 7.2 mm). After adjustment, there was no significant difference in preoperative pain intensity scores between the groups at pre-URS (p=0.06), 7-10 days postop (p=0.87), and 4-6 weeks postop (p=0.99, Figure). Pain interference followed a similar pattern, with no significant differences observed at any timepoint. There was no difference in satisfaction scores, as measured both 7-10 days (p=0.46) and 4-6 weeks (p=0.47) after URS. CONCLUSIONS: Rates of opiate prescription have declined after URS in Michigan. Using a novel PRO system, we confirmed that utilization of opioid-free pathways has not resulted in increased pain nor decreased patient satisfaction. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e654 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Higgins More articles by this author Russell Becker More articles by this author Stephanie Daignault-Newton More articles by this author Golena Fernandez Moncaleano More articles by this author John Ludlow More articles by this author Hector Pimentel More articles by this author Brian Seifman More articles by this author David Wenzler More articles by this author Bronson Conrado More articles by this author Karla Witzke More articles by this author Khurshid Ghani Casey Dauw More articles by this author Expand All Advertisement PDF downloadLoading ...

MP55-10 LOWER RATES OF CLINICALLY-SIGNIFICANT PROSTATE CANCER ARE PRESENT IN PI-RADS 4 AND 5 LESIONS IN THE TRANSITIONAL ZONE THAN PERIPHERAL ZONE

You have accessJournal of UrologyCME1 Apr 2023MP55-10 LOWER RATES OF CLINICALLY-SIGNIFICANT PROSTATE CANCER ARE PRESENT IN PI-RADS 4 AND 5 LESIONS IN THE TRANSITIONAL ZONE THAN PERIPHERAL ZONE Jessica Shannon, Sabrina L. Noyes, Andrew Moriarity, Grand Rapids, Mi, Ji Qi, Bruce Lyu, Brian R Lane, and For the Michigan Urological Surgery Improvement Collaborative Jessica ShannonJessica Shannon More articles by this author , Sabrina L. NoyesSabrina L. Noyes More articles by this author , Andrew MoriarityAndrew Moriarity More articles by this author , Grand RapidsGrand Rapids More articles by this author , Mi Mi More articles by this author , Ji QiJi Qi More articles by this author , Bruce LyuBruce Lyu More articles by this author , Brian R LaneBrian R Lane More articles by this author , and For the Michigan Urological Surgery Improvement CollaborativeFor the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003308.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is limited data comparing prostate cancer (PC) detection rates in lesions identified within the peripheral zone (PZ) and transitional zone (TZ) on prostate MRI (pMRI). We compared the diagnostic performance of PIRADSv2 for detecting clinically significant (CS) PC in the PZ and TZ. METHODS: Data were queried from the Michigan Urological Surgery Improvement Collaborative (MUSIC) and Spectrum Health EMR to identify patients undergoing MRI assessed using PIRADS v2 by Advanced Radiology Services physicians between June 2016 and September 2022. All patients identified as having one or more PIRADS 4 or 5 lesions were included if they underwent targeted biopsy within 12 months of the MRI. The primary outcome was CSPC defined as GG2 or greater in biopsy of the targeted lesion. RESULTS: A total of 322 lesions in 224 patients were identified, with mean age 67 years, mean PSA 7.1 ng/ml, and mean prostate volume 63.4 cm3. Overall detection of PC was 75.2%, CSPC was 47.2%, and predominant pattern 4-5 (GG3-GG5) was 47.2%. 131 lesions were in the TZ and 191 in the PZ. CSPC was detected in 41.2% of TZ lesions and 51.3% of PZ lesions (p=0.075). CSPC detection was significantly higher for PI-RADS 4 lesions in the PZ compared to TZ (44.7% vs. 29.4%, p=0.034) and trended towards significance in PI-RADS 5 lesions (70.0% vs. 54.0%, p=0.0823). For GG3-GG5 PC, there was also a significant difference seen with PI-RADS 4 (8.8% vs. 20.6%, p=0.033) and a trend with PI-RADS 5 lesions (12.7% vs. 24.0%, p=0.117). CONCLUSIONS: Overall detection of PC was consistent with prior literature for PI-RADS 4 and 5 lesions. Lesions in the TZ were more likely to be benign or low-grade PC. This is important information for clinicians managing patients with TZ lesions and may suggest re-consideration of the precise features leading to PI-RADS assignments in the TZ in subsequent revisions. Source of Funding: The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided in part by the Spectrum Health Foundation. Funding was provided in part by the Value Partnerships program at Blue Cross Blue Shield of Michigan. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e767 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Shannon More articles by this author Sabrina L. Noyes More articles by this author Andrew Moriarity More articles by this author Grand Rapids More articles by this author Mi More articles by this author Ji Qi More articles by this author Bruce Lyu More articles by this author Brian R Lane More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP06-03 EXTERNAL VALIDATION OF DECREASED ED VISITS AFTER URETEROSCOPY DUE TO QUALITY IMPROVEMENT INITIATIVES OF A STATEWIDE COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023MP06-03 EXTERNAL VALIDATION OF DECREASED ED VISITS AFTER URETEROSCOPY DUE TO QUALITY IMPROVEMENT INITIATIVES OF A STATEWIDE COLLABORATIVE Andrew Higgins, Stephanie Daignault-Newton, Russell Becker, Golena Fernandez Moncaleano, Bronson Conrado, John Hollingsworth, Khurshid Ghani, and Casey Dauw Andrew HigginsAndrew Higgins More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Russell BeckerRussell Becker More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Bronson ConradoBronson Conrado More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , and Casey DauwCasey Dauw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Michigan Urological Surgery Improvement Collaborative Reducing Operative Complications from Kidney Stones (ROCKS) was created to optimize outcomes after ureteroscopy (URS). Through outcomes data collection, distribution of performance reports, patient educational efforts, and standardization of an opioid-free postoperative pain regimen, emergency department (ED) visits in Michigan have declined. It is unclear, whether this trend is unique to Michigan and thus a reflection of these quality efforts or is similar to national data. We thus sought to understand ED visit rates in Michigan compared to a large national dataset. METHODS: We used data from two sources for this study to understand 30-day ED visits after URS. In Michigan, the ROCKS database, a prospectively maintained registry including more than 90% of participating urologic practices in the state was utilized, capturing patients from 2016-2021. To serve as comparison, we used Optum claims data from 2011 to 2021 (excluding Michigan), which includes commercially insured adults and dependents. We identified patients who underwent URS defined by CPT codes and calculated the proportion who had an ED visit within 30 days of URS. Cohort age and gender were compared with rank and chi-square tests, respectively. ED rates were modeled (logistic) adjusting for age and gender to compare cohorts over time. RESULTS: Overall, we identified 24,163 patients in ROCKS who underwent URS and 162,642 patients in Optum. Significant differences were seen with regards to gender (51% vs 44% female, p<0.01) and median age (58 vs 62 years, p<0.01) between ROCKS and Optum cohorts. The mean ED rate in ROCKS was 7.9% (range 6.3 to 10.5%) with a significant decline over time (p<0.01, Figure 1). The ED rate in Optum was 9.9% (range 9.1 to 10.5%) with an increase over time (p<0.01). Comparing ED visits between the two cohorts after adjusting for observed demographic differences, the ROCKS ED visit rate declined significantly relative to national Optum rates (p<0.01). CONCLUSIONS: ED visit rates in Michigan have declined significantly after URS since establishment of the ROCKS initiative. This decline outpaces national ED rates, which have gradually increased over the past 10 years. This lends credence to systematic quality initiatives seeking to improve urologic care. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e53 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Higgins More articles by this author Stephanie Daignault-Newton More articles by this author Russell Becker More articles by this author Golena Fernandez Moncaleano More articles by this author Bronson Conrado More articles by this author John Hollingsworth More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author Expand All Advertisement PDF downloadLoading ...

MP61-07 EARLY SECONDARY TREATMENT OF LYMPH NODE POSITIVE PROSTATE CANCER AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH AGGRESSIVE TUMOR FEATURES AND DETECTABLE PROSTATE SPECIFIC ANTIGEN

You have accessJournal of UrologyCME1 Apr 2023MP61-07 EARLY SECONDARY TREATMENT OF LYMPH NODE POSITIVE PROSTATE CANCER AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH AGGRESSIVE TUMOR FEATURES AND DETECTABLE PROSTATE SPECIFIC ANTIGEN Daniel Triner, Ji Qi, Udit Singhal, Michael Sessine, Kevin Ginsburg, Brian Lane, and Todd Morgan Daniel TrinerDaniel Triner More articles by this author , Ji QiJi Qi More articles by this author , Udit SinghalUdit Singhal More articles by this author , Michael SessineMichael Sessine More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Brian LaneBrian Lane More articles by this author , and Todd MorganTodd Morgan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003319.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy (RP) and pelvic lymphadenectomy (PLND) are at high risk of disease recurrence and progression. There is ongoing debate with regards to optimal care of pN+patients. While data supports the use of adjuvant androgen deprivation therapy (ADT) with or without radiation (RT), most guidelines include observation as an alternative. We sought to understand contemporary practice patterns of patients with pN+prostate cancer (PCa) in a diverse, statewide quality collaborative. METHODS: Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with PCa who underwent RP with PLND and pN+on final pathology and 12 months follow up between March 2012 and Feb 2021 were identified. Patients who received neoadjuvant therapy were excluded. The primary outcome was early post-RP treatment (ADT, RT, ADT+RT) within 12 months of diagnosis, which was categorized as either adjuvant (PSA<0.1 ng/ml) or salvage (PSA≥0.1 ng/ml). Time to any post-RP treatment and type of treatment were secondary outcomes. Multivariable logistic and Cox regression models were fit to identify factors associated with post-RP treatment. Kaplan-Meier analysis was performed to assess treatment-free survival. RESULTS: We identified 425 patients who had pN+disease at the time of RP, of which 280 (66%) underwent early post-RP treatment (86 adjuvant and 194 salvage) and 145 (34%) were observed. One year treatment-free survival for patients with first post-RP PSA≥0.1 was 18% (95% CI 14%-24%) compared to 58% (95% CI 51%-65%) for PSA<0.1 ng/ml (p<0.001). In the multivariable Cox model, pathologic grade group, tumor stage, margin status, first post-RP PSA, and race were associated with time to secondary treatment (p<0.05 for each). Of 145 patients on initial observation, 23% had post-RP PSA≥0.1. ADT was most common early adjuvant therapy (45.4%), followed by ADT+RT (36%), RT alone (17.4%), and other (1.2%) CONCLUSIONS: Most patients with pN+PCa in MUSIC received early post-RP treatment and men with a first post-RP PSA<0.1ng/mL had improved secondary treatment free survival. Early treatment, which was predominantly ADT±RT, is influenced by aggressive disease features and detectable post-RP PSA. Nearly one out of four patients with pN+cancer not receiving early post RP treatment had a detectable PSA, suggesting an opportunity for quality improvement by increasing use of postoperative therapy. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e855 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Triner More articles by this author Ji Qi More articles by this author Udit Singhal More articles by this author Michael Sessine More articles by this author Kevin Ginsburg More articles by this author Brian Lane More articles by this author Todd Morgan More articles by this author Expand All Advertisement PDF downloadLoading ...

MP64-09 THREE-YEAR FOLLOW-UP FOR SURVEILLANCE OF T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP64-09 THREE-YEAR FOLLOW-UP FOR SURVEILLANCE OF T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS Samantha Wilder, JI Qi, Mahin Mirza, Sabrina Noyes, Mohammad Jafri, Brian Seifman, Alice Semerjian, Craig Rogers, Brian Lane, and For The Michigan Urological Surgery IMPROVEMENT Collaborative Samantha WilderSamantha Wilder More articles by this author , JI QiJI Qi More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Sabrina NoyesSabrina Noyes More articles by this author , Mohammad JafriMohammad Jafri More articles by this author , Brian SeifmanBrian Seifman More articles by this author , Alice SemerjianAlice Semerjian More articles by this author , Craig RogersCraig Rogers More articles by this author , Brian LaneBrian Lane More articles by this author , and For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003322.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Questions remain regarding the durability of surveillance as a management option for cT1 renal masses (T1RM). MUSIC-KIDNEY prospectively collects data regarding patients with newly diagnosed T1RM that are evaluated in any of 21 Michigan urologic practices. We evaluated imaging study performance and delayed intervention for patients who were initially placed on surveillance prior to 2020. METHODS: Between 5/2017 and 12/2019, patients in the MUSIC-KIDNEY registry who were initially managed without definitive treatment within 90 days of initial evaluation for T1RM were included. Follow-up imaging studies and treatment data were summarized. Treatment-free survival was calculated using the Kaplan-Meier method. RESULTS: A total of 443 patients were managed without definitive treatment within 90 days, including 347 (78%) with solid, 49 (11%) with complex cystic (Bosniak III-IV), and 47 (11%) with indeterminate T1RM. Median length of follow up since initial urology encounter was 26 months (IQR 13-34). Median age was 69 (IQR 59-77). Median tumor size was 2.2cm (IQR 1.5-3.2). After initiating surveillance, 36 patients have died (1 from prostate cancer, 1 from kidney cancer, 30 from other causes, 4 from unknown causes). Among patients with at least 1 year of clinical follow-up (n=339), 202 (60%) received at least one follow up imaging study during the 1st year. 59 (17%) underwent treatment during the 1st year, including radical nephrectomy (RN) (n=17), partial nephrectomy (PN) (n=32), tumor ablation (TA) (n=8), and stereotactic body radiation therapy (SBRT) (n=2). Among patients with at least 2 years of follow up (n=233), 113 (48%) received at least one follow up imaging study per year. During these 2 years, 66 (28%) were treated, including 19 RN, 34 PN, 8 TA, and 5 SBRT. Three-year treatment-free survival for all T1RM was 67% (95% CI 61%-72%) (Figure). CONCLUSIONS: MUSIC data demonstrate that surveillance is a durable option for management of T1RM, with over 65% of patients initially managed without intervention remaining treatment-free at 3 years. Future investigations will include examining predictors of delayed intervention and outcomes of delayed vs. primary intervention. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e884 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha Wilder More articles by this author JI Qi More articles by this author Mahin Mirza More articles by this author Sabrina Noyes More articles by this author Mohammad Jafri More articles by this author Brian Seifman More articles by this author Alice Semerjian More articles by this author Craig Rogers More articles by this author Brian Lane More articles by this author For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP41-06 ASSESSING UTILIZATION OF RENAL MASS BIOPSY IN THE MANAGEMENT OF T1A VS. T1B RENAL MASSES

You have accessJournal of UrologyCME1 Apr 2023MP41-06 ASSESSING UTILIZATION OF RENAL MASS BIOPSY IN THE MANAGEMENT OF T1A VS. T1B RENAL MASSES Dennis Boynton, Sabrina Noyes, Mahin Mirza, Brian Seifman, Edward Schervish, Mohit Butaney, Ji Qi, Craig Rogers, Brian R. Lane, and for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI Dennis BoyntonDennis Boynton More articles by this author , Sabrina NoyesSabrina Noyes More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Brian SeifmanBrian Seifman More articles by this author , Edward SchervishEdward Schervish More articles by this author , Mohit ButaneyMohit Butaney More articles by this author , Ji QiJi Qi More articles by this author , Craig RogersCraig Rogers More articles by this author , Brian R. LaneBrian R. Lane More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003279.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The appropriate and optimal use of renal mass biopsy (RMB) lacks standardization and varies from physician to physician. Our objective is to explore the impact that RMB has on active surveillance (AS), nephron-sparing intervention (NSI), and radical nephrectomy (RN) rates for cT1 renal masses (cT1RM). METHODS: Data regarding 3,466 patients with a newly diagnosed cT1RM and managed with AS, NSI (partial nephrectomy, tumor ablation, and stereotactic body radiation), or RN was collected retrospectively by MUSIC-KIDNEY registrars. Patient, tumor, RMB, and management data were extracted from the registry. RESULTS: Of 3,466 patients, 626 (18%) underwent RMB, including 17% with T1a and 20% with T1b tumors. There were no significant differences in age, race, sex, GFR >or ≤60, or T1a vs. T1b in the cohorts with or without RMB. Management differed somewhat between the cohorts with vs. without RMB; AS was elected by 41% vs. 50%, NSI by 45% vs. 35%, and RN by 14% vs. 15% (p<0.001, Fig. 1). In patients with T1a masses with or without RMB, AS was elected by 44% vs. 58%, NSI by 48% vs. 36%, and RN by 7.8% vs. 6.0% (p<0.001). In contrast, management in T1b patients with or without RMB, AS was elected by 33% vs. 23%, NSI by 37% vs. 33%, and RN by 30% vs. 44% (p=0.0027, Fig. 2). CONCLUSIONS: While academic discussion of RMB tends to focus more on patients with T1a renal masses, RMB appears to impact treatment choice for T1b more than for T1a masses. Utilization of RMB in patients with T1b renal masses resulted in increased rates of NSI and AS; for every 8 RMB in this group of patients, 1 kidney will be saved from RN. More patients with T1a masses underwent intervention after RMB than those not having RMB. Perhaps providing a cancer diagnosis to patients who were initially considering AS for their ‘renal mass’ pressured them to pursue unnecessary intervention. Source of Funding: The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided in part by the Spectrum Health Foundation. Funding was provided in part by the Value Partnerships program at Blue Cross Blue Shield of Michigan. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e556 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dennis Boynton More articles by this author Sabrina Noyes More articles by this author Mahin Mirza More articles by this author Brian Seifman More articles by this author Edward Schervish More articles by this author Mohit Butaney More articles by this author Ji Qi More articles by this author Craig Rogers More articles by this author Brian R. Lane More articles by this author for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI More articles by this author Expand All Advertisement PDF downloadLoading ...

MP62-13 THE PATIENT'S VOICE AT SCALE: UNDERSTANDING WHY PATIENTS ARE NOT SEXUALLY ACTIVE POST RADICAL PROSTATECTOMY THROUGH QUALITATIVE CODING OF RESPONSES ON A PATIENT REPORTED OUTCOME INSTRUMENT

You have accessJournal of UrologyCME1 Apr 2023MP62-13 THE PATIENT'S VOICE AT SCALE: UNDERSTANDING WHY PATIENTS ARE NOT SEXUALLY ACTIVE POST RADICAL PROSTATECTOMY THROUGH QUALITATIVE CODING OF RESPONSES ON A PATIENT REPORTED OUTCOME INSTRUMENT Mahmoud Hijazi, David Gandham, Alice Semerjian, Thomas Maatman, Mohammad Jafri, Kenneth Kernen, James Peabody, Arvin George, Kevin Ginsburg, and Andrew Krumm Mahmoud HijaziMahmoud Hijazi More articles by this author , David GandhamDavid Gandham More articles by this author , Alice SemerjianAlice Semerjian More articles by this author , Thomas MaatmanThomas Maatman More articles by this author , Mohammad JafriMohammad Jafri More articles by this author , Kenneth KernenKenneth Kernen More articles by this author , James PeabodyJames Peabody More articles by this author , Arvin GeorgeArvin George More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , and Andrew KrummAndrew Krumm More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While Patient reported outcome measures (PROMs) can capture the patient perspective at scale, that perspective is often constrained by available survey items. To amplify the patient′s voice as communicated through a PROM, free text, or open response, items may provide a more nuanced rendering of what a patient is experiencing. The objective of this abstract is to understand in qualitative terms, why patients are not sexually active pre- and post-radical prostatectomy. METHODS: Survey responses from the Michigan Urological Surgery Improvement Collaborative prostate cancer disease registry were collected pre-treatment and at 3-, 6-, 12-, and 24-months post-surgery. Written responses to the question “Why are you not sexually active?” beyond were independently analyzed and iteratively refined into higher-level codes. For the same question, patients could select 8 other options (“Lack of a willing partner”, “Lack of interest,” “Lack of confidence,” “No ejaculate,” “No erection,” “Urine leak during intercourse”, “Pain/discomfort during intercourse”, and "Not applicable"); a free-response option was provided next to the “Other” option. Prevalence of codes was examined after two independent raters reached agreement on code definitions. RESULTS: Between 1/2018 and 12/2021, 24,568 PROMs were collected, and 20,268 patients responded to the sexual activity question. Approximately 7% of patients provided a text response: 1,448 unique patients submitted 1,875 written responses. Table 1 summarizes the identified codes and the percent of overall responses with each code. The three most common codes were complications (e.g., treatment-specific change in anatomy of function), partner (e.g., own health and interest), and structural issues (e.g., lack of time). Other factors that patients identified included comorbidities and explicit choices not to be sexually active. CONCLUSIONS: Written responses provide a glimpse into a more nuanced view of post-treatment sexual activity that can be used to not only develop a more robust understanding of patients but also develop survey items that better capture patient concerns and hesitancies. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e866 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mahmoud Hijazi More articles by this author David Gandham More articles by this author Alice Semerjian More articles by this author Thomas Maatman More articles by this author Mohammad Jafri More articles by this author Kenneth Kernen More articles by this author James Peabody More articles by this author Arvin George More articles by this author Kevin Ginsburg More articles by this author Andrew Krumm More articles by this author Expand All Advertisement PDF downloadLoading ...