High-volume Providers Research Articles

Impact of Provider Volume on Outcomes of Patients With Hodgkin Lymphoma.

BackgroundWhile the provider volume-outcome relationship has been established for many complex surgeries and invasive procedures, the provider volume impact on outcomes for Hodgkin lymphoma (HL) is less certain. We hypothesized that high-volume providers (HVPs) may have superior outcomes compared with low-volume providers (LVPs).MethodsWe performed a chart-based, retrospective review of all patients receiving adriamycin, doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) for HL at the West Cancer Center from January 2010 to June 2015. Patients were divided into HVP (> 3 inpatient chemotherapy (CT)/month (m)) versus LVP (< 3 CT per m) groups. Of 95 patients identified, 93 received at least one dose of ABVD, 21 treated by HVP and 72 by LVP. Patient characteristics were well balanced between groups.ResultsHVPs were less likely to prescribe dose delays (odds ratio (OR): 0.32; confidence interval (CI): 0.16 - 0.65; P = 0.0007) and to hold doses for afebrile neutropenia (OR: 0.05; CI: 0.00 - 0.85; P = 0.0006). HVP delivered significantly fewer prophylactic growth factors (0% of doses vs. 42%, OR: 0.00; CI < 0.00 - 0.06; P < 0.0001). Both event-free survival (EFS) (HR: 6.68; CI: 1.10 - 7.63; P = 0.0321) and overall survival (OS) (HR: 3.68; CI: 1.11 - 12.22; P = 0.032) were significantly inferior in the patients treated by LVP.ConclusionsIn this study, patients with HL treated by LVP had inferior outcomes compared with those treated by HVP. HVPs were less likely to prescribe dose delays, hold doses for afebrile neutropenia or administer growth factor prophylaxis. These observations need to be confirmed in alternative datasets.

Examining Healthcare Segregation Among Racial and Ethnic Minorities Receiving Spine Surgical Procedures in the State of Florida.

This was a retrospective review of the Florida Inpatient Dataset (2011-2014). To examine healthcare segregation among African American and Hispanic patients treated with one of four common spine surgical procedures. Racial and ethnic minorities are known to be at increased risk of adverse events after spine surgery. Healthcare segregation has been proposed as a source for these disparities, but has not been systematically examined for patients undergoing spine surgery. African American, Hispanic, and White patients who underwent one of the four lumbar spine surgical procedures under study were included. Volume cut-offs were previously established for surgical providers and hospitals. Surgeons and hospitals were dichotomized based on these metrics as low- or high-volume providers. Multivariable logistic regression analysis was used to determine the likelihood of patients receiving surgery from a low volume provider, adjusting for sociodemographic and clinical characteristics. African Americans were found to be at significantly increased odds of receiving surgery from a low-volume surgeon (P < 0.001) and were significantly more likely to receive surgery at a low-volume hospital (P < 0.007) for all procedures except decompression (P = 0.56). Like findings were encountered for Hispanic patients. Hispanic patients were 55% to three-times more likely to receive surgery from a low-volume surgeon depending on the procedure and 28% to 56% more likely to be treated at a low-volume hospital. African Americans were 34% to 82% more likely to receive surgery from a low-volume surgeon depending on the procedure and 10% to 17% more likely to be treated at a low-volume hospital. The results of this work identify the phenomenon of racial and ethnic healthcare segregation among low-volume providers for lumbar spine procedures in the State of Florida. This may be a contributing factor to the increased risk of adverse events after spine surgery known to exist among minorities. 3.

Volume-Outcome Relationship in Surgical Interventions for Spinal Metastases.

Surgery for spinal metastases is challenging and carries a high risk of perioperative morbidity and mortality. Procedures with such characteristics often exhibit a volume-outcome relationship. This has not been previously characterized for spinal metastasis surgery to our knowledge. The Florida State Inpatient Database (2011 through 2014) was queried to identify patients who had undergone surgery for spinal metastases. Surgeon and hospital surgical volumes were compared with 90-day complication and readmission rates to develop procedural cut-points used to define high and low-volume providers. These were included in a multivariable logistic regression analysis that was adjusted for confounders. A separate analysis was performed to evaluate the effect of race/ethnicity and insurance status on the likelihood of receiving care from a high-volume surgeon or hospital. This study included 3,135 patients treated by 1,488 surgeons at 162 hospitals. Patients treated at low-volume hospitals had significantly higher odds of having postoperative complications (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.13, 1.91) and readmissions (OR = 1.36; 95% CI = 1.06, 1.75). Those treated by low-volume surgeons also demonstrated a higher likelihood of complications (OR = 1.40; 95% CI = 1.16, 1.69) and readmissions (OR = 1.38; 95% CI = 1.17, 1.62). The likelihood of receiving intervention from a high-volume surgeon was significantly lower for African Americans (OR = 0.55; 95% CI = 0.41, 0.75) and Hispanics (OR = 0.60; 95% CI = 0.44, 0.83). The odds of being treated at a high-volume hospital were also significantly lower for African Americans (OR = 0.58; 95% CI = 0.40, 0.84) and Hispanics (OR = 0.28; 95% CI = 0.20, 0.38). There is a clear relationship between the volume and outcomes of surgical treatment of spinal metastases, with high-volume providers demonstrating reduced complication and readmission rates. Racial and ethnic minorities appear to experience health-care segregation when it comes to surgical care for spinal metastases. Regionalization of care for these conditions may help improve access to high-volume providers and mitigate disparities in care. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Superior 3-Year Value of Open and Endovascular Repair of Abdominal Aortic Aneurysm with High-Volume Providers

Conflicting literature exists regarding resource utilization for cardiovascular care when stratified by provider volume. This study investigates the differences in value of abdominal aortic aneurysm (AAA) repair by high- and low-volume providers. The hypothesis of this study is that high-volume providers will provide superior value AAA repairs when compared to low-volume providers. Using the New York Statewide Planning and Research Cooperative System database and its linked death database, patients undergoing intact open and endovascular aneurysm repair (EVAR) were identified over a 10-year period. Charge data were normalized to year 2016 dollars and the data stratified by repair modality and annual surgeon volume. Univariate technique was used to compare the 2 groups over a 3-year follow-up period. Nine hundred eleven surgeons performed open AAA repairs and 615 performed EVAR. For both repair modalities, and despite a patient population with more vascular risk factors, the cumulative adjusted charge for all aneurysm-related care was significantly less for high-volume providers than low-volume providers. The calculated 3-year value-patient life years per cumulative charge-was also superior for high-volume providers compared to low-volume providers. This difference in charge and value persisted after propensity score matching for race, sex, insurance status, and common vascular comorbidities including hypertension, dyslipidemia, and a history of smoking. High-volume surgeons performing repair of aortic aneurysms provide superior value when compared to low-volume providers. The improved value margin is driven by both lower charge and improved survival, despite an increased incidence of cardiovascular comorbidities. This study adds support for the regionalization of care for patients with aortic aneurysm.

The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh.

Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh. Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty. From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery. Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery.

Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume

Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year). Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P=0.3121; 6.3% for VS and 3.8% for others combined, P=0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P=0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P=0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P=0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P=0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P=0.5969). Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.

Superior 3-Year Value of Open and Endovascular Repair of AAA with High Volume Providers

Abstract Introduction and Objectives: Conflicting literature exists regarding resource utilization for cardiovascular care when stratified by provider volume. This study investigates the differences in value of abdominal aortic aneurysm (AAA) repair by high and low volume providers. The hypothesis of this study is that high volume providers will provide superior value AAA repairs when compared to low volume providers. Methods Using the New York Statewide Planning and Research Cooperative System (SPARCS) database and its linked death database, patients undergoing intact open and endovascular aneurysm repair (EVAR) were identified over a 10-year period. Charge data was normalized to year 2016 dollars and the data stratified by repair modality and annual surgeon volume. Univariate technique was used to compare the two groups over a 3-year follow up period. Results 911 surgeons performed open AAA repairs and 615 performed EVAR. For both repair modalities, and despite a patient population with more vascular risk factors, the cumulative adjusted charge for all aneurysm related care was significantly less for high volume providers than low volume providers. The calculated 3-year value — patient life years per cumulative charge — was also superior for high volume providers compared to low volume providers (Table). This difference in charge and value persisted after propensity score matching for race, sex, insurance status, and common vascular comorbidities including hypertension, dyslipidemia, and a history of smoking. Conclusions High volume surgeons performing repair of aortic aneurysms provide superior value when compared to low volume providers. The improved value margin is driven by both lower charge and improved survival, despite an increased incidence of cardiovascular comorbidities. This study adds support for the regionalization of care for patients with aortic aneurysm.

The Volume-Outcome Effect: Impact on Trial-to-Permanent Conversion Rates in Spinal Cord Stimulation

Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have important implications for healthcare resource utilization (HCRU) and pain management. We hypothesized that there is a volume-outcome effect, with chronic pain patients who visit high volume SCS implanters will have higher trial-to-permanent conversion rates. We designed a large, retrospective analysis using the Truven MarketScan database analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007 to 2012 was designed. Patients were divided into three provider-based groups: high (>25), medium (9-24), and low (3-8) volume providers. Univariate and multivariate models identified factors associated with successful conversion. A total of 17,850 unique trial implants were performed by 3028 providers. Of 13,879 patients with baseline data available, 8981 (64.7%) progressed to permanent SCS. Higher volume providers were associated with slightly higher conversion rates (65.9% vs. 63.3% low volume, p = 0.029), explant rates (9.2% vs. 7.7% medium volume, p = 0.026), younger age (52.0 ± 13.4 years vs. 53.0 ± 13.4 years, p = 0.0026), Medicare/Medicaid (47.8% vs. 35.0% low volume, p < 0.0001), Southern region (53.5% vs. 38.9% low volume, p < 0.0001), and higher Charlson comorbidity scores (1.0 [SD = 1.4], p = 0.0002). Multivariate regression results showed female gender (1.13 [95% CI: 1.05-1.22], p < 0.001) and high volume providers associated with higher odds of successful trial conversion (1.12 [95% CI: 1.02-1.22], p = 0.014). In this nationwide analysis, high volume providers achieved higher trial-to-permanent SCS conversion rates than lower volume providers. The study has implications for both training requirements and referral patterns to delineate minimum implant experience necessary for provider proficiency. Future studies may be useful to understand HCRU differences.

MP97-19 SURGICAL OUTCOMES IN THE MANAGEMENT OF HIGH RISK PROSTATE CANCER USING THE SURGICAL OUTCOMES FOR ADVANCED PROSTATE CANCER SCORE

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VIII1 Apr 2017MP97-19 SURGICAL OUTCOMES IN THE MANAGEMENT OF HIGH RISK PROSTATE CANCER USING THE SURGICAL OUTCOMES FOR ADVANCED PROSTATE CANCER SCORE John Francis, Simon Kim, Hui Zhu, and Robert Abouassaly John FrancisJohn Francis More articles by this author , Simon KimSimon Kim More articles by this author , Hui ZhuHui Zhu More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3063AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Principles of high quality oncologic surgery suggest that complete excision be achieved with negative surgical margins and adequate staging. Obtaining quality outcomes in Radical prostatectomy (RP) for high risk prostate cancer can be difficult given the increased risk of extra-prostatic extension and inability to directly visualize the disease intra-operatively. Little is known about the clinical predictors of a quality surgical outcome in patients with high risk prostate cancer. We hypothesize that higher volume providers have improved surgical outcomes. METHODS Patients diagnosed with prostate cancer were selected from the National Cancer Database between 2010-2013. Patients with biopsy Gleason sum ≥ 8 or PSA > 20 and no clinical evidence of metastasis were included for analysis. A Surgical Outcomes for Advanced Prostate cancer (SOAP) score was generated for each patient. Patients received 2 points each for negative surgical margins and sampling of ≥ 5 pelvic lymph nodes and 1 point each for no readmission with in 30 days, no mortality within 30 days, and hospital length of stay ≤ 2 days. Patients were considered to have a good surgical outcome with a SOAP score ≥ 6. Provider volume was calculated by number of RPs reported from the treatment facility with high volume centers considered to be ones in the top third of reported RPs. Multivariable logistic regression was conducted to determine factors independently associated with quality surgical outcomes using the SOAP score. RESULTS We identified 72,864 patients with high risk disease, of whom 42.5% (n=31,008) were treated with RP. Overall, 34.1% of patients had a quality surgical outcome with a SOAP score ≥ 6. On multivariable logistical regression, factors associated with a quality surgical outcome included surgery at a high volume center (OR 1.8: CI 1.6-1.9; p= <0.01), surgery at an academic hospital (OR 1.8: CI 1.7-1.9: p= <0.01), cN1 stage (OR 1.6: CI 1.2-2.0; p= <0.01), and omission of neoadjuvent hormonal therapy (OR 1.4: CI 1.3-1.5; p= <0.01). Factors associated with a poor surgical outcome include robotic approach (OR 0.81: CI 0.76-0.87; p= <0.01), PSA > 30 (OR 0.59: CI 0.55-0.64; p= <0.01), and African American ethnicity (OR 0.89: CI 0.82-0.96; p= <0.01). CONCLUSIONS For patients with high risk prostate cancer, treatment at high volume centers and at academic centers appear to be associated with a high quality surgical outcomes. Given the increased use of this management strategy, optimizing surgical quality is needed in order to achieve the best outcomes for this aggressive malignancy. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1310-e1311 Advertisement Copyright & Permissions© 2017MetricsAuthor Information John Francis More articles by this author Simon Kim More articles by this author Hui Zhu More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Access to high-volume surgeons and the opportunity cost of performing radical prostatectomy by low-volume providers

BackgroundEvidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered. MethodsMedicare Provider Utilization and Payment Data, SEER 18, and US Incidence data were used to determine the geographic distribution and radical prostatectomy volume for providers. Access was defined as availability of a high-volume provider within driving distance of 100 miles. The opportunity cost was defined as the value of benefits achievable by performing the surgery by a high-volume provider that was forgone by not making a referral. The savings per referral were derived from a published Markov model for radical prostatectomy. ResultsA total of 14% of providers performed>27% of the radical prostatectomies with>30 cases per year and were designated high-volume providers. Providers with below-median volume (≤16 prostatectomies per year) performed>32% of radical prostatectomies. At least 47% of these were within a 100-mile driving distance (median = 22 miles), and therefore had access to a high-volume provider (>30 prostatectomies per year). This translated into a discounted savings of more than $24 million per year, representing the opportunity cost of not making a referral. The average volume for high- and low-volume providers was 55 and 13, respectively, resulting in an annual experience gap of 43 and a cumulative gap of 125 surgeries over 3 years. In 2014, the number of surgeons performing radical prostatectomy decreased by 5% while the number of high- and low-volume providers decreased by 25% and 11% showing a faster decline in the number of high-volume providers compared with low-volume surgeons. ConclusionsAbout half of prostatectomies performed by surgeons with below-median annual volume were within a 100-mile driving distance (median of 22 miles) of a high-volume surgeon. Such a referral may result in minimal additional costs and substantially improved outcomes.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence.

Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI. The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location. A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures. InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery.

Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States. To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis. Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering. A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis. Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.

Impact of Surgeon Volume on Outcomes of Older Stage I Lung Cancer Patients Treated via Video-assisted Thoracoscopic Surgery

Surgeon procedure volume influences outcomes of patients undergoing cancer operations. Limited data are available, however, on the volume-outcome relationship for video-assisted thoracoscopic surgery (VATS) in the treatment of non-small cell lung cancer (NSCLC). In this study, we used population-based data to evaluate the extent to which surgeon volume is associated with postoperative and long-term oncological outcomes following VATS resection for older patients with early-stage NSCLC. Stage I NSCLC patients >65 years treated with VATS wedge, segmentectomy, or lobectomy between 2000 and 2010 were identified from the Surveillance, Epidemiology, and End Results registry linked to Medicare. Surgeon volume was grouped into tertiles (low, intermediate, and high). Outcomes included perioperative complications, intensive care unit admission, extended length of stay, perioperative (30-day) mortality, and long-term overall and lung cancer-specific survival. We used propensity score methods to compare adjusted survival of patients by surgical volume group. A total of 2295 study patients were identified. Patients treated by high-volume surgeons had decreased intensive care unit admissions (hazard ratio [HR]: 0.46, 95% CI: 0.41-0.51) and postoperative length of stay (HR: 0.75, 95% CI: 0.61-0.92). Adjusted analyses showed that overall (HR: 0.73, 95% CI: 0.62-0.87) and lung cancer-specific (HR: 0.76, 95% CI: 0.58-0.99) survival was better for patients treated by high-volume surgeons. Elderly stage I NSCLC patients undergoing VATS by high-volume surgeons have reduced postoperative complications and improved survival. Organization of care favoring referrals of VATS candidates to high-volume providers may help improve the outcomes of patients with early-stage lung cancer.

Health status and use of partial nephrectomy in older adults with early-stage kidney cancer

IntroductionThe long-term benefits of nephron-sparing surgery for kidney cancer depend on patient health. Accordingly, we examined whether receipt of partial nephrectomy varied with baseline comorbidity or functionality among older adults with stage I kidney cancer. Materials and methodsUsing Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 to 2009, we identified patients treated with partial or radical nephrectomy for stage I kidney cancer. We examined treatment trends according to baseline comorbidity, function, and relevant health conditions. We then estimated the probability of partial nephrectomy using multivariable, mixed-effects models adjusting for patient, surgeon, and hospital characteristics. ResultsOverall, 2,956 of 11,678 patients (25.3%) underwent treatment with partial nephrectomy. Receipt of partial nephrectomy was associated with younger age, male sex, higher socioeconomic position, smaller tumor size, and treatment by a high-volume provider, cancer center, or academic institution (P<0.001). During the study period, utilization increased significantly (P<0.001) but did not differ according to comorbidity or patient function. Adjusting for patient, surgeon, and hospital characteristics, the probability of partial nephrectomy by comorbidity and function categories remained within a narrow range from 19.6% to 22.8%. Only preexisting kidney disease appeared to be linked to partial nephrectomy usage (odds ratio = 1.49, 95% CI: 1.33–1.66). ConclusionWith the exception of kidney disease, the increasing use of partial nephrectomy did not vary with respect to health status. As the potential benefits of partial nephrectomy differ according to a patient׳s underlying health, selection tools and algorithms that match treatment to patient comorbidity or function may be needed to optimize kidney cancer care in the United States.

Geographic Concentration Of Home-Based Medical Care Providers.

The United States faces a shortage of providers who care for homebound patients. About 5,000 primary care providers made 1.7million home visits to Medicare fee-for-service beneficiaries in 2013, accounting for 70percent of all home-based medical visits. Nine percent of these providers performed 44percent of visits. However, most homebound people live more than thirty miles from a high-volume provider.

Pessary Practices of Nurse-Providers in the United States.

Our purposes were to describe pessary-care practices and education of a sample of nurse providers in the United States and identify a cohort of high-volume providers. An e-mail survey was sent to members of 3 related nursing professional organizations. Questions addressed general pessary care within the respondent's practice and specific pessary care choices of responding direct providers. Data were managed using REDCap electronic data capture tools. Of 323 respondents, 279 (86.4%) reported pessary care occurred in their office settings, 84.5% of which were urban or suburban, and 65.4% were private practices. Responders were evenly distributed through 4 regions of the United States and represented a variety of specialties. Physicians and advanced practice registered nurses provided the majority of care (up to 80%), along with registered and licensed practical nurses and medical assistants. Care routines varied, most often including 3-month-interval follow-up with speculum-assisted vaginal examinations and no routine use of vaginal products (eg, moisturizers, acidifiers, antimicrobials, or vaginal estrogens). On-the-job mentoring was the primary knowledge source (64%). Comparison of practice patterns suggested possible variation by region and certification. This exploratory study provides data related to the pessary-care practices of nurse providers in the United States. The range of responses emphasizes a need for evidence-based guidelines for optimal care, based on patient outcomes, satisfaction, and costs of care. Findings also illustrate a need for effective, evidence-based educational programs and clinical mentorship options with experienced providers. A cohort of expert providers was identified to continue work toward these goals.

PI-04 SURGEON AND HOSPITAL VARIATION IN THE COSTS OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN THE UNITED STATES

You have accessJournal of UrologyBest Abstract1 Apr 2016PI-04 SURGEON AND HOSPITAL VARIATION IN THE COSTS OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN THE UNITED STATES Alexander Cole, Jeffrey Leow, Steven Chang, Christian Meyer, Nawar Hanna, Adam Kibel, Mani Menon, Jesse Sammon, Firas Abdollah, Benjamin Chung, Maxine Sun, and Quoc-Dien Trinh Alexander ColeAlexander Cole More articles by this author , Jeffrey LeowJeffrey Leow More articles by this author , Steven ChangSteven Chang More articles by this author , Christian MeyerChristian Meyer More articles by this author , Nawar HannaNawar Hanna More articles by this author , Adam KibelAdam Kibel More articles by this author , Mani MenonMani Menon More articles by this author , Jesse SammonJesse Sammon More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , Maxine SunMaxine Sun More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1209AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In a cost-conscious healthcare environment, eliminating unwarranted costs and understanding cost variation are paramount. Prostate cancer is the most common malignancy among men and surgical treatment with radical prostatectomy (RP) is associated with substantial costs, particularly with the recent rapid adoption of robot-assisted RP (RARP). We sought to assess individual surgeon-level variation in costs of RARP and identify independent predictors of high and low-cost surgery. METHODS We identified 291,015 men in the Premier all-payer discharge database who underwent RARP for prostate cancer by 667 unique surgeons at 197 different hospitals across the United States from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 US$). High costs were defined as costs superior to the 90th percentile of all patient costs (≥$18,564/RARP), while low costs were defined as the costs inferior to the 10th percentile of all patient costs (≤$5,585/RARP). Multivariable logistic regression models identified independent predictors of high and low costs, while multilevel hierarchal models determined variability of various characteristics on costs RESULTS Mean costs for each RARP patient was $11,878 (95% CI 11,804-11,952), Mean costs per RARP in the low-cost group was $2837 (95% CI: $2805-$2869) compared to $25,906 (95% CI: $24702-$25490) in the high-cost group. Nearly a third of the variation in RARP cost was attributable to hospital characteristics, and over a fifth was attributable to surgeon characteristics (R-squared for each 30.43% and 21.25%, respectively). Factors associated with high-cost surgeries included Black race (vs. Whites; OR: 1.42, 95% CI: 1.12 to 1.33), Charlson comorbidity≥2 (vs. 0; OR 1.88 95% CI 1.55-2.29) and teaching hospitals (vs. non-teaching; OR 2.27, 95% CI 1.28-4.04). High-volume providers (≥90th percentile) was associated with significantly lower odds of high-cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105 95% CI 0.02-0.46). As for predictors for low-cost surgeries, high-volume surgeons were found to be less likely to have low-cost RARPs (OR: 0.41, 95% CI: 0.20-0.84). Conversely, high-volume hospitals were highly associated with low-cost RARPs (OR: 839, p<0.0001). CONCLUSIONS This study provides new insight into the key role played by individual surgeons performing RARP across a large nationally representative sample. Given the substantial variability in RARP costs contributed by hospital and surgeon characteristics, future steps to identify and remedy the root cause of outliers costs, and to reduce unwarranted variability in costs may yield great benefits for patients, physicians and the health system as a whole. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e410 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alexander Cole More articles by this author Jeffrey Leow More articles by this author Steven Chang More articles by this author Christian Meyer More articles by this author Nawar Hanna More articles by this author Adam Kibel More articles by this author Mani Menon More articles by this author Jesse Sammon More articles by this author Firas Abdollah More articles by this author Benjamin Chung More articles by this author Maxine Sun More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Travel Burden and the Direct Medical Costs of Urologic Surgery.

Background: Increased surgical volume is associated with better patient outcomes and shorter lengths of hospitalization. As a consequence, traveling to receive care from a high volume provider may be associated with better outcomes. However, travel may also be associated with a decision by the healthcare provider to increase the length of stay due to a decreased ability to return to the primary hospital should complications arise. Thus, research is needed to understand the relationship between the distance a patient must travel and their outcomes following urologic surgery.Objective: The purpose of this study was to determine whether the distance a patient travels to receive urologic surgery is associated with their length of hospital stay and direct medical hospitalization costs.Methods: This was a retrospective observational cohort study of 12 106 patients over 50 years of age undergoing transurethral resection of the prostate (TURP), radical prostatectomy (RP) or radical cystectomy (RC) in Washington State hospitals between 2009 and 2013. Distance traveled was determined by calculating the linear distance between zip code centroids of patient residence and the hospital performing their procedure. Patients were sorted into four groups classified by distance traveled (≤5 miles, 6-20 miles, 21-50 miles and ≥51 miles) and cost calculated using a charges-to-reimbursement ratio for each hospital. Statistical significance was determined using a Kruskal-Wallis test.Results: Patients traveling greater distances had significantly lower median medical costs compared with patients who lived closer to the hospitals where they underwent TURP and RP (TURP: ≤5 miles, $6243 and ≥51 miles, $5105, p≤0.001; RP: ≤5 miles, $12 407 and ≥51 miles, $11 882, p≤0.001), whereas there was no significant difference for patients undergoing RC (≤5 miles, $27 554 and ≥51 miles, $26 761, p=0.17). Likewise, patients traveling greater distances had significantly lower median lengths of hospitalization for TURP and RP (TURP: p≤0.001, RP: p≤0.001), while there was no difference for RC (p=0.50).Conclusions: Patient travel burden does appear to play a role in cost and length of hospital stay for select urologic procedures with variable levels of morbidity and recovery time. Although these findings are statistically significant, the magnitude of the effect is small.

Factors associated with colorectal cancer occurrence after colonoscopy that did not diagnose colorectal cancer

Up to 6% of colorectal cancers (CRCs) are diagnosed within 5 years of a colonoscopy that did not diagnose CRC (post-colonoscopy colorectal cancer, PCCRC). PCCRC and associated risk factors were examined within a national hospital episode database. A retrospective case-control study of all colonoscopies performed on adults recorded in Hospital Episode Statistics (HES) between 2003 and 2009 in England. PCCRC cases underwent colonoscopy 6 to 60 months before diagnosis; controls had not undergone colonoscopy 6 to 60 months before diagnosis. Multivariate logistic regression analysis examined associations with PCCRC. A total of 1,439,684 colonoscopies were analyzed, including 67,202 cases of CRC and 8147 cases of PCCRC (12.1%). Multivariate analysis revealed that female sex (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.08-1.19; P< .001), older age (70-74 years) (OR, 1.09; 95% CI, 1.00-1.18; P= .039), increased comorbidity (Charlson index 5+) (OR, 1.16; 95% CI, 1.05-1.28; P< .003), and CRC of the right side of the colon (OR, 1.17; 95% CI, 1.11-1.23; P< .0001) were associated with PCCRC. Emergency colonoscopy (OR, 0.54; 95% CI, 0.59-0.69; P< .0001) was negatively associated with PCCRC. More individuals with PCCRC developed metastases within 12 months and fewer underwent surgery (OR, 0.33; 95% CI, 0.32-0.35; P< .0001) or chemotherapy (OR, 0.66; 95% CI, 0.62-0.69), P< .0001). PCCRC rates varied 2-fold between providers and PCCRC was associated with medium-volume providers compared with high-volume providers (OR, 1.13; 95% CI, 1.01-1.27; P= .035). The PCCRC rate fell from 13.8% in 2003 to 11.9% in2009. PCCRC occurred in 12.1% of patients with CRC between 2003 and 2009. PCCRC was associated with female sex, older age, increased comorbidity, CRC of the right side of the colon, elective procedures, and colonoscopy volume. PCCRC was associated with worse outcomes.

Importance of Radiation Oncologist Experience Among Patients With Head-and-Neck Cancer Treated With Intensity-Modulated Radiation Therapy.

Over the past decade, intensity-modulated radiation therapy (IMRT) has replaced conventional radiation techniques in the management of head-and-neck cancers (HNCs). We conducted this population-based study to evaluate the influence of radiation oncologist experience on outcomes in patients with HNC treated with IMRT compared with patients with HNC treated with conventional radiation therapy. We identified radiation providers from Medicare claims of 6,212 Medicare beneficiaries with HNC treated between 2000 and 2009. We analyzed the impact of provider volume on all-cause mortality, HNC mortality, and toxicity end points after treatment with either conventional radiation therapy or IMRT. All analyses were performed by using either multivariable Cox proportional hazards or Fine-Gray regression models controlling for potential confounding variables. Among patients treated with conventional radiation, we found no significant relationship between provider volume and patient survival or any toxicity end point. Among patients receiving IMRT, those treated by higher-volume radiation oncologists had improved survival compared with those treated by low-volume providers. The risk of all-cause mortality decreased by 21% for every additional five patients treated per provider per year (hazard ratio [HR], 0.79; 95% CI, 0.67 to 0.94). Patients treated with IMRT by higher-volume providers had decreased HNC-specific mortality (subdistribution HR, 0.68; 95% CI, 0.50 to 0.91) and decreased risk of aspiration pneumonia (subdistribution HR, 0.72; 95% CI, 0.52 to 0.99). Patients receiving IMRT for HNC had improved outcomes when treated by higher-volume providers. These findings will better inform patients and providers when making decisions about treatment, and emphasize the critical importance of high-quality radiation therapy for optimal treatment of HNC.