Surgeon-level Variation Research Articles

Uptake of Same-Day Discharge for Patients Undergoing Robot-Assisted Radical Prostatectomy in the Michigan Urological Surgery Improvement Collaborative.

Postoperative length of stay (LOS) after robot-assisted radical prostatectomy (RARP) is a potentially modifiable aspect of prostate cancer care. Our objective was to evaluate the use of same-day discharge (SDD) RARP and compare pre- and perioperative characteristics of these men with those who underwent hospitalization postoperatively. Perioperative outcomes for patients undergoing RARP were evaluated from the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Men were classified by hospital LOS: SDD, 1 day, and 2 days. Practice and surgeon-level variation of SDD and the change in SDD use over time were assessed. The primary outcome was 30-day readmission after RARP. We identified 10,249 men undergoing RARP in MUSIC from 2018 to 2022. Most patients had 1-day LOS (79.6%), with 2.8% undergoing SDD. The proportion of patients undergoing RARPs with SDD rose from 0.6% in 2018 to 1.2% in 2019 and 4.4% for 2020 to 2022. At least one SDD was performed in 12 of 28 MUSIC practices (42.9%) and by 52 of 138 urologists (37.7%). In multivariable analysis, odds of 30-day readmission were not significantly different between patients .undergoing SDD and LOS 1 day (OR: 1.72, 95% CI: 0.92-3.22, P = .090). Limitations include retrospective, registry-based observational study with nonuniform utilization of SDD. Although more patients have undergone SDD after RARP beginning in 2018, rates across Michigan have remained < 5% annually. Importantly, patients undergoing SDD RARP did not experience significantly more readmissions compared to hospitalized patients. SDD appears safe and feasible for select patients who are motivated by this approach.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Real-world Practice Stone-free Rates After Ureteroscopy: Variation and Outcomes in a Surgical Collaborative

BackgroundStudies assessing the stone-free rate (SFR) after ureteroscopy are limited to expert centers with varied definitions of stone free. Real-world data including community practices related to surgeon characteristics and outcomes are lacking. ObjectiveTo evaluate the SFR for ureteroscopy and its predictors across diverse surgeons in Michigan. Design, setting, and participantsWe assessed the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry for patients with renal or ureteral stones treated with ureteroscopy between 2016 and 2021 who had postoperative imaging. Outcome measurements and statistical analysisStone free was defined as no fragments on imaging reports within 60 d entered by independent data abstractors. Factors associated with being stone free were examined using logistic regression, including annual surgeon volume. We then assessed variation in surgeon-level SFRs adjusted for risk factors. Results and limitationsWe identified 6487 ureteroscopies from 164 surgeons who treated 2091 (32.2%) renal and 4396 (67.8%) ureteral stones. The overall SFRs were 49.6% (renal) and 72.7% (ureteral). Increasing stone size, lower pole, proximal ureteral location, and multiplicity were associated with not being stone free. Female gender, positive urine culture, use of ureteral access sheath, and postoperative stenting were associated with residual fragments when treating ureteral stones. Adjusted surgeon-level SFRs varied for renal (26.1–72.4%; p < 0.001) and ureteral stones (52.2–90.2%; p < 0.001). Surgeon volume was not a predictor of being stone free for renal stones. Limitations include the lack of imaging in all patients and use of different imaging modalities. ConclusionsThe real-world complete SFR after ureteroscopy is suboptimal with substantial surgeon-level variation. Interventions focused on surgical technique refinement are needed to improve outcomes for patients undergoing ureteroscopy and stone intervention. Patient summaryResults from a diverse group of community practicing and academic center urologists show that for a large number of patients, it is not possible to be completely stone free after ureteroscopy. There is substantial variation in surgeon outcomes. Quality improvement efforts are needed to address this.

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 ...

Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample.

To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States. A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation. The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063. The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.

8459 Prevalence, Predictors and Hospital- and Surgeon-Level Variation of Preoperative Anemia: A Multi-Centre Retrospective Study

<h3>Study Objective</h3> Evaluate prevalence, predictors, and hospital- and surgeon-level variation of preoperative anemia, a quality metric, prior to elective hysterectomy. <h3>Design</h3> Multi-center retrospective review. <h3>Setting</h3> 9 Ontario, Canada hospitals (6 academic, 3 community). <h3>Patients or Participants</h3> Patients undergoing elective hysterectomy from July 2016-December 2020. Patients with malignancy, invasive placentation and pregnancy were excluded. <h3>Interventions</h3> Primary outcome was preoperative anemia (hemoglobin <12 g/dL) within three months prior to surgery. <h3>Measurements and Main Results</h3> Patient, case and surgeon characteristics for those with and without anemia were recorded and bivariate comparisons between groups were completed. Linear mixed effects regression assessed associations between anemia and several patient and surgeon variables, and adjusted odds ratios (aORs) were reported. A multilevel model was created to calculate median odds ratios (MOR) to assess surgeon- and hospital-level variability in preoperative anemia rates. A total of 4557 hysterectomies by 113 surgeons at nine hospitals were included. One in five patients (909 patients, 19.9%) were anemic preoperatively. Several patient, case and surgeon characteristics were associated with preoperative anemia: Preoperative diagnosis of abnormal uterine bleeding (aOR 1.48, 95%CI 1.20-1.81, p<0.001); uterine weight in the two uppermost quartiles (aOR 2.41, 95%CI 1.71-3.38, p<0.001 and aOR 3.52, 95%CI 2.34-4.50, p<0.001, respectively); surgeon length of practice >11 years (aOR 1.66, 95%CI 1.29-2.12, p<0.001); and community practice (aOR 2.05, 95%CI 1.44-2.93, p<0.001). There was considerable variability in preoperative anemia rates among surgeons (MOR 1.29) and hospitals (MOR 1.54), suggesting that a patient had a 54% higher chance of preoperative anemia at one randomly selected hospital compared to another; and a 29% higher chance of being anemic if cared for by one surgeon compared to another. <h3>Conclusion</h3> Several factors are associated with preoperative anemia among hysterectomy patients and variation in preoperative anemia exists at both the hospital- and surgeon-level. Quality improvement initiatives aimed at surgeons with longer duration of practice and those at community hospitals may reduce variability.

Between-hospital and between-surgeon variation in thresholds for hip and knee replacement.

Total hip replacement (THR) and total knee replacement (TKR) are cost-effective interventions to reduce pain and disability associated with osteoarthritis, however there is no clear guidelines available to determine appropriate patient selection and the timing of surgery. This prospective cohort study aimed to evaluate the hospital- and surgeon-level variation in the severity of patient-reported symptoms prior to THR and TKR. Patients undergoing primary THR (n= 4330) or TKR (n= 7054) for osteoarthritis who participated in a national registry-led Patient Reported Outcome Measures (PROMs) pilot program were included in the analysis. Pre-operative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) (range 0-48; representing worst to best hip/knee pain and function) data were examined for variation between private and public hospitals and between surgeons using linear mixed models. Pre-operative mean OHS was significantly higher (better) in patients whose surgery was performed in a private hospital compared to public hospitals; 21.39 versus 18.11 (mean difference 3.27, 95% CI 1.75, 4.79). For OKS, the difference between private hospital and public hospital scores was dependent on BMI and gender. Most of the variation in pre-operative OHS and OKS was not at the individual hospital- or surgeon-level, which explained only a negligible proportion of the model variance (⟨5%) for THR and TKR. Apart from a difference between private and public hospitals, there was little between-hospital or between-surgeon symptom variation in joint-specific pain and function prior to THR or TKR. The findings suggest consistency in the surgical thresholds for patients being offered hip and knee joint replacement procedures.

Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis.

Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively. The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. "High-intensity" surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors. In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (-1.0 morphine milligram equivalents per day difference; 95% CI, -1.4 to -0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small. Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

MP57-12 PATIENT REPORTED SEXUAL AND URINARY FUNCTIONAL OUTCOMES IN MEN WITH INTERMEDIATE RISK PROSTATE CANCER UNDERGOING RADICAL PROSTATECTOMY: ANALYSIS OF THE MUSIC REGISTRY

You have accessJournal of UrologyCME1 May 2022MP57-12 PATIENT REPORTED SEXUAL AND URINARY FUNCTIONAL OUTCOMES IN MEN WITH INTERMEDIATE RISK PROSTATE CANCER UNDERGOING RADICAL PROSTATECTOMY: ANALYSIS OF THE MUSIC REGISTRY Roshan Paudel, John Cochrane, Ji Qi, Michael Cher, Richard Sarle, James Peabody, S. Mohammad Jafri, Brian Lane, Alice Semerjian, Arvin George, and Kevin Ginsburg Roshan PaudelRoshan Paudel More articles by this author , John CochraneJohn Cochrane More articles by this author , Ji QiJi Qi More articles by this author , Michael CherMichael Cher More articles by this author , Richard SarleRichard Sarle More articles by this author , James PeabodyJames Peabody More articles by this author , S. Mohammad JafriS. Mohammad Jafri More articles by this author , Brian LaneBrian Lane More articles by this author , Alice SemerjianAlice Semerjian More articles by this author , Arvin GeorgeArvin George More articles by this author , and Kevin GinsburgKevin Ginsburg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess patient reported continence and sexual function outcomes among men with intermediate risk prostate cancer (IRPC) undergoing radical prostatectomy (RP) in MUSIC. METHODS: We reviewed the Patient Reported Outcome program in the MUSIC prostate cancer registry for men with IRPC undergoing RP from May 2014-- to June 2021. EPIC-26 surveys are administered at baseline and 1, 3, 6, 12, and 24 month postoperatively. To quantify deterioration in function resulting from surgery, patients were included in this analysis if they report good urinary and/or sexual function at baseline. Social continence (SC) was defined as self-reported use of 0-1 pad per day and assessed at 3 and 6 months postoperatively. Good sexual function (SF) was defined as erections firm enough for penetration and assessed at 12 and 24 months postoperatively. Proportions of patients with social continence and good sexual function were compared between favorable (F-IRPC) and unfavorable (U-IRPC) with the Chi-squared test. Surgeon level variation was assessed graphically. RESULTS: Among 3967 patients undergoing RP for IRPC, 2911 and 2614 patients with good baseline urinary function completed the 3m and 6m surveys and 984 and 666 patients with good baseline sexual function completed the 12m and 24m surveys. Post-operative SC was reported in 67% and 86% of patients at 3m and 6m. We noted similar SC for men with F-IRPC and U-IRPC at 3m (68% vs. 67%, p=0.61) and 6m (86% vs. 85%, p=0.74) postoperatively. Recovery of SF was less robust, with 26% and 30% of men reporting good SF at 12m and 24m postoperatively. Men with F-IRPC had improved SF at 12m compared with men with U-IRPC (30% vs. 24%, p=0.031), although this difference was not statistically significant at 24m (34% vs. 28%, p=0.064). There was notable variability in recovery of SC and SF by contributing surgeon for both men with F-IRPC and U-IRPC (Figure). CONCLUSIONS: As reported in MUSIC PRO, men with IRPC had reasonable urinary continence recovery postoperatively overall, but generally poor recovery of erectile function, with notable variation in postoperative urinary and sexual function by surgeon. These data may inform patients and surgeons regarding the range of expected outcomes as well as drive future quality improvement efforts. Source of Funding: Funding from Blue Cross Blue Shield of Michigan © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e986 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roshan Paudel More articles by this author John Cochrane More articles by this author Ji Qi More articles by this author Michael Cher More articles by this author Richard Sarle More articles by this author James Peabody More articles by this author S. Mohammad Jafri More articles by this author Brian Lane More articles by this author Alice Semerjian More articles by this author Arvin George More articles by this author Kevin Ginsburg More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP44-04 REAL-WORLD PRACTICE STONE-FREE RATES AFTER URETEROSCOPY FROM A SURGICAL COLLABORATIVE: MUCH TO IMPROVE

You have accessJournal of UrologyCME1 May 2022MP44-04 REAL-WORLD PRACTICE STONE-FREE RATES AFTER URETEROSCOPY FROM A SURGICAL COLLABORATIVE: MUCH TO IMPROVE Hyung Joon Kim, Stephanie Daignault-Newton, John M. DiBianco, S. Mohammad Jafri, Brian Seifman, Eduardo Kleer, Casey A. Dauw, and Khurshid R. Ghani Hyung Joon KimHyung Joon Kim More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , John M. DiBiancoJohn M. DiBianco More articles by this author , S. Mohammad JafriS. Mohammad Jafri More articles by this author , Brian SeifmanBrian Seifman More articles by this author , Eduardo KleerEduardo Kleer More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , and Khurshid R. GhaniKhurshid R. Ghani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002610.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The stone-free rate (SFR) is an important outcome measure of quality after ureteroscopy for urinary stones. Recent studies show SFRs may not be as high as previously reported. However, these studies are from expert centers, and data from real-world community practice is lacking. We examined the SFR and its predictors following ureteroscopy among diverse practices in the state of Michigan. METHODS: We used the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stone (ROCKS) registry to identify ureteroscopy cases for renal and ureteral stone location, respectively, treated between 2016 and 2021, that had postoperative imaging. Stone-free was defined as no fragment detected on imaging within 60 days. Practice and surgeon-level SFR variation was assessed. Surgeon volume was categorized according to quartiles of annual volume. Factors associated with SFR were examined using logistic regression. RESULTS: 6,487 ureteroscopies were performed across 29 practices and 164 surgeons, to treat 2,091 (32.2%) renal and 4396 (67.8%) ureteral stones. The SFR was 49.6% and 72.7% for renal and ureteral stone location, respectively. For renal stones, larger stone size, lower pole location, and multiplicity were significantly associated with residual fragments (Table 1). For ureteral stones, female gender, larger stone size, proximal location, multiplicity, positive urine culture, use of ureteral access sheath, and post-ureteroscopy stenting were predictors for low SFR (Table 1). No significant differences in SFRs were identified regarding pre-stenting and surgeon volume. Surgeon variation in the SFR for renal and ureteral stones, when adjusted for risk factors, was 29.0-68.7% (p <0.0001) and 51.4-86.4% (p <0.0001), respectively (Figure 1). CONCLUSIONS: There is substantial surgeon-level variation in the SFR after ureteroscopy in Michigan. Our findings demonstrate the need for quality efforts to improve these outcomes. Source of Funding: Blue Cross Blue Shield of Michigan © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e752 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hyung Joon Kim More articles by this author Stephanie Daignault-Newton More articles by this author John M. DiBianco More articles by this author S. Mohammad Jafri More articles by this author Brian Seifman More articles by this author Eduardo Kleer More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author Expand All Advertisement PDF DownloadLoading ...

Prevalence, Predictors, and Hospital- and Surgeon-Level Variation of Preoperative Anemia: A Multicentre Retrospective Study

Evaluate prevalence, predictors, and hospital- and surgeon-level variation of preoperative anemia, a quality metric, prior to elective hysterectomy.

Patient- and Surgeon-Level Variation in Patient-Reported Sexual Function Outcomes Following Radical Prostatectomy Over 2 Years

Of patient-reported outcomes for individuals undergoing radical prostatectomy, sexual function outcomes are among the most reported and the most detrimental to quality of life. Understanding variations at the patient and surgeon level may inform collaborative quality improvement. To describe patient- and surgeon-level sexual function outcomes for patients undergoing radical prostatectomy in the Michigan Urological Surgery Improvement Collaborative (MUSIC) and to examine the correlation between surgeon case volume and sexual function outcomes. This is a prospective cohort study using the MUSIC registry and patient-reported sexual function outcome data. Patient- and surgeon-level variation in sexual function outcomes were examined among patients undergoing radical prostatectomy from May 2014 to August 2019. Sexual function outcome data were collected using validated questionnaires, which were completed before surgery and at 3, 6, 12, and 24 months' follow-up following surgery. All participants were male. Race and ethnicity data were self-reported and were included to examine potential variation in outcomes by race and/or ethnicity. Data were analyzed from January 2021 to March 2021. There were 4 outcomes in this study, including the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) sexual function scores at 3, 6, 12, and 24 months' follow-up; patient-level sexual function recovery at 12- and 24-month follow-up; surgeon-level variation in sexual function outcomes at 12- and 24-month follow-up; and correlation between surgeon case volume and sexual function outcomes. A total of 1426 male patients met inclusion criteria for this study. The median (IQR) age was 64 (58-68) years. A total of 115 participants (8%) were Black, 1197 (84%) were White, 25 (2%) were of another race or ethnicity (consolidated owing to low numbers), and 89 (6%) were of unknown race or ethnicity. Among patients undergoing bilateral nerve-sparing radical prostatectomy, mean (SD) EPIC-26 sexual function scores at 12- and 24-month follow-up (12 months, 39 [28]; 24 months, 63 [29]) did not return to baseline levels. There was wide variation in EPIC-26 sexual function scores at both 12-month follow-up (range, 23-69; P < .001) and 24-month follow-up (range, 27-64; P < .001). Similar variations were found in EPIC-26 sexual function scores and recovery of sexual function by surgeon. Recovery rates ranged from 0% to 40% of patients at 12-month follow-up (18 surgeons; P < .001) and 3% to 44% of patients at 24-month follow-up (12 surgeons; P < .001). Surgeon case volume and sexual function outcomes were not significantly correlated. On multivariable analysis, the following variables were associated with better recovery at 24-month follow-up: younger age (P < .001), lower baseline EPIC-26 sexual function score (P < .001), lower Gleason score (P = .05), and nonobesity (P = .03). In this study, there was significant patient- and surgeon-level variation in sexual function recovery over 2 years following radical prostatectomy. Variation in surgeon-level sexual function outcomes presents an opportunity and model for surgical collaborative quality improvement.

Surgeon level variation in outcome of repair of congenital diaphragmatic hernia with particular reference to the management of recurrence

IntroductionThe aim of this study is to investigate firstly, the rate of recurrence following primary repair of a congenital diaphragmatic hernia (CDH) and secondly, the rate of recurrence following revisional surgical repair. The primary outcome is rate of recurrence. Secondary outcomes are to establish whether recurrence is related to surgeon, surgeon volume, side of defect, the use of a patch, or a thoracopscopic approach MethodsAll repairs performed in an English regional center over 22 years were recorded. Possible explanatory variables were whether the repair was itself of a recurrence, the surgeon's identity, the surgeon's volume of prior repairs, the side of the defect, the use of a patch. Results198 repairs were performed; 170 primary repairs and 28 of recurrences. Failure occurred significantly more commonly among recurrences (32%) than primary repairs (11%), p = 0.005. Failure of the primary repair was significantly more common where a patch was used 8/34 (23%) rather than a sutured repair 10/136 (7%), p = 0.006, or where a thoracoscopic technique was used 4/13 (31%) rather than laparotomy 14/157 (9%) p = 0.01. Failure of the primary repair was unrelated to the identity of the surgeon (Χ2 = 5, p = 0.9) or the volume of prior repairs (t = 0.3, p = 0.6). However, failure of repair of a recurrence was significantly related to the surgeon's volume of prior repairs (t = 2.3, p = 0.01) and the identity of the surgeon (Χ2 = 17, p = 0.014), but not the use of a patch (Χ2 = 1.6, p = 0.2). ConclusionsRepair of a recurrence of a CDH has a higher probability of failure than the original repair and is related to both the identity of the surgeon and the prior volume of experience. There is a volume outcome relationship for the repair of recurrence, but not the primary repair of CDH. Our study suggests the repair of recurrence of CDH should be restricted to surgeons with proven outcomes for this procedure.

Trading the Proximal Risk for the Distal Payout in Annular Enlargement With Aortic Valve Replacement

Trading the Proximal Risk for the Distal Payout in Annular Enlargement With Aortic Valve Replacement

Surgeon-Level Variation in Outcome following Esophageal Atresia Repair Is Not Explained by Volume.

To assess whether there is a difference in operative outcome for esophageal atresia (EA) depending on a surgeon's seniority as defined by years in consultant practice or number of cases performed. In addition a Clavien-Dindo score was used to sequentially analyze the outcome of each surgeon's EA procedure. All repairs performed over 22 years in an English regional center were analyzed. Outcomes were: death, anastomotic leak, need for dilatation, need for more than three dilatations, need for fundoplication, and a Clavien-Dindo adverse outcome of ≥3b. Possible explanatory variables were: number of prior repairs by the surgeon, surgeon's years of consultant experience. We also examined the effect of variables intrinsic to the infant as possible confounding variables and as independent predictors of outcome. A total of 190 repairs were performed or supervised by 12 consultants. There was no significant association between consultant experience and any objective outcome. However, sequential analysis suggests there is variation between surgeons in the incidence of Clavien-Dindo events of ≥3b. Performance showed deterioration in one case. Mortality was explicable by cardiac and renal anomalies. There are surgeon-level variations in outcomes for the procedure of EA repair, but they are not explained by volume. Surgeon performance can deteriorate. Our study would not support the concept that patient outcomes could be improved by concentrating the provision of this surgery to fewer hospitals or surgeons.

Ureteroscopy in Patients Taking Anticoagulant or Antiplatelet Therapy: Practice Patterns and Outcomes in a Surgical Collaborative.

AUA guidelines recommend ureteroscopy as first line therapy for patients on anticoagulant or antiplatelet therapy and advocate using a ureteral access sheath. We examined practice patterns and unplanned health care use for these patients in Michigan. Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry we identified ureteroscopy cases from 2016 to 2019. We assessed outcomes and adherence to guidelines based on therapy at time of ureteroscopy: 1) anticoagulant: continuous warfarin or novel oral agent therapy; 2) antiplatelet: continuous clopidogrel or aspirin therapy; 3) control: not on anticoagulant/antiplatelet therapy. We fit multivariate models to assess anticoagulant or antiplatelet therapy association with emergency department visits, hospitalization and ureteral access sheath use. In total, 9,982 ureteroscopies were performed across 31 practices with 3.1% and 7.8% on anticoagulant and antiplatelet therapy, respectively. There were practice (0% to 21%) and surgeon (0% to 35%) variations in performing ureteroscopy on patients on anticoagulant/antiplatelet therapy regardless of volume. After adjusting for risk factors, anticoagulant or antiplatelet therapy was not associated with emergency department visits. Hospitalization rates in anticoagulant, antiplatelet and control groups were 4.3%, 5.5% and 3.2%, respectively, and significantly increased with antiplatelet therapy (OR 1.48, 95% CI 1.02-2.14). Practice-level ureteral access sheath use varied (23% to 100%) and was not associated with anticoagulant/antiplatelet therapy. Limitations include inability to risk stratify between type/dosage of anticoagulant/antiplatelet therapy. We found practice-level and surgeon-level variation in performing ureteroscopy while on anticoagulant/antiplatelet therapy. Ureteroscopy on anticoagulant is safe. However, antiplatelet therapy increases the risk of hospitalization. Despite guideline recommendations, ureteral access sheath use is not associated with anticoagulant/antiplatelet therapy.

PD09-09 EVALUATION OF POSTOPERATIVE OPIOID PRESCRIBING FOLLOWING COMMON UROLOGIC PROCEDURES IN THE STATE OF WISCONSIN

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II (PD09)1 Apr 2020PD09-09 EVALUATION OF POSTOPERATIVE OPIOID PRESCRIBING FOLLOWING COMMON UROLOGIC PROCEDURES IN THE STATE OF WISCONSIN Aravind Viswanathan*, Caprice Greenberg, Jessica Schumacher, Manasa Venkatesh, Jonathan Kohler, Elise Lawson, Kyle Richards, Edwin Abel, Tracy Downs, David Jarrard, and Tudor Borza Aravind Viswanathan*Aravind Viswanathan* More articles by this author , Caprice GreenbergCaprice Greenberg More articles by this author , Jessica SchumacherJessica Schumacher More articles by this author , Manasa VenkateshManasa Venkatesh More articles by this author , Jonathan KohlerJonathan Kohler More articles by this author , Elise LawsonElise Lawson More articles by this author , Kyle RichardsKyle Richards More articles by this author , Edwin AbelEdwin Abel More articles by this author , Tracy DownsTracy Downs More articles by this author , David JarrardDavid Jarrard More articles by this author , and Tudor BorzaTudor Borza More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000836.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Postoperative opioid prescribing is associated with a 6% new persistent use rate in previously opioid naïve patients and accounts for significant supply available for diversion to the illicit market. Increased awareness of the opioid epidemic has let to various efforts to curb overprescribing. To assess the effect of these efforts we evaluated prescribing patterns following common urologic procedures in the state of Wisconsin. METHODS: We used Wisconsin Health Information Organization data, an all-payer claims database covering 75% of Wisconsin’s population to identify patients undergoing common urologic procedures (Major: cystectomy, prostatectomy, nephrectomy and Minor: vasectomy, prostate biopsy, ESWL, ureteroscopy, TURP, TURBT). We limited our analysis to Medicaid and commercial insurance data to ensure complete ascertainment of prescription fills. We measured the opioid dose prescribed within 7 days of discharge and identified surgeon level variation in prescribing following both Major and Minor procedures. RESULTS: We identified 11,139 patients undergoing Minor procedures and 937 patients undergoing Major procedures. Initial fill rates ranged from 3.6% (prostate biopsy) to 70.6% (prostatectomy, Table). Higher initial doses were prescribed following Major surgery with a median range of 200-247 morphine milligram equivalents (MME) compared to Minor surgery, where the median range was 75-146 MME. We noted significant surgeon level variation within Minor and Major procedures (Figure). CONCLUSIONS: Opioid prescribing remains common after the majority of common urologic procedures. Significant surgeon level variation exists within the state of Wisconsin in regards to initial postoperative opioid prescriptions. Understanding drivers of this variation is critical to ongoing efforts attempting to address opioid overprescribing. Source of Funding: Pilot grant from Wisconsin Urologic Society © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e177-e178 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aravind Viswanathan* More articles by this author Caprice Greenberg More articles by this author Jessica Schumacher More articles by this author Manasa Venkatesh More articles by this author Jonathan Kohler More articles by this author Elise Lawson More articles by this author Kyle Richards More articles by this author Edwin Abel More articles by this author Tracy Downs More articles by this author David Jarrard More articles by this author Tudor Borza More articles by this author Expand All Advertisement PDF downloadLoading ...

Assessment of Surgeon Variation in Adherence to Evidence-Based Recommendations for Treatment of Trigger Finger

Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources. To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment. This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 (excluding a washout period from July 1, 2008, until June 30, 2010), with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019. Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger. After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach. In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; P = .27). Substantial variation in adherence was observed at the surgeon level (intraclass correlation, 33%). Plastic surgeons had no change in adherence over time compared with orthopedic surgeons (odds ratio [OR], 1.00; 95% CI, 0.98-1.02; P = .90), whereas general surgeons had increased adherence (OR, 1.04; 95% CI, 1.02-1.06; P < .001). Higher-volume surgeons were also more adherent to these evidence-based recommendations (OR, 1.59; 95% CI, 1.53-1.65; P < .001). This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger.

Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study

An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics. Retrospective cohort study. National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through2015. Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation. Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to2014. Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects. Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile. The study relied on administrative data, limiting capture of some factors affecting access outcomes. There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.

Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse

Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.