Payments and Patient Cost Sharing for Prostate Biopsies According to Image Guidance, Practice Site and Use of Anesthesia.

INTRODUCTION: Use of magnetic resonance imaging for prostate biopsies has increased and more biopsies are performed in nonoffice based settings. These changes will likely impact payments related to prostate biopsies. METHODS: Using private insurance claims from 2009 to 2015 we identified men who underwent transrectal ultrasound guided (CPT 55700) or transperineal (CPT 55706) prostate biopsies. We assumed any magnetic resonance imaging of the pelvis within 3 months prior to biopsy was for image based guidance. We assigned biopsy site as being performed in the office, ambulatory surgical center or hospital. Use of anesthesia was based on CPT codes 00100-01999. Our primary outcome was aggregate payments for anesthesia, pathology, imaging and procedural services. We also studied patient out-of-pocket costs. Multivariable regression was used to generate predicted payments based on magnetic resonance imaging performance, anesthesia and site of biopsy. RESULTS: We identified 304,388 biopsy episodes, of which 2.2% were magnetic resonance imaging guided and 0.7% were transperineal. Median cost of magnetic resonance imaging guided biopsies was greatest at $4,396 (IQR $2,784-$7,127) compared to the costs of transperineal and transrectal ultrasound guided biopsies. Imaging accounted for the greatest share of magnetic resonance imaging guided biopsy costs (median $1,704, IQR $975-$3,043). Magnetic resonance imaging guided biopsies in a hospital with anesthesia had the highest cost at $5,832 per episode (95% CI $5,732-$5,934). There was a fivefold difference in patient cost sharing between the least expensive (transperineal, office and no anesthesia $168) and most expensive (magnetic resonance imaging guided, ambulatory surgical center with anesthesia $891) modality. CONCLUSIONS: Total and out-of-pocket costs for prostate biopsies vary substantially based on modality, location and anesthesia use.

Efficacy of Percutaneous Tibial Nerve Stimulation for Overactive Bladder in Women and Men at a Safety Net Hospital.

PURPOSE: We investigated efficacy and compliance related to percutaneous tibial nerve stimulation in patients treated for overactive bladder at a large, urban safety net hospital. MATERIALS AND METHODS: Consecutive patients who underwent percutaneous tibial nerve stimulation at Grady Memorial Hospital from May 2015 through January 2019 were included in our cohort and records were reviewed retrospectively. Primary outcomes of interest included self-reported urinary symptoms and episodes of urinary incontinence. Our secondary outcome of interest was patient compliance, defined as completion of 12 or more treatment sessions. Descriptive analysis and paired t-tests were performed. RESULTS: Of the 50 patients with a mean ± SD age of 59 ± 12 years 80% were black, 52% were male, 34% were uninsured and 54% subscribed to government insurance. Prior treatment included behavioral modification in 100% of cases, anticholinergics in 86% and mirabegron in 4%. Patients completed a mean of 10.7 ± 2.7 of the 12 planned weekly percutaneous tibial nerve stimulation treatments. Of the patients 70% completed all 12 weekly treatments and 77% of those who completed 12 treatments continued to maintenance treatment. After percutaneous tibial nerve stimulation treatment average symptoms improved across all metrics, including mean daytime frequency (from 11.0 to 6.6 episodes per day or -24.5%), nighttime frequency (from 4.8 to 2.5 episodes per night or -47.1%), urgency score (from 3.4 to 1.9 or -42.1%) and incontinence (from 1.6 to 0.4 episodes per day or -79.6%) (each p <0.001). A total of 43 patients (86%) reported symptom improvement. CONCLUSIONS: Percutaneous tibial nerve stimulation had favorable efficacy and compliance in a traditionally underserved patient population. This should be considered as a feasible modality to manage overactive bladder symptoms in patients in a similar demographic.

Gaps in male infertility health services research.

The field of male infertility remains a niche specialty within urology. Although a male factor is implicated in at least 50% of all cases of infertility, and male infertility is thought to be associated with overall male health and longevity, this subspecialty comprises a relatively small proportion of urologic training. There remains a large knowledge gap with regards to prevalence of male factor infertility, as well as the need for health services for the diagnosis and treatment of male infertility. Health services research is a multidisciplinary approach that combines both qualitative and quantitative methodologies to improve patient care and outcomes pertaining to male infertility. This review summarizes the current literature pertaining to health services for male infertility and identifies opportunities for future research to improve access to and outcomes of male infertility care, including improvements in costs of care, patient education, and health policy.

The Clinical Course of Patients With Prostate-Specific Antigen ≥100 ng/ml: Insight Into a Potential Population for Targeted Prostate-Specific Antigen Screening.

OBJECTIVE: To characterize men presenting to a tertiary care safety-net hospital with prostate-specific antigen (PSA) values ≥100 ng/mL and to identify a potential population for targeted PSA screening. MATERIALS AND METHODS: Retrospective review of 100 randomly selected patients of a total of 204 who presented to Grady Memorial Hospital from 2004 to 2011 with initial PSA ≥100 ng/mL was performed. Demographics, disease characteristics, and survival status were obtained via the Tumor Registry and a combination of electronic medical records and older paper charts, with missing data from paper charts excluded on analyses. RESULTS: Sixty-five patients were newly diagnosed with prostate cancer on presentation and 35 were previously diagnosed. Median PSA at presentation was 405.5 ng/mL (minimum, 100 and maximum, 7805), 81% had metastatic disease, and 94% had Gleason ≥7. Median Cancer of the Prostate Risk Assessment score was 8. Median age at presentation was 67.4 years (minimum, 40.8 and maximum, 90.6). Eighty-nine percent of patients were African American, 24% lived alone, 12% were homeless or incarcerated, 51% were insured by Medicare or Medicaid, and 47% were uninsured. Only 1% had human immunodeficiency virus, 19% had diabetes, and 13% had chronic kidney disease. Of the 65 newly diagnosed patients, only 23% had ever been screened and 9% were previously biopsied. Median time from presentation to death was 17.8 months (minimum, 0.16 and maximum, 107.1). CONCLUSION: Among men presenting with PSA ≥100 ng/ml at a safety-net hospital, the majority were African American, of lower socioeconomic status, and had metastatic disease. Uniform absence of prostate cancer screening may expose greater numbers of at-risk men to similar outcomes. Discussion is needed regarding targeted PSA screening in higher risk, vulnerable patients.

What are Infertility Treatment Center Websites Telling Couples about Male Factor Infertility?

INTRODUCTION: We evaluated patient directed information provided on the websites of infertility treatment centers. METHODS: We identified 428 infertility treatment centers based on the 2011 CDC (Centers for Disease Control and Prevention) Fertility Clinic Success Rates Report. The website of each center was evaluated for the presence and/or description of terms related to the etiology, workup and treatment of male factor infertility using a standardized data abstraction form. Differences in the variables were examined with respect to United States Census Bureau geographic regions, academic center status and affiliation with urologists. The Flesch-Kincaid readability score was assessed. RESULTS: Only 78% of websites acknowledged a male factor etiology for infertility, 85% mentioned any evaluation of the male partner, 63% mentioned any treatment options for male factor infertility and 23% discussed referral to a urologist. When stratified by geographic region, academic status and urologist affiliation, differences in the variables of interest were most likely when stratified by urologist affiliation. The median website reading level was twelfth grade. CONCLUSIONS: Patient directed information pertaining to the etiology, workup and treatment of male factor infertility on the websites of infertility treatment centers is variable at best. Etiology is completely lacking on more than 20% of websites. It is likely that couples relying on Internet based information regarding infertility evaluation and treatment are not well informed about the importance or the benefit of a male factor evaluation.

Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database.

PURPOSE: Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables. MATERIALS AND METHODS: We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort. RESULTS: Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214. CONCLUSIONS: Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.

GABAB agonism promotes sleep and reduces cataplexy in murine narcolepsy.

γ-Hydroxybutyrate (GHB) is an approved therapeutic for the excessive sleepiness and sudden loss of muscle tone (cataplexy) characteristic of narcolepsy. The mechanism of action for these therapeutic effects is hypothesized to be GABAB receptor dependent. We evaluated the effects of chronic administration of GHB and the GABAB agonist R-baclofen (R-BAC) on arousal state and cataplexy in two models of narcolepsy: orexin/ataxin-3 (Atax) and orexin/tTA; TetO diphtheria toxin mice (DTA). Mice were implanted for EEG/EMG monitoring and dosed with GHB (150 mg/kg), R-BAC (2.8 mg/kg), or vehicle (VEH) bid for 15 d-a treatment paradigm designed to model the twice nightly GHB dosing regimen used by human narcoleptics. In both models, R-BAC increased NREM sleep time, intensity, and consolidation during the light period; wake bout duration increased and cataplexy decreased during the subsequent dark period. GHB did not increase NREM sleep consolidation or duration, although NREM delta power increased in the first hour after dosing. Cataplexy decreased from baseline in 57 and 86% of mice after GHB and R-BAC, respectively, whereas cataplexy increased in 79% of the mice after VEH. At the doses tested, R-BAC suppressed cataplexy to a greater extent than GHB. These results suggest utility of R-BAC-based therapeutics for narcolepsy.