Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network.

BACKGROUND: Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE: With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN: A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS: Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION: Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Variations in payment patterns for surgical care in the centers for Medicare and Medicaid Services.

BACKGROUND: We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations. METHODS: We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions. RESULTS: The 20th, 40th, 60th, and 80th percentiles for the services-per-beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively (n = 83,376). Greater-earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios (P < .01), and we noted significant regional variation in the ratio of services per unique beneficiary (P < .001 for each of the 10 Standard Federal Regions). CONCLUSION: We found significant variation in patterns of payments for surgical care in CMS.

Engaging Physician Learners Through a Web-Based Platform: Individualized End-of-Life Education.

BACKGROUND: Web-based modules provide a convenient and low-cost education platform, yet should be carefully designed to ensure that learners are actively engaged. In order to improve attitudes and knowledge in end-of-life (EOL) care, we developed a web-based educational module that employed hyperlinks to allow users access to auxiliary resources: clinical guidelines and seminal research papers. METHODS: Participants took pre-test evaluations of attitudes and knowledge regarding EOL care prior to accessing the educational module, and a post-test evaluation following the module intervention. We recorded the type of hyperlinks (guideline or paper) accessed by learners, and stratified participants into groups based on link type accessed (none, either, or both). We used demographic and educational data to develop a multivariate mixed-effects regression analysis to develop adjusted predictions of attitudes and knowledge. RESULTS: 114 individuals participated. The majority had some professional exposure to EOL care (prior instruction 62%; EOL referral 53%; EOL discussion 56%), though most had no family (68%) or personal experience (51%). On bivariate analysis, non-partnered (p = .04), medical student training level (p = .03), prior palliative care referral (p = .02), having a family member (p = .02) and personal experience of EOL care (p < .01) were all associated with linking to auxiliary resources via hyperlinks. When adjusting for confounders, ß coefficient estimates and least squares estimation demonstrated that participants clicking on both hyperlink types were more likely to score higher on all knowledge and attitude items, and demonstrate increased score improvements. CONCLUSION: Auxiliary resources accessible by hyperlink are an effective adjunct to web-based learning in end-of-life care.

A Scalable Web-Based Module for Improving Surgical and Medical Practitioner Knowledge and Attitudes about Palliative and End-of-Life Care.

BACKGROUND: We built a web-based, interactive, self-directed learning module about end-of-life care. OBJECTIVE: The study objective was to develop an online module about end-of-life care targeted at surgeons, and to assess the effect of the module on attitudes towards and knowledge about end-of-life care. METHODS: Informed by a panel of experts in supportive care and educational assessment, we developed an instrument that required approximately 15 minutes to complete. The module targets surgeons, but is applicable to other practitioners as well. We recruited general surgeons, surgical subspecialists, and medical practitioners and subspecialists from UCLA and the GLA-VA (N=114). We compared pre- and post-intervention scores for attitude and knowledge, then used ANOVA to compare the pre- and postmodule means for each level of the covariate. We performed bivariable analyses to assess the association of subject characteristic and change in score over time. We ran separate analyses to assess baseline and change scores based on the covariates we had selected a priori. RESULTS: Subjects improved meaningfully in all five domains of attitude and in each of the six knowledge items. Individuals younger than 30 years of age had the greatest change in attitudes about addressing pain, addressing end-of-life goals, and being actively involved as death approached; they also had the most marked improvement in total knowledge score. Having a family member die of cancer within the last five years or a personal experience with palliative care or hospice were associated with higher change scores. CONCLUSIONS: A web-based education module improved surgical and medical provider attitudes and knowledge about end-of-life care.

Building a medical neighborhood in the safety net: an innovative technology improves hematuria workups.

OBJECTIVE: To analyze whether ereferral is associated with decreased time to completion of hematuria workup. METHODS: We included 100 individuals referred to Olive View-UCLA Medical Center for urologic consultation for hematuria. Half were referred before implementation of ereferral, and half were referred after the system was implemented. We performed bivariate analysis to assess correlations of baseline subject sociodemographic and clinical characteristics with ereferral status. We also created a multivariate linear regression model for log days to completion of hematuria workup, with ereferral as the main predictor and subject sociodemographic and clinical characteristics as covariates. RESULTS: Excluding cases with an infectious cause, the mean number of days from urinalysis documenting hematuria to completed hematuria workup was 404 days before ereferral and 192 days after implementation of ereferral (median 239 vs 170; 2-sample median P = .0013). Upper tract imaging was obtained at a median of 76 days after initial positive urinalysis in the absence of infection, 122 days before ereferral, and 41 days after implementation of ereferral (2-sample median P = .1114). In all cases, lower tract evaluation was completed after upper tract imaging. Our multivariable model evaluating factors associated with time to hematuria workup demonstrated that ereferral use was independently associated with shorter time to hematuria workup (P = .006). CONCLUSION: Electronic consultations can significantly shorten the time to work-up of hematuria in the safety net.

Selective use of voiding cystourethrography in children undergoing renal transplant evaluation.

PURPOSE: Voiding cystourethrography is a routine component in evaluating children awaiting renal transplantation. We examined whether this assessment is necessary in children with renal failure due to dysplasia/aplasia/hypoplasia syndrome and unknown etiology, which account for up to 25% of those with renal failure requiring renal replacement therapies. MATERIALS AND METHODS: We performed an institutional review board approved, retrospective review of 191 children undergoing transplantation between 2002 and 2007. We reviewed clinical factors associated with positive findings on voiding cystourethrogram. We also reviewed cystography results in children with chronic kidney disease due to renal dysplasia and unknown etiology. RESULTS: We identified 113 boys and 78 girls who underwent renal transplantation during the study period. Pre-transplant voiding cystourethrography was documented in 108 children (57%). Predictors of positive pre-transplant results included history of hydronephrosis, urinary tract infections and renal failure due to urological causes. No pre-transplant cystogram was positive in children with renal failure due to dysplasia or unknown etiology. CONCLUSIONS: We recommend selective use of voiding cystourethrography to evaluate children awaiting renal transplantation. We continue to support performing this test in children with renal failure due to urological causes and those with a history of urinary tract infection, hydronephrosis or voiding dysfunction. In the absence of these findings children with renal failure due to renal dysplasia/aplasia/hypoplasia syndrome or unknown etiology need not undergo pre-transplant voiding cystourethrography.

Myelomeningocele information on the internet is accessible and of variable quality, and requires a high reading level.

PURPOSE: We assessed the accessibility, readability and quality of myelomeningocele information on the Internet. MATERIALS AND METHODS: We entered the term "spina bifida" into the Google, Yahoo! and Microsoft Network search engines, and stored the first 100 links from each Web site. A total of 164 unique Web sites remained for analysis, of which 159 were classified as relevant. Relevant Web sites were considered to have relevant content if more than 50% of the text was directly relevant to the disease, and to have relevant educational content if more than 50% of the text was aimed at relaying educational information. Readability was assessed using the Flesch-Kincaid Grade Level scale. The quality of the 159 Web sites with relevant content was assessed using American Public Health Association Criteria for Assessing Health Information on the Internet. Six criteria were assessed, namely credibility, content, links, design, interactivity and caveats. Web sites were analyzed by 2 separate medical doctors, with each reviewer blinded to the findings of the other. A weighted kappa statistic was used to calculate interrater reliability. RESULTS: Of 159 relevant sites 146 (91.8%) had relevant content and 122 (76.7%) had relevant educational content. The average Flesch-Kincaid reading level was 10.9 (range 6 to 12). Quality was assessed on a 3-point scale, with 1 denoting poor quality, 2 fair and 3 good. Average scores were 1.92 for credibility, 1.88 for content, 2.29 for links, 2.53 for design, 1.99 for interactivity and 2.90 for caveats. The weighted kappa statistic for interrater reliability was 0.83. CONCLUSIONS: Myelomeningocele information on the Internet is relatively accessible, requires a high reading level for comprehension and is of variable quality.

Outcomes of bladder neck closure for intractable urinary incontinence in patients with neurogenic bladders.

OBJECTIVE: Recent reports of outcomes of bladder neck closure for neurogenic urinary incontinence reveal poor initial continence and high vesicourethral fistula rates. We evaluated a large series of patients who underwent complete transection and closure of the bladder neck with modified abdominal stoma creation. MATERIALS AND METHODS: The medical records of 52 consecutive patients (23 males and 29 females) undergoing bladder neck closure by a single surgeon between July 1996 and January 2003 were reviewed. Mean follow up was 20 months (range 2-68 months) and mean age was 13.9 years (range 1.5-58 years). Forty-two patients (81%) underwent concomitant bladder augmentation. Catheterizable stomas included 46 appendicovesicostomies (88%) and six Monti tubes (12%). Of the 52 patients, 22 were confined to wheelchairs (42%), and the majority of patients had spinal cord pathology (40/52, 77%). Mean preoperative vesical leak point pressure was 25 cm/H(2)O (range 4-69 cm/H(2)O). RESULTS: Complete postoperative urinary continence was achieved in 44 patients (88%) after one procedure. Of the six patients who were incontinent (12%), one had a vesicourethral fistula (2%) and five had incontinence at the urinary diversion stoma (10%). Twelve of 50 patients had urinary stomal stenosis (24%), with six requiring urgent evaluation (12%) and six requiring surgical revision (12%). Postoperative urinary continence was unknown in two patients due to inadequate follow-up data. CONCLUSIONS: Our findings suggest that bladder neck closure is a safe and effective method of achieving urinary continence in children with neurogenic voiding dysfunction. While there are risks of stomal stenosis and fistula formation, modifications in surgical technique may reduce them to acceptable levels.

Measurement of bladder compliance can be standardized by a dimensionless number: theoretical perspective.

OBJECTIVES: To: (i) calculate traditional compliance (CTrad) for a normal bladder by DeltaV/DeltaPdet, where DeltaV is the mean volumetric capacity and DeltaPdet is the detrusor pressure rise; (ii) assess its usefulness; (iii) identify the variables that are necessary for correctly assessing bladder compliance; and (iv) using these variables, report a method that, because it includes the effect of patient age, sex and size, correctly assesses compliance for management strategies. METHODS: We obtained the mean volumetric capacity of a normal bladder (V(cap,NL)) and the mean detrusor pressure rise (P(cap,NL)) on filling a normal bladder to its volumetric capacity from our and other published work; (ii) calculated CTrad for a normal bladder; (ii) showed that the variables necessary for assessing compliance correctly are DeltaV, DeltaPdet, V(cap,NL), and P(cap,NL); and (iii) showed that the relationship among these is the dimensionless number, NWahl(-1), calculated as (DeltaV/V(cap,NL))/(DeltaPdet/P(cap,NL)). This value for individuals with a normal bladder was calculated, tabulated and graphed. RESULTS: Because a normal individual's bladder capacity increases with age while the detrusor pressure increase does not, CTrad increases with age and therefore cannot be used for assessing compliance. Published data substantiate our result that CTrad for an individual with a normal bladder varies from 6.3 at 0.5 years old to 90 mL/cmH2O at 18 years old. NWahl(-1) correctly assesses bladder compliance because it is the same for all normal cases; consequently NWahl(-1) is more practical for clinical use. CONCLUSIONS: Bladder compliance is standardized using DeltaV, DeltaPdet, V(cap,NL), and P(cap,NL) to give NWahl(-1), and bladder compliance is usefully reported using this value.

Measurement of bladder compliance can be standardized by a dimensionless number: clinical perspective.

OBJECTIVE: To devise a new, practical and more accurate method for measuring bladder compliance, and to show that traditional estimates of compliance are impractical. MATERIALS AND METHODS: Childhood bladder capacity varies greatly with age while detrusor pressure in a normal bladder does not. Consequently, traditional bladder compliance (DeltaV/DeltaP) increases with age, i.e. maturation. Therefore we devised a standard method that includes normal values of pressures and volumes to calculate and report bladder compliance in children, and that also applies to adults. A dimensionless number (NWahl(-1)) was computed for standardizing bladder compliance, comparing the normalized capacity to normalized pressure by the ratio (DeltaV/V(cap,NL))/(DeltaP/P(cap,NL)), where DeltaP is the pressure at bladder capacity, DeltaV the volume at bladder capacity, V(cap,NL) the volume at mean expected bladder capacity and P(cap,NL) the pressure at mean expected bladder capacity. V(cap,NL) is obtained from nomograms of published data. RESULTS: The bladder compliance of patients undergoing urodynamic testing was calculated using NWahl(-1) and the traditional equation (DeltaV/DeltaP). NWahl(-1) provided a more accurate diagnosis and therefore was of more practical use. CONCLUSIONS: Bladder compliance depends on patient age, sex and size; the new estimate used to standardize bladder compliance is based on these factors and is a dimensionless number. This may help when comparing patients and assessing outcomes.