Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) can generally be performed with 1-2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day. METHODS: Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications. RESULTS: Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0-2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications. CONCLUSIONS: This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.

Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists.

INTRODUCTION: Patients who seek urologic care have recently reported a high degree of financial toxicity from prescription medications, including management for nephrolithiasis, urinary incontinence, and urological oncology. Estimating out-of-pocket costs can be challenging for urologists in the US because of variable insurance coverage, local pharmacy distributions, and complicated prescription pricing schemes. This article discusses resources that urologists can adopt into their practice and share with patients to help lower out-of-pocket spending for prescription medications. METHODS: We identify 4 online tools that are designed to direct patients toward more affordable prescription medication options: the Medicare Part D Plan Finder, GoodRx, Amazon, and the Mark Cuban Cost Plus Drug Company. A brief historical overview and summary for patients and clinicians are provided for each online resource. A patient-centered framework is provided to help navigate these 4 available tools in clinic. RESULTS: Among the 4 tools we identify, there are multiples tradeoffs to consider as financial savings and features can vary. First, patients insured by Medicare should explore the Part D Plan Finder each year to compare drug plans. Second, patients who need to urgently refill a prescription at a local pharmacy should visit GoodRx. Third, patients who are prescribed recurrent generic prescriptions for chronic conditions can utilize the Mark Cuban Cost Plus Drug Company. Finally, patients who are prescribed 3 or more chronic medications can benefit from subscribing to Amazon RxPass. CONCLUSIONS: Prescription medications for urologic conditions can be expensive. This article includes 4 online resources that can help patients access medications at their most affordable costs. Urologists can provide this framework to their patients to help support lowering out-of-pocket drug costs.

Vulnerability to Financial Toxicity From Stone Surgery.

PURPOSE: Financial toxicity has been described in stone formers however little is understood regarding its causes and how it may relate to stone surgery. We therefore aimed to longitudinally describe markers of financial strain in stone formers from the preoperative to postoperative time points. MATERIALS AND METHODS: A prospective cohort study was conducted from January 2022 to April 2023. Patients were enrolled in the waiting area prior to undergoing elective ureteroscopy or percutaneous nephrolithotomy. Participants completed the Commonwealth Fund's Biennial Health Insurance Survey at this time point and at 30 days postop. Items were pre-selected from the survey to capture markers of financial strain due to healthcare costs. RESULTS: One hundred nine participants were enrolled. Participants were a majority white (70%), college educated (62%), and privately ensured (72%). Despite these traditionally protective sociodemographic features, 42% of patients reported some marker of financial strain at the preoperative timepoint. Patients with Medicaid reported even higher financial stress (67%). Furthermore, 46% of patients did not know their deductible amount. Response rate was low at 30 days postop (35%) but suggested some patients were experiencing new financial strains. CONCLUSIONS: This paper shows that a significant proportion of stone patients are already displaying markers of financial strain from healthcare bills even prior to surgery as well as poor understanding of the costs they may incur. This makes them vulnerable to experiencing financial toxicity postoperatively and emphasizes the importance of understanding all contributing factors when developing future strategies to intervene in financial toxicity.

Prostate-Specific Antigen Screening in Smokers: A Comprehensive Analysis Using a National Behavioral Survey.

INTRODUCTION: Cigarette smoking is associated with higher-risk prostate cancer at the time of diagnosis and increased overall and prostate cancer‒specific mortality. Previous studies indicate smokers are less likely to undergo PSA screening. Herein we investigate the association between smoking and PSA screening using a nationally representative US survey. We hypothesize that smokers are less likely to undergo guideline-concordant PSA screening. METHODS: We performed a cross-sectional analysis of men aged 55 to 69 who responded to the cigarette smoking and PSA screening questions of the 2018 Behavioral Risk Factor Surveillance System survey. Adjusted prevalence and adjusted risk differences were calculated using complex weighted multivariable Poisson regression modeling. RESULTS: We identified 58,996 individuals who qualified for analysis. PSA screening prevalence was 39% (95% CI: 39%-40%) nationally, 42% (95% CI: 41%-44%) for never smokers, 42% (95% CI: 39%-40%) for former smokers, and 27% (95% CI: 25%-29%) for current smokers, including 27% (95% CI: 24%-29%) for daily smokers and 29% (95% CI: 24%-33%) for nondaily smokers. Compared to never smokers, the adjusted relative risk for undergoing PSA screening was 0.81 for current smokers (95% CI: 0.75-0.88, P < .01) and 0.99 for former smokers (95% CI: 0.94-1.03, P = .53). CONCLUSIONS: Current smokers are less likely to undergo recommended PSA screening, but former smokers are screened at similar rates as never smokers. As delays in diagnosis may substantially contribute to worse prostate cancer outcomes, targeted interventions to increase screening in this population may yield significant effects.

Race/Ethnicity and Insurance's Impact on Delays to Kidney Stone Surgery Scheduling.

OBJECTIVE: To evaluate the association between ethnicity/insurance status and time to kidney stone surgery. METHODS: We retrospectively assessed all patients with evaluation of nephrolithiasis in the emergency room (ED), followed by definitive stone surgery (ureteroscopy/percutaneous nephrolithotomy/ESWL) at our major academic health system consisting of 3 hospitals in a dense, urban center. RESULTS: A total of 682 patients were included. A total of 2.8% (n = 19) were uninsured, 19.3% (n = 132) were enrolled in Medicaid, 23.3% (n = 159) were enrolled in Medicare and 54.5% (n = 372) had commercial insurance. Uninsured patients had a short median time to surgery of only 21 days (IQR 6-49), while Medicare patients had a longer time at 39 days, (IQR 17-64), although these were not significantly different (P =.12). Black race was associated with a higher percentage of uninsured and Medicaid patients (P ≤.001). There was no difference in clinical or patient reported characteristics between the insurance groups (all P >.05) 6.9%, 17.7%, 26.7%, and 48.6% of patients self-identified as Hispanic, Other, Black, and White, respectively. Hispanic patients had the shortest median time to surgery of 28 days (IQR 10-48), while Black patients the longest with a median of 38.5 days (18-72) (P =.007). Clinical variables at presentation including nausea/vomiting, hydronephrosis and sepsis were not statistically significant between the patient groups (all P >.05). CONCLUSION: Our study illustrates persistent delays in surgery scheduling for Black patients regardless of insurance status. This should inform practice patterns for urology providers, highlighting our need to enact institutional safety nets to promote expedient follow up for a vulnerable population.

Emergency department and hospital revisits after ambulatory surgery for kidney stones: an analysis of the Healthcare Cost and Utilization Project.

Our objective was to identify the rate of revisit to either emergency department (ED) or inpatient (IP) following surgical stone removal in the ambulatory setting, and to identify factors predictive of such revisits. To this end, the AHRQ HCUP ambulatory, IP, and ED databases for NY and FL from 2010 to 2014 were linked. Cases were selected by primary CPT for shock-wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL) with accompanying ICD-9 for nephrolithiasis. Cystoscopy (CYS) was selected as a comparison group. The risk of revisit was explored using multivariate models. The overall unplanned revisit rate following stone removal was 6.4% (4.2% ED and 2.2% IP). The unadjusted revisit rates for SWL, URS, and PNL are 5.9%, 6.8%, and 9.0%, respectively. The adjusted odds of revisit following SWL, URS, and PNL are 1.93, 2.25, and 2.70 times higher, respectively, than cystoscopy. The majority of revisits occurred within the first two weeks of the index procedure, and the most common reasons for revisit were due to pain or infection. Younger age, female sex, lower income, Medicare or Medicaid insurance, a higher number of chronic medical conditions, and hospital-owned surgery centers were all associated with an increased odds of any revisit. The most important conclusions were that ambulatory stone removal has a low rate of post-operative revisits to either the ED or IP, there is a higher risk of revisit following stone removal as compared to urological procedures that involve only the lower urinary tract, and demographic factors appear to have a moderate influence on the odds of revisit.

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms.

Importance: Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. Objective: To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. Design, Setting, and Participants: This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. Exposures: State Medicaid expansion status. Main Outcomes and Measures: Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. Results: Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. Conclusions and Relevance: These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.