The Cost Burden of Complications after Major Surgery for Urological Cancer: Opportunities for Value Creation in Urology.

INTRODUCTION: While improving patient outcomes and controlling costs have become primary pursuits in health care, priority areas for value creation remain unclear. In urology operative morbidity serves as a major barrier to high value care. To guide improvement efforts we assessed the prevalence and cost of inpatient complications among patients undergoing major surgery for urological cancer. METHODS: Using the Nationwide Inpatient Sample from 2009 to 2011 we identified hospital admissions for cancer related prostatectomy, nephrectomy and cystectomy among adults age 18 years or older. We then measured the occurrence of inpatient complications, medical and surgical, and used multivariable, mixed effect models to estimate the associated marginal cost. RESULTS: Among weighted samples of 229,743 prostatectomies, 111,683 nephrectomies and 31,213 cystectomies, inpatient complications occurred in 9.4% (95% CI 8.6-10.2), 32.0% (95% CI 30.7-33.4) and 57.7% (95% CI 54.7-60.6) of hospital admissions, respectively. For these respective samples an adverse event added $4,947 (95% CI 4,523-5,454), $6,782 (95% CI 6,336-7,293) and $10,756 (95% CI 9,999-11,759) to the cost of inpatient care. While surgical events occurred most frequently, medical complications generated $1,699 (95% CI 994-2,423), $2,052 (95% CI 1,545-2,662) and $4,852 (95% CI 3,519-6,531) more in expense per episode for prostate, kidney and bladder cancer cases, respectively. CONCLUSIONS: Many patients undergoing major surgery for urological cancer experience a complication, adding substantially to health care costs. As urologists seek to generate value in urological cancer care, the prevention and management of complications, especially medically driven events, represent an immediate opportunity for quality improvement and cost savings.

Health Insurance Status and Disparities in Kidney Cancer Care.

INTRODUCTION: Through PPACA (Patient Protection and Affordable Care Act) many adults have or will gain health insurance via Medicaid expansion. To understand how this policy change may potentially impact patients with kidney cancer we examined the relationship between insurance status and cancer related outcomes. METHODS: Using SEER (Surveillance, Epidemiology and End Results) data we identified 18,632 patients 26 to 64 years old with kidney cancer from 2007 to 2009. For each patient we classified insurance status as no insurance, Medicaid or private insurance. After adjusting for patient and county characteristics we measured the association of insurance status with cancer stage, treatment and 1-year mortality using multinomial logistic regression with clustering or generalized estimating equations as appropriate. RESULTS: In our study cohort 937 (5.0%) and 2,027 patients (10.9%) had no insurance and Medicaid, respectively. These patients were more likely to be younger, nonwhite, unmarried and residing in areas with lower income, education or employment (p <0.001). On adjusted analyses uninsured and Medicaid patients more often presented with advanced disease (21.3% vs 19.6% vs 11.0%) but less frequently received treatment (86.2% vs 87.9% vs 93.4%, each p <0.001) compared with privately insured patients. These adults also died of kidney cancer more often (13.6% vs 12.5% vs 6.4%, p <0.001) likely due to differences in stage and receipt of cancer directed therapy. CONCLUSIONS: Uninsured and Medicaid patients suffer disproportionately from kidney cancer with equal magnitude. Given the reliance on Medicaid, even as insurance coverage expands differences in outcomes will likely persist, underscoring the need for additional efforts that address disparities in kidney cancer care.

Technique and outcomes of bladder neck intussusception during robot-assisted laparoscopic prostatectomy: A parallel comparative trial.

INTRODUCTION: Postprostatectomy incontinence significantly impairs quality of life. Although bladder neck intussusception has been reported to accelerate urinary recovery after open radical retropubic prostatectomy, its adaption to robotic surgery has not been assessed. Accordingly, we describe our technique and compare outcomes between men treated with and without bladder neck intussusception during robot-assisted laparoscopic prostatectomy. MATERIALS AND METHODS: We performed a comparative trial of 48 men undergoing robot-assisted laparoscopic prostatectomy alternating between bladder neck intussusception (n = 24) and nonintussusception (n = 24). Intussusception was completed using 3-0 polyglycolic acid horizontal mattress sutures anterior and posterior to the bladder neck. We assessed baseline characteristics and clinicopathologic outcomes. Adjusting for age, body mass index, race, and D׳Amico risk classification, we prospectively compared urinary function at 2 days, 2 weeks, 2 months, and last follow-up using the urinary domain of the Expanded Prostate Cancer Index-Short Form. RESULTS: Baseline patient characteristics and clinicopathologic outcomes were similar between treatment groups (P>0.05). Median catheter duration (8 vs. 8d, P = 0.125) and rates of major postoperative complications (4.2% vs. 4.2%, P = 1.000) did not differ. In adjusted analyses, Expanded Prostate Cancer Index-Short Form urinary scores were significantly higher for the intussusception arm at 2 weeks (65.4 vs. 46.6, P = 0.019) before converging at 2 months (69.1 vs. 68.3, P = 0.929) after catheter removal and at last follow-up (median = 7mo, 80.5 vs. 77.0; P = 0.665). CONCLUSIONS: Bladder neck intussusception during robot-assisted laparoscopic prostatectomy is feasible and safe. Although the long-term effects appear limited, intussusception may improve urinary function during the early recovery period.