Financial Implications of the Merit-Based Incentive Payment System for Surgical Health Care Professionals.

This study describes financial implications of the merit-based incentive payment system for surgical health care professionals.

Rural For-Profit Hospitals Are Associated With Higher Commercial Prices for 3 Common Urological Procedures.

INTRODUCTION: Rural patients lack access to urological services, and high local prices may dissuade underinsured patients from surgery. We sought to describe commercially insured prices for 3 urological procedures at rural vs metropolitan and for-profit vs nonprofit hospitals. METHODS: A cross-sectional analysis of commercially insured prices from the Turquoise Health Transparency data set was performed for ureteroscopy with laser lithotripsy, transurethral resection of bladder tumor, and transurethral resection of prostate. Hospital characteristics were linked using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Linear modeling analyzed median hospital price and its association with hospital characteristics. RESULTS: Overall, 1,532 hospitals reported urological prices in Turquoise. Median prices for each procedure were higher at rural for-profits (ureteroscopy $16,522, transurethral resection of bladder tumor $5,393, transurethral resection of prostate $9,999) vs rural nonprofits (ureteroscopy $4,512, transurethral resection of bladder tumor $2,788, transurethral resection of prostate $3,881) and metropolitan for-profits (ureteroscopy $5,411, transurethral resection of bladder tumor $3,420, transurethral resection of prostate $4,874). Rural for-profit status was independently associated with 160% higher price for ureteroscopy (relative cost ratio 2.60, P < .001), 50% higher for transurethral resection of bladder tumor (relative cost ratio 1.50, P = .002), and 113% higher for transurethral resection of prostate (relative cost ratio 2.13, P < .001). CONCLUSIONS: Prices are higher for 3 common urological surgeries at rural for-profit hospitals. Differential pricing may contribute to disparities for underinsured rural residents who lack access to nonprofit facilities. Interventions that facilitate transportation and price shopping may improve access to affordable urological care.

Financial Health of People Living With Dementia and Their Informal Care Partners: Protocol for a Mixed Methods Study.

BACKGROUND: There is a growing body of academic literature focusing on the significant financial burdens placed on people living with cancer, but little evidence exists on the impact of rising costs of care in other vulnerable populations. This financial strain, also known as financial toxicity, can impact behavioral, psychosocial, and material domains of life for people diagnosed with chronic conditions and their care partners. New evidence suggests that populations experiencing health disparities, including those with dementia, face limited access to health care, employment discrimination, income inequality, higher burdens of disease, and exacerbating financial toxicity. OBJECTIVE: The three study aims are to (1) adapt a survey to capture financial toxicity in people living with dementia and their care partners; (2) characterize the degree and magnitude of different components of financial toxicity in this population; and (3) empower the voice of this population through imagery and critical reflection on their perceptions and experiences relating to financial toxicity. METHODS: This study uses a mixed methods approach to comprehensively characterize financial toxicity among people living with dementia and their care partners. To address aim 1, we will adapt elements from previously validated and reliable instruments, including the Comprehensive Score for Financial Toxicity and Patient-Reported Outcomes Measurement Information System, to develop a financial toxicity survey specific to dyads of people living with dementia and their care partners. A total of 100 dyads will complete the survey, and data will be analyzed using descriptive statistics and regression models to address aim 2. Aim 3 will be addressed using the process of "photovoice," which is a qualitative, participatory research method that combines photography, verbal narratives, and critical reflection by groups of individuals to capture aspects of their environment and experiences with a certain topic. Quantitative results and qualitative findings will be integrated using a validated, joint display table mixed methods approach called the pillar integration process. RESULTS: This study is ongoing, with quantitative findings and qualitative results anticipated by December 2023. Integrated findings will enhance the understanding of financial toxicity in individuals living with dementia and their care partners by providing a comprehensive baseline assessment. CONCLUSIONS: As one of the first studies on financial toxicity related to dementia care, findings from our mixed methods approach will support the development of new strategies for improving the costs of care. While this work focuses on those living with dementia, this protocol could be replicated for people living with other diseases and serve as a blueprint for future research efforts in this space. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47255.

Association Between Cancer Center Accreditation and Compliance With Price Disclosure of Common Oncologic Surgical Procedures.

BACKGROUND: Cancer center accreditation status is predicated on several factors that measure high-value healthcare. However, price transparency, which is critical in healthcare decisions, is not a quality measure included for accreditation. We reported the rates of price disclosure of surgical procedures for 5 cancers (breast, lung, cutaneous melanoma, colon, and prostate) among hospitals ranked by the American College of Surgeon's Commission on Cancer (ACS-CoC). METHODS: We identified nonfederal, adult, and noncritical access ACS-CoC accredited hospitals and used the commercial Turquoise Health database to perform a cross-sectional analysis of hospital price disclosures for 5 common oncologic procedures (mastectomy, lobectomy, wide local excision for cutaneous melanoma, partial colectomy, prostatectomy). Publicly available financial reporting data were used to compile facility-specific features, including bed size, teaching status, Centers for Medicare & Medicaid wage index, and patient revenues. Modified Poisson regression evaluated the association between price disclosure and ACS-CoC accreditation after adjusting for hospital financial performance. RESULTS: Of 1,075 total ACS-CoC accredited hospitals, 544 (50.6%) did not disclose prices for any of the surgical procedures and only 313 (29.1%) hospitals reported prices for all 5 procedures. Of the 5 oncologic procedures, prostatectomy and lobectomy had the lowest price disclosure rates. Disclosing and nondisclosing hospitals significantly differed in ACS-CoC accreditation, ownership type, and teaching status. Hospitals that disclosed prices were more likely to receive Medicaid disproportionate share hospital payments, have lower average charge to cost ratios (4.53 vs 5.15; P<.001), and have lower net hospital margins (-2.03 vs 0.44; P=.005). After adjustment, a 1-point increase in markup was associated with a 4.8% (95% CI, 2.2%-7.4%; P<.001) higher likelihood of nondisclosure. CONCLUSIONS: More than half of the hospitals did not disclose prices for any of the 5 most common oncologic procedures despite ACS-CoC accreditation. It remains difficult to obtain price transparency for common oncologic procedures even at centers of excellence, signaling a discordance between quality measures visible to patients.

Long term cost comparisons of radical cystectomy versus trimodal therapy for muscle-invasive bladder cancer.

BACKGROUND: Earlier studies on the cost of muscle-invasive bladder cancer treatments are limited to short-term costs of care. We determined the 2- and 5-year costs associated with trimodal therapy (TMT) vs. radical cystectomy (RC). METHODS: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Total Medicare costs at 2 and 5 years following RC vs. TMT were compared using inverse probability of treatment-weighted propensity score models. RESULTS: A total of 2,537 patients aged 66 to 85 years were diagnosed with clinical stage T2-4a muscle-invasive bladder cancer. Total median costs for patients that received no definitive treatment(s) were $73,780 and $88,275 at 2-and 5-years. Costs were significantly higher for TMT than RC at 2-years ($372,839 vs. $191,363, Median Difference $127,815, Hodges-Lehmann Estimate (H-L) 95% Confidence Interval (CI), $112,663-$142,966) and 5-years ($424,570 vs. $253,651, Median Difference $124,466, H-L 95% CI, $105,711-$143,221). TMT had higher outpatient costs than RC (2-years: $318,221 vs. $100,900; 5-years: $367,092 vs. $146,561) with significantly higher costs with radiology, medications, pathology/laboratory, and other professional services. RC had higher inpatient costs than TMT (2-years: $62,240 vs. $33,631, Median Difference $-29,174, H-L 95% CI, $-32,364-$-25,984; 5-years: $75,499 vs. $45,223, Median Difference $-29,843, H-L 95% CI, $-33,905-$-25,781). CONCLUSIONS AND RELEVANCE: The excess spending associated with trimodal therapy vs. radical cystectomy was largely driven by outpatient expenditures. The relatively high long-term trimodal therapy costs are prime targets for cost containment strategies to optimize future value-based care.

The Impact of Health Delivery Integration on Cancer Outcomes.

Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.

The role of neoadjuvant chemotherapy, lymph node dissection, and treatment delay in patients with muscle-invasive bladder cancer undergoing partial cystectomy.

OBJECTIVES: To investigate treatment patterns of partial cystectomy (PC), neoadjuvant chemotherapy (NAC), lymph node dissection (LND), and treatment delays, and the associations with overall survival (OS) among patients with muscle-invasive bladder cancer. PATIENTS AND METHODS: We identified patients with cT2-4cN0cM0 urothelial carcinoma of the bladder in the National Cancer Database who underwent PC from 2007 through 2015. We performed descriptive statistics and assessed temporal trends using the Cochrane-Armitage test. Our outcomes of interest were NAC, LND, and treatment delay defined as ≥8 or ≥12 weeks for patients who underwent NAC or upfront surgery, respectively. We used logistic regression and multivariable Cox proportional hazards models to evaluate predictors and associations with OS, respectively. RESULTS: A total of 9,199 patients met inclusion criteria. Over the study period, PC utilization decreased from 9% to 7% (P = 0.06). Compared with patients who underwent radical cystectomy, patients treated with PC less frequently received NAC (7% vs. 17%, P < 0.01) and LND (57% vs. 91%, P < 0.01), but were less likely to experience treatment delays (25% vs. 31%, P < 0.01). Only 4.1% (27/655) of patients treated with PC received the combination of NAC, LND, and no treatment delay. In a Cox model, adequacy of LND was associated with improved OS (<10 nodes: HR 0.62, 95% CI 0.48-0.81 and ≥10 nodes: HR 0.48, 95% Cl 0.32-0.72). CONCLUSION: PC is uncommon and associated with poorer utilization of NAC and LND, but fewer treatment delays. The adequacy of LND was associated with improved OS while NAC and treatment delay were not.

Peripherally Acting µ-Opioid Receptor Antagonists in the Management of Postoperative Ileus: a Clinical Review.

Postoperative ileus (POI) and constipation are common secondary effects of opioids and carry significant clinical and economic impacts. µ-Opioid receptors mediate opioid analgesia in the central nervous system (CNS) and gastrointestinal-related effects in the periphery. Peripherally acting µ-opioid receptor antagonists (PAMORAs) block the peripheral effects of opioids in the gastrointestinal tract, while maintaining opioid analgesia in the CNS. While most are not approved for POI or postoperative opioid-induced constipation (OIC), PAMORAs have a potential role in these settings via their selective effects on the µ-opioid receptor. This review will discuss recent clinical trials evaluating the safety and efficacy of PAMORAs, with a focus on alvimopan (Entereg®) and methylnaltrexone (Relistor®) in patients with POI or postoperative OIC. We will characterize potential factors that may have impacted the efficacy observed in phase 3 trials and discuss future directions for the management and treatment of POI.

Trends in management of ureteral urothelial carcinoma and effects on survival: a hospital-based registry study.

BACKGROUND: High-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU). OBJECTIVES: To evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS). DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Chi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS. RESULTS: Of the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (≥pT2 or pN+) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84-1.44) and SU (HR 0.94, 95% CI 0.61-1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89-1.21, P = 0.83). CONCLUSION: Our study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology.

Analysis of guideline recommended use of renal mass biopsy and association with treatment.

INTRODUCTION: Renal mass biopsy (RMB) may not be indicated when the results are unlikely to impact management, such as in young and/or healthy patients and in elderly and/or frail patients. We analyzed the utility of RMB in three patient cohorts stratified by age-adjusted Charlson comorbidity index score (ACCI). MATERIALS AND METHODS: We identified patients with cT1a renal tumors in the National Cancer Database from 2004-2014. We combined age and Charlson-Deyo scores to identify young and/or healthy patients ('healthy-ACCI'), elderly and/or frail patients ('frail-ACCI'), and a reference cohort. We performed multivariable logistic regression to identify predictors of RMB and treatment. We evaluated the impact of RMB on management by analyzing the proportion of high-grade disease on final pathology as a surrogate for risk stratification. RESULTS: We identified 36,720 healthy-ACCI, 2,516 frail-ACCI, and 18,989 reference-ACCI patients. Healthy-ACCI patients were less likely to undergo RMB (7.5% versus 10.8%; p < 0.001) while frail-ACCI patients underwent RMB at similar rates (11.8% versus 10.8%; p = 0.14) compared with reference-ACCI patients. On multivariable logistic regression, in both healthy-ACCI and frail-ACCI patients, RMB was associated with decreased odds of surgical treatment, and increased odds of ablation and surveillance (all p < 0.01). In the frail-ACCI patients, higher grade disease at surgery was identified in the RMB cohort (32.9% versus 23.5%, p = 0.05). CONCLUSIONS: RMB is performed less frequently in healthy-ACCI patients compared with the reference cohort. RMB is associated with decreased odds of surgical treatment and increased odds of surveillance and ablation in all cohorts. In frail-ACCI patients who underwent surgery, RMB may provide additional risk stratification as these patients had lower rates of low-grade disease.

The Role of Opioids and Their Receptors in Urological Malignancy: A Review.

PURPOSE: We reviewed the literature surrounding the role of opioids and their receptors in urological malignancy. Recent studies have suggested clinically significant effects of agonism or antagonism of opioid receptors on cancer related outcomes and tumorigenesis. The focus of these efforts has centered on nonurological malignancies. However, a compelling body of evidence is growing in the fields of prostate, bladder and kidney cancer. MATERIALS AND METHODS: A systematic review of English language articles published through 2020 was conducted with key phrases related to kidney, bladder or prostate cancer, and opioids or narcotics. A total of 837 unique records were identified, of which 49 were selected for full text review and 33 were included in the qualitative analysis. Eight records were identified via citation review and 1 study was recently presented at a national meeting. RESULTS: Retrospective reviews suggest poorer disease specific and recurrence-free survival with increased perioperative opioid administration in patients undergoing prostate or bladder cancer surgery. However, the data are controversial. Kappa opioid receptors are implicated in both proliferation and inhibition of prostate cancer cell growth across in vitro studies, with a proposed interaction with the androgen cascade. Similarly opioid growth factor receptor is highly expressed in prostate cancer cells and repressed by androgens. Prostate cancer tissue stains more intensely for the mu opioid receptor, and patients with higher expression have poorer oncologic outcomes. Opioid agonism in vitro induces urothelial cell carcinoma proliferation, migration and invasion, with possible additional influence from interactions with the bradykinin b2 receptor. Agonism of the mu, kappa and delta opioid receptors induces renal cell carcinoma tumorigenesis, possibly via upregulation of survivin. Meanwhile, opioid growth factor receptor agonism has the opposite effect in renal cell carcinoma. CONCLUSIONS: Evidence surrounding the role of opioids and their receptors in urological malignancy is provocative and should serve as an impetus for further investigation.

Trends in palliative care interventions among patients with advanced bladder, prostate, or kidney cancer: A retrospective cohort study.

BACKGROUND: Palliative care has an established role in improving the quality of life in patients with advanced cancer, but little is known regarding its delivery among patients with urologic malignancies. OBJECTIVE: To determine trends in the utilization of palliative interventions among patients with advanced bladder, prostate, and kidney cancer. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of patients from years 2004 to 2013 in the National Cancer Database diagnosed with stage IV bladder (n = 17,997), prostate (n = 23,322), and kidney (n = 34,697) cancer, after excluding those with missing disease stage, treatment, and outcomes data. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and logistic regression were performed to evaluate utilization of palliative care intervention. Utilization was analyzed by cancer type and by overall survival strata (<6, 6-24, and >24 months). Kaplan-Meier and Cox proportional hazards models analyzed overall survival. RESULTS AND LIMITATIONS: Palliative interventions were utilized in 12.5% (2,257/17,997), 14.7% (3,442/23,322), and 19.9% (6,935/34,697) of advanced bladder, prostate, and kidney cancer patients, respectively. Older age and longer survival were associated with lower odds of palliative intervention utilization in each malignancy, as was minority race in kidney and bladder cancer patients. Palliative radiation was used most commonly, and utilization of any palliative intervention was associated with poorer overall survival. Limitations largely stem from imperfect data abstraction, and the analysis of interventions' incomplete reflection of palliative care. CONCLUSIONS: Palliative interventions were seldom used among patients with advanced urologic malignancies. Palliative interventions were less frequently used in older patients and minority races. Further study is warranted to define the role of palliative interventions in advanced urologic malignancies and guide their utilization.

Predictors of adequate lymph node dissection in patients with non-muscle invasive bladder cancer undergoing radical cystectomy and effect on survival.

INTRODUCTION: Radical cystectomy (RC) is the standard of care for refractory high-risk non-muscle invasive bladder cancer (NMIBC). We aim to identify predictors of adequate lymph node dissection (LND) in a cohort of NMIBC patients undergoing RC, as well as its impact on clinical outcomes. METHODS: The National Cancer Database was queried for patients who underwent RC for urothelial cell carcinoma for clinical stage Tis/a/1 N0M0 disease between 2004 and 2013. Patients were stratified by LND: none, inadequate (<10) or adequate (≥10 nodes). Factors associated with LND were analyzed. Inverse-probability weighted propensity score matching was used to assess the impact of adequate LND on overall survival. RESULTS: The final cohort of 3,226 patients had a median follow-up of 39.0 months, had a mean age of 65.3 years, was 70% male, and was 81% Caucasian. Overall, 16.6% received no LND, 28.5% inadequate LND, and 55.0% adequate LND. Treatment at an academic facility, Charlson-Deyo Comorbidity score of 1, and later year of treatment were significantly associated with adequate LND. Overall survival was significantly higher with adequate LND compared to a matched-cohort of inadequate LND patients (68.7% vs. 60.6% at 5 years, P < 0.01). CONCLUSIONS: Nearly half of NMIBC patients undergoing RC do not receive an adequate LND, despite an association with increased overall survival. Treatment at an academic facility was associated with increased likelihood of adequate LND. Initiatives to improve adequate LND in this population may be warranted.

The association between N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, and clinical outcomes in patients undergoing robotic-assisted radical cystectomy.

PURPOSE: To assess the impact of N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, on the post-operative recovery of patients undergoing robotic-assisted radical cystectomy for bladder cancer. METHODS: We retrospectively reviewed patients undergoing robotic-assisted radical cystectomy by a single surgeon (KC) prior to (control group) and after (treatment group) the routine use of N-methylnaltrexone. Kaplan-Meier curves and the log-rank test were used to quantify time to flatus, bowel movement, and discharge. Daily mean opioid use, daily pain assessment rating, and episodes of severe pain (7-10/10) were compared. Gastrointestinal-related complications, including ileus, emesis, and/or need for post-op nasogastric tube placement, and 30-day readmissions were also compared between groups. Charge capture data were compared between groups to analyze cost impact. RESULTS: 29 patients each in the control and treatment group met inclusion criteria. Patients receiving N-methylnaltrexone had reduced length of stay compared with no N-methylnaltrexone (median 4 vs. 7 days, p < 0.01). Time to flatus and bowel movement, however, were similar. In a multivariable analysis controlling for possible confounders, however, the improvement in length of stay associated with N-methylnaltrexone use did not reach statistical significance (p = 0.11). Episodes of severe pain and composite gastrointestinal-related complications were reduced in the N-methylnaltrexone group (44.8% vs. 10.3%, p < 0.01). The reduction in length of stay was associated with approximately $10,500 in cost savings per patient. CONCLUSIONS: In this study, N-methylnaltrexone was associated with reduced length of stay, fewer episodes of severe pain, and reduced costs. These results provide the impetus for further study.

Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy.

BACKGROUND: One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy-a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data. OBJECTIVE: To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy. DESIGN SETTING AND PARTICIPANTS: This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy. RESULTS AND LIMITATIONS: Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00-1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14-1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07-1.62). CONCLUSIONS: We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy. PATIENT SUMMARY: In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.

Positive surgical margins at radical prostatectomy in the United States: Institutional variations and predictive factors.

INTRODUCTION: Positive surgical margins (PSMs) are associated with treatment failure after radical prostatectomy (RP) for patients with prostate cancer (CaP). We investigated institutional variations in PSM after RP, as well as clinical and demographic factors predicting PSM. PATIENTS AND METHODS: Patients undergoing RP for clinically localized CaP were identified in the National Cancer Database in 2010 to 2013 and clinicodemographics were recorded. Treating institution was defined as academic (AMC) or nonacademic medical centers (nAMC). The primary outcome was the PSM rate. Multivariable logistic regression and propensity matching with inverse probability treatment weighing were used to both compare outcomes between AMC and nAMC and to identify predictors of PSM following RP. RESULTS: A total of 167,260 patients met our inclusion criteria. PSM rate was significantly lower in patients treated at AMC (13,435, 18.9%) compared with 22,145 (23.0%) in those treated at nAMC (P < 0.01). The difference between PSM rate in AMC and nAMC was more pronounced in lower volume centers while it was not significant in higher volume centers. On multivariable analysis, age, race, prostate-specific antigen (PSA), biopsy Gleason score, comorbidity profile, insurance type, income, and treatment facility were significantly associated with PSM rate. CONCLUSION: PSM rates appear to be lower at AMC and higher volume facilities, which can potentially reflect institutional differences in surgical quality. In addition, we identified several socioeconomic and demographic factors that contribute to the likelihood of PSM following RP for localized CaP, suggesting potential systematic variation in the quality of surgical care. The cause of this variation warrants further investigation and evaluation.

Predicting Short-term Outcomes After Radical Cystectomy Based on Frailty.

OBJECTIVE: To evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer. MATERIAL AND METHODS: We identified 9459 adults (age ≥18) in the Nationwide Readmission Database who underwent radical cystectomy in 2014 for bladder cancer. We defined patients' frailty status using Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator and compared in-hospital mortality, ICU-level complications, 30-day readmissions, nonhome discharge, length of hospitalization, and hospital-related costs between frail and nonfrail patients using χ2 tests. We used multivariate logistic regression to identify predictors of the primary outcomes of interest. RESULTS: Of 9459 patients undergoing radical cystectomy, 7.1% (n = 673) met criteria. Frail patients were more likely than nonfrail patients to have comorbid conditions (68.2% vs 59.7%; P= .005), in-hospital mortality (4.2% vs 1.5%; P= .04), ICU-level complications (52.9% vs 18.6%; P<.001), nonhome discharge (33.9% vs 11.6%; P <.001), longer length of stay (median 15 vs 7 days; P<.001), and higher median cost of the index admission ($39,665 vs $27,307). Frailty was the strongest independent predictor of ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs of any covariate. CONCLUSION: Frail patients receiving radical cystectomy were more likely than nonfrail patients to have adverse perioperative outcomes and higher odds of in-hospital mortality, ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs. Preoperative consideration of frailty may be useful in clinical guidance and shared decision-making.

Cytoreductive nephrectomy in patients with metastatic renal cell carcinoma and venous thrombus-Trends and effect on overall survival.

PURPOSE: Patients with metastatic renal cell carcinoma (mRCC) commonly present with tumor thrombi in the renal vein and inferior vena cava (IVC). The benefit of cytoreductive nephrectomy (CN) in this population is unclear and the effect on overall survival (OS) has been incompletely evaluated. MATERIALS AND METHODS: We queried the National Cancer Database from 2010 to 2013 for patients diagnosed with mRCC and tumor thrombi, which was defined as renal vein, infradiaphragmatic IVC, or supradiaphragmatic IVC. Descriptive statistics were performed and associations between clinicopathologic variables and utilization of CN were analyzed. Patients were matched on the receipt of CN and Kaplan-Meier analyses and multivariable Cox proportional hazards models were used to estimate survival. RESULTS: In total, 8,629 patients were found to have mRCC during the study period. Approximately 27% (n = 2,376) had tumor thrombus. Tumor thrombus was associated with increased rates of CN utilization, however rates decreased as thrombus level increased. In a matched Kaplan-Meier analysis, CN was associated with improved OS in patients without thrombus, and with renal vein or infradiaphragmatic thrombus (all P < 0.01). Patients with supradiaphragmatic thrombus did not benefit from CN (P = 0.46). This effect was confirmed in a Cox proportional hazards model. CONCLUSIONS: Tumor thrombus is common in patients with mRCC. OS is poor, and patient and tumor specific factors influence the use of CN. Despite discrepancies in utilization, CN is associated with improved OS, although this effect appears to be limited to those with mRCC and tumor thrombus limited to the renal vein and infradiaphragmatic IVC.

Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model.

PURPOSE: The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery. MATERIALS AND METHODS: A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment. RESULTS: Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services. CONCLUSIONS: Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.