A Cost Analysis of Phosphodiesterase Type 5 Inhibitors in the United States.

OBJECTIVE: To perform a cost analysis of generic and brand-name Phosphodiesterase Type 5 (PDE5) inhibitors at different dosages and pharmacies across the US. METHODS: Using an all-payer retail pharmacy-claims database, we analyzed prescription drug data for three generic and six brand-name oral PDE5 inhibitors at different dosages across US chain and independent pharmacies in 2019. RESULTS: We obtained cash price data from 60,186 pharmacies (35,976 chain and 24,210 independent). The nationwide mean cash price per unit (PPU) ranged from $8.6 ± 5.2 (sildenafil 20 mg at chain pharmacies) to $107.1 ± 71 (Adcirca 20 mg at independent pharmacies) equal to 1145.3% difference. Chain pharmacies provided significantly lower average prices for one brand-name and six generic PDE5 inhibitors. Tadalafil PPU was cheaper at higher quantities, however, PPU increased with quantity prescribed for sildenafil. Looking at the top 10 metropolitan statistical areas, the highest PPUs were observed for tadalafil (Cialis) 10 mg and sildenafil (Viagra) 50 mg in Atlanta ($67.4 ± 8.7) and Los Angeles ($50.3 ± 24.0), while New York ($9.7 ± 2.6) and Miami ($27.9 ± 16.4) had the lowest PPUs for tadalafil (Cialis) 5 mg and sildenafil (Viagra) 100 mg, respectively. CONCLUSION: A substantial variability in PDE5 inhibitor cash prices exists across manufacturer, dosage, quantity, pharmacy type, and location. In addition, the pricing does not necessarily correlate with the regional socioeconomic factors. This highlights the importance of provider awareness and patient counseling on drug price including potentially assisting patients in identifying opportunities for cost savings.

Association Between Private Equity Acquisition of Urology Practices and Physician Medicare Payments.

OBJECTIVE: To assess whether private equity (PE) acquisitions of urology practices were associated with changes in Medicare payments and patient volume. METHODS: We identified PE acquisitions of urology practices through financial databases, industry news outlets, practice websites, and Google search. Using the Centers for Medicare and Medicaid Service's Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (2012-2019), we conducted descriptive statistics and trends analysis to examine whether PE acquisition was associated with changes in Medicare payments and patient volume in comparison to non-PE affiliated urologists within the same states. RESULTS: We identified PE acquisitions of 10 independent urology practices across 6 states during the study period. In the preacquisition period, urologists later joining private-equity groups received greater mean inflation-adjusted Medicare payments ($246,977 vs $160,038; P <.001) and had greater patient volume (839.7 vs 674.2 patients; P = .001) than urologists who did not. In the postacquisition period, PE affiliated urologists had an 11.0% (95% CI: -0.2% to 22.3%) increase in inflation-adjusted Medicare payments (P = .054) and a 12.5% (95% CI: 6.5%-18.6%) increase in patient volume (P <.001). Non-PE affiliated urologists exhibited a 6% decline in Medicare payments (P <.001) and a 2.7% increase in patient volume (P <.001). CONCLUSION: PE affiliated urologists exhibited increases in Medicare payments even prior to acquisition, in contrast to declines for geographically similar, non-PE urologists. These findings may highlight characteristics of practices targeted by PE firms and local practice trends that may further diverge following acquisition.

Access to Urological Care for Medicaid-Insured Patients at Urology Practices Acquired by Private Equity Firms.

OBJECTIVE: To characterize appointment access for Medicaid-insured patients seeking care at urology practices affiliated with private equity firms in light of the recent national trends in practice consolidation. METHODS: We identified 214 urology offices affiliated with private equity firms that were geographically matched with 231 non-private equity affiliated urology offices. Using a standardized script, researchers posed as an adult patient with either Medicaid or commercial insurance in the clinical setting of new onset, painless hematuria. The primary outcome was whether the patient's insurance was accepted for an appointment. The secondary outcome was appointment wait time. RESULTS: We conducted 815 appointment inquiry calls to 214 private equity (PE) and 231 non-PE-affiliated urology offices across 12 states. Appointment availability was higher for commercially-insured patients (99.0%; 95% CI: 98.1%-99.9%) vs Medicaid-insured patients (59.8%; 95% confidence interval [CI]: 55.0%-64.6%) (P < .0001). Medicaid acceptance was higher at non-PE affiliated (66.8%; CI 60.4%-73.2%) than PE-affiliated practices (52.1%; 95% CI 45.0%-59.2%) (P = .003). On multivariable logistic regression analysis, state Medicaid expansion status (odds ratio [OR] 2.20; CI 1.14-4.28; P = .020) was independently associated with Medicaid appointment availability, whereas PE-affiliation (OR 0.55; CI 0.37-0.83; P = .004) was independently associated with lower Medicaid access. Appointment wait times did not differ significantly for commercially-insured vs Medicaid patients (19.2 vs 20.1 days; p = .59), but PE-affiliated practices offered shorter mean wait times than non-PE offices (17.5 vs 21.4 days; P = .017). CONCLUSION: Access disparities for urologic evaluation in patients with Medicaid insurance at urology practices and were more pronounced at private equity acquired practices.

Urology Practice Acquisitions by Private Equity Firms from 2011-2021.

INTRODUCTION: Private equity firms have recently acquired several large urology practices in the United States. As little is known about these acquisitions, we sought to characterize trends in urology practice consolidation. METHODS: We compiled urology practice acquisition data via financial databases, news outlets, practice websites, and Internet keyword search for the time period January 1, 2011 through March 15, 2021. For each acquisition, we determined the acquiring group, number of employed urologists, practice locations, and status of ancillary services (pathology, radiology, or surgery centers). We estimated workforce effects based on the 2019 American Urological Association workforce census. RESULTS: We identified 69 independent practice acquisitions in the study period, including 19 (28.4%) by hospital systems, 7 (10.4%) by multispecialty physician groups, 23 (34.3%) by urology practices, and 20 (29.9%) by private equity-backed platforms. Private equity firms initially targeted large urology practices (mean of 60.8±32.6 urologists) with ownership of ancillary services and consolidated local market share through acquisitions of smaller practices (mean of 15.9±14.5 urologists). As of March 2021, we estimate that 7.2% of private practice urologists in the U.S. were employed by one of 5 private equity-backed platforms; over 25% of all urologists practicing in New Jersey and Maryland are employed by a private equity-backed platform. CONCLUSIONS: Private equity acquisitions have accelerated to become a dominant form of urology practice consolidation in recent years and have achieved significant market influence in certain regions. Future research should assess the impact of private equity investment on practice patterns, health outcomes, and expenditures.

Characteristics of Online Crowdfunding Campaigns for Urological Cancers in the United States.

INTRODUCTION: We examined the characteristics and financial outcomes of online crowdfunding campaigns for patients with major urological cancers in the U.S. METHODS: This cross-sectional study analyzed publicly available data from GoFundMe, the largest online medical crowdfunding service, via automated web scraping. Online campaigns from 2010 to 2018 with the following primary cancer types were included: kidney, prostate, bladder and testicular. Financial outcomes were compared using Kruskal-Wallis and Wilcoxon rank-sum tests. Multivariable analyses were utilized to identify predictors of campaign financial outcomes. RESULTS: Kidney cancers were the most frequent online campaign type (478), followed by prostate (379), bladder (202) and testicular (175) malignancies. Urological cancer campaign recipients frequently requested funding for medical expenses (71%) during active treatment (57%). After adjustment, testicular cancer and children's cancer campaigns generated more donations than other urological and adult cancer campaigns (p <0.05). Family and friend-authored campaigns generated more donations and average donation amounts than self-authored campaigns (p <0.05). Campaign narratives focused on disheartening circumstances received fewer donations than narratives focused on the recipient's high moral character or contributions to society (p <0.05), and unclear narratives received the smallest donation amounts (p <0.05). CONCLUSIONS: Urological cancer crowdfunding in the U.S. is primarily used to finance uncovered costs associated with medical care during active treatment. Crowdfunding financial outcomes are likely related to the campaign recipient's age, malignancy type, social network and primary appeal of the narrative. Urologists should be aware of trends in medical crowdfunding in order to better understand the financial burden this patient population faces.

Pre-Operative Assessment Tool To Predict Post-operative Pain and Opioid Use in Outpatient Urologic Surgery.

OBJECTIVE: To better understand the pain requirements of urologic patients in the post-operative outpatient setting. Healthcare providers are one of the leading contributors to the current opioid epidemic. Understanding opioid prescribing practices and patients' narcotic requirements while not over-prescribing opioids is a public health priority. METHODS: We conducted a prospective study to examine opioid consumption among adult patients who presented for outpatient urologic surgery at the University of California San Francisco (UCSF) and Zuckerberg San Francisco General (ZSFG) hospitals. We administered a Pre-Operative Pain Requirement Assessment Tool (POPRAT) electronically via text message 3 days prior to surgery to identify objective factors that may predict post-operative pain and opioid requirements. Patients were followed for 7 days post-operatively, in a similar fashion, to assess daily pain, and opioid use. RESULTS: Two hundred and sixty-four participants were eligible for the study and 211 completed the study. Urology patients undergoing outpatient elective procedures used a mean of 5 morphine milligram equivalents (MME) (SD = 14.9) in a 7-day period. Women and patients less than 45 years of age had the highest opioid use. Based on the POPRAT, major predictors of post-operative pain were pre-operative anxiety (0.34 estimate, P value <.001) and anticipated pain (0.34 estimate, P value <.001). Anticipated opioid use, however, did not predict actual opioid use. CONCLUSION: Urologic outpatient surgeries require minimal opioids for pain management. The POPRAT may help identify which patients may experience more pain after surgery. Certain factors such as age and gender may need to be considered when prescribing opioids.

Access to Urologic Care at Urgent Care Centers.

OBJECTIVE: To evaluate Medicaid insurance access disparities for urologic care at urgent care centers (UCCs) in the United States. MATERIALS AND METHODS: We conducted a cross-sectional study using a "secret shopper" methodology. We sampled 240 UCCs across 8 states. Using a standardized script, researchers posed as a patient with either Medicaid or commercial insurance in the clinical setting of obstructing nephrolithiasis. The primary study endpoint was whether a patient's insurance (Medicaid vs commercial) was accepted. We assessed factors associated with Medicaid acceptance using logistic regression models adjusted for state-level and facility-level characteristics. Additionally, we calculated triage rates, emergency department referral rates, and the ability of a UCC to refer the patient to a specialist. RESULTS: Of 240 UCCs contacted, 239 (99.6%) accepted commercial insurance and 159 (66.2%) accepted Medicaid. UCCs in Medicaid expansion states more frequently accepted patients with Medicaid insurance (74.2% vs 58.3%, respectively, P < .01). On multivariable logistic regression analysis, state Medicaid expansion (OR 1.84, 95% CI 1.04-3.26, P = .04) and affiliation with an institution (OR 2.97, 95% CI 1.59-5.57, P < .01) were independently associated with greater odds of accepting Medicaid. Medicaid-insured patients were significantly less likely to be triaged or referred to the emergency department compared to commercial patients. CONCLUSION: We identified significant disparities in access to UCCs for Medicaid patients presenting with a urologic condition. Given the expanding national role of UCCs, these findings highlight potential sources of insurance disparity in the context of a urologic emergency.

Characterizing online crowdfunding campaigns for patients with kidney cancer.

BACKGROUND: Cancer patients incur high care costs; however, there is a paucity of literature characterizing unmet financial obligations for patients with urologic cancers. Kidney cancer patients are particularly burdened by costs associated with novel systemic treatments. This study aimed to ascertain the characteristics of GoFundMe® crowdfunding campaigns for patients with kidney cancer, in order to better understand the financial needs of this population. METHODS: We performed a cross-sectional, quantitative, and qualitative analysis of all kidney cancer GoFundMe® campaigns since 2010. Fundraising metrics such as goal funds and amount raised, were extracted. Eight independent investigators collected patient, disease and campaign-level variables from campaign stories (κ = 0.72). In addition, we performed a content analysis of campaign narratives spotlighting the primary appeal of the patient's life story. RESULTS: A total of 486 GoFundMe® kidney cancer campaigns were reviewed. The median goal funds were 10,000USD [IQR = 5000, 20,000] and the median amount raised was 1450USD [IQR = 578, 4050]. Most campaigns were for adult males (53%) and 62% of adults had children. A minority were for pediatric patients (17%). Thirty-seven percent of adult patients were primary wage earners and 43% reported losing their job or substantially reducing hours due to illness. Twenty-nine percent reported no insurance or insufficient coverage. Campaigns most frequently sought funds for medical bills (60%), nonmedical bills (27%), and medical travel (23%). Qualitative campaign narratives mostly emphasized patients' hardship (46.3%) or high moral character (35.2%). Only 8% of campaigns achieved their target funds. CONCLUSIONS: Despite fundraising efforts, patients with kidney cancer face persistent financial barriers, incurring both medical and nonmedical cost burdens. This may be compounded by limited or no insurance. Cancer care providers should be aware of financial constraints placed on kidney cancer patients, and consider how these may impact treatment regimens.

Contemporary Trends and End-Results of National Institutes of Health Grant Funding to Departments of Urology in the United States: A 10-year Analysis.

PURPOSE: We explored the patterns and distribution of National Institutes of Health grant funding for urological research in the United States. MATERIALS AND METHODS: The National Institutes of Health RePORTER database was queried for all grants awarded to urology departments between 2010 and 2019. Information regarding the value of the grant, funded institution, successful publication of the research, and the category of urological subspecialty were collected. Data on principal investigators were extracted from publicly available information. RESULTS: There were 509 grants awarded to Urology between 2010 and 2019 for a total value of $640,873,867, and a median per-project value of $675,484 (IQR 344,170-1,369,385). Over the study period, total funding decreased by 15.6% and was lower compared to other surgical subspecialties. Most grants were awarded by the National Cancer Institute and National Institute of Diabetes and Digestive and Kidney Diseases (85%) to Western or North Central institutions (52.5%), and had principal investigators specialized in urologic oncology (56.4%), followed by general urologists (21.5%). Female principal investigators led 21.6% of Urology grants and were more likely PhD basic scientists than males (64.4% vs 38.2%, p=0.001). In total, 10,404 publications linked to the 509 grants were produced, of which 28.5% were published in journals with an impact factor ≥10. CONCLUSIONS: Urology is underrepresented in National Institutes of Health grant funding compared to other surgical fields. During the past decade there was a further decrease in the total budget of National Institutes of Health grants to Urology.

The Applicant's Perspective on Urology Residency Interviews: A Qualitative Analysis.

OBJECTIVE: To better understand what urology applicants look for on interview day and what they care about in selecting a residency program through an analysis of anonymous online posts about the urology interview process. METHODS: We collected 3 years (2016-2018) of comments and posts from the Interview Impressions tab of the Urology Match Google Sheet for 133 urology residencies. Qualitative data analysis was performed using grounded theory methodology. RESULTS: We identified 6 categories of themes on (1) interview day structure, (2) diverse faculty, (3) program culture, (4) surgical training, (5) research, and (6) program benefits. These themes appeared in comments for 77%-86% of the residency programs except for research which was present for 44% of the programs. The efficiency and structure of interview day are very important. Applicants also care about young and diverse fellowship-trained faculty across a wide breadth of subspecialties. They believe they are able to discern the program culture and collegiality between residents and faculty. Applicants want a balance of surgical and clinical training with a focus on robotics and surgical autonomy. Not all applicants are interested in research but those that are appreciate a strong support system. Finally, additional program benefits and the positives and negatives of the program's location are frequently discussed. CONCLUSION: Analysis of anonymous social media posts can help improve the interview process for applicants and programs alike. Programs can also identify areas of improvement for residency training. Our findings provide additional insight towards the ultimate goal of improving the match process.

Resident-Driven Holistic Lean Daily Management System to Enhance Care Experience at a Safety Net Hospital.

OBJECTIVE: To describe the use of Lean in urology at Zuckerberg San Francisco General, a community safety-net and trauma hospital that serves as a major teaching site for the University of California San Francisco. METHODS: We examined our process improvement activities from 2016 to 2018. Our Lean Daily Management System (DMS) includes a 15-minute team huddle ("urology Lean work") of service residents, faculty, clinic and operating room nursing staff, and anesthesia liaisons. Our DMS also includes a 5-minute preoperative huddle. Besides team-building, urology Lean work surfaces logistics, safety or equipment improvement ideas, and ensures progress and completion of initiated projects. RESULTS: Over a 2-year period we developed and completed 67 projects. Projects impacted the outpatient setting (57%), followed by the operating room (22%), the Urology service (12%), and inpatient setting (9%). We completed projects in the following domains: safety (26%), quality (22%), care experience (21%), workforce care and development (13%), equity (11%), and financial stewardship (7%). Urology Lean work reduced new patient clinic access time (119-21 days) and Bacillus Calmette-Guérin in clinic treatment time (180-105 minutes). The average proportion of urology on-time surgeries was better than the overall surgery on-time surgeries (71% v 61%). CONCLUSION: Urology Lean work successfully applied DMS in a service specific yet holistic approach. Urology Lean work improved resident engagement in quality and safety endeavors and served as a DMS model throughout perioperative and clinic areas.

Use of GoFundMe® to crowdfund complementary and alternative medicine treatments for cancer.

PURPOSE: Complementary and alternative medicine (CAM) use is common amongst cancer patients. However, there is growing concern about its safety and efficacy. Online crowdfunding campaigns represent a unique avenue to understand the cancer patient's perspective for using CAM or declining conventional cancer therapy (CCT). METHODS: Five hundred GoFundMe campaigns from 2012 to 2019 detailing financial need for cancer treatment were randomly selected and reviewed for endorsement of CAM use, reasons for using CAM, and reasons for declining CCT. Descriptive statistics were used to compare patient and campaign characteristics between 250 CAM users and 250 non-CAM users. RESULTS: Compared to non-CAM users, CAM users were more likely to be female (70% vs. 54%, p < 0.01), to report more stage IV cancer (54% vs. 12%, p < 0.01), and to have a history of delayed, missed, or misdiagnosis (10% vs. 4%, p < 0.01). Reasons for using CAM include endorsing curative/therapeutic effects 212 (85%), pain/stress reduction 137 (55%), and dissatisfaction with current or past medical treatment options 105 (42%). 87 (35%) CAM users that declined CCT reported that they wanted to try to fight off cancer using CAM first 57 (61%), that CCT was too "toxic" to the body 39 (42%), and cancer was already too advanced, so that CCT would be futile or too aggressive 25 (27%). CONCLUSION: Cancer patients on GoFundMe using CAM highly value quality of life, comfort, and autonomy. Physicians should educate themselves on CAM to set realistic expectations and provide comprehensive counseling of the risks and benefits of CAM usage to patients who choose to use CAM to either augment or completely replace CCT.

Promotion Disparities in Academic Urology.

OBJECTIVE: To better understand promotion timelines across gender and race/ethnicity and how academic output impacts promotion in urology. METHODS: We examined the 2017 census. An academic subset was asked questions regarding their promotion timeline. We obtained demographic, academic output, and family responsibility data. RESULTS: Of 2926 academic urologists who identified a position of Assistant, Associate, or Full professor, 11.2% were women, 75% were White, and 94% were non-Hispanic. Men authored more papers and achieved principal investigator status more often than women. Non-Hispanics authored more papers than Hispanics. On average, women took 1.2 years longer than men to advance from Assistant to Associate Professor (7.3 years [95% CI: 6.8-7.8] vs 6.1 years, [95% CI: 5.8-6.6, P <.001]). Advancement from Associate to Full Professor was similar between women and men (6.0 years [95% CI: 5.1-6.9] vs 6.6 [95% CI: 6.1-7.1, P = .25]). Compared to women, men were more likely to experience rapid promotion (≤4 years) to Associate Professor (odds ratio 3 [95% CI: 1.8-5.1]). There was no statistical difference across race/ethnicity for promotion from Assistant to Associate, Associate to Full Professor, or rapid promotion. CONCLUSION: We identified disparities in promotion times based on gender but not race and ethnicity. The number of under-represented minority faculty in urology is low. Understanding the causes of disparities should be a priority in order to support fair promotion practices and retention of diverse faculty.

More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults.

BACKGROUND: Little is known about sexual problems and genitourinary health of older sexual minority adults, who comprise up to 4% of the adult population but may differ in experiences of genitourinary aging, given known health disparities and behavior differences. AIM: To examine and compare genitourinary and sexual complaints among older sexual minority and sexual majority adults. METHODS: We analyzed data from the 2010-2011 National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of older community-dwelling U.S. adults. Sexual minority men were defined as those who have sex with men or with both women and men. Sexual minority women were those who have sex with women or with both women and men. Descriptive statistics, weighted frequencies, and the chi-square test were used to compare outcomes by sexual orientation group and gender. MAIN OUTCOME MEASURES: Structured questionnaires examined sexual activity, practices, and genitourinary problems such as erectile dysfunction, insufficient vaginal lubrication, and urinary incontinence (UI). RESULTS: Of 2,813 participants (median age 69.6 years), 4.2% were sexual minorities (5.3% of men, 3.5% of women). Among men, sexual minorities were more likely to report UI (35.6% vs 21.8%; P = .029), but otherwise the 2 groups had similar prevalences of other urinary symptoms, importance of sexual activity, sexual practices, sexual activity within the last 3 months, and erectile difficulty (P > .10 for all). Among women, sexual minorities were more likely to report receiving oral sex (42.5% vs. 21.2%; P = .004), but otherwise the 2 groups had similar prevalences of UI, other urinary symptoms, importance of sexual activity, sexual activity within the last 3 months, and difficulty with lubrication (P > .10 for all). CLINICAL IMPLICATIONS: Sexual activity and sexual problems may be as common among older sexual minority adults as in their sexual majority counterparts, whereas UI may be more common in sexual minority men compared with sexual majority men. Therefore, clinicians should employ culturally-relevant health screening, diagnosis, and treatment to ensure reaching all adults regardless of sexual orientation. STRENGTHS & LIMITATIONS: Strengths include a national population-based sample of older adults that describes sexual and genitourinary health. Statistical power was limited by the small numbers of sexual minority individuals. CONCLUSION: Here we provide new evidence that older sexual minority men may experience UI more often than sexual majority men, and that sexual practices may differ between sexual minority and majority women, but frequency of sexual problems is similar. Given the challenges faced by sexual minority individuals in accessing equitable health care, clinicians must ensure that diagnosis and treatment are relevant to people of all sexual orientations. Obedin-Maliver J, Lisha N, Breyer BN. More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults. J Sex Med 2019;16:347-350.

Gender and Racial Disparities in Early Urology Exposures during Medical School.

INTRODUCTION: Workforce disparities in medicine have been well documented. Early medical school exposures have been shown to highly influence career choice. We hypothesized that gender and racial disparities exist in early medical school exposures to urology. METHODS: We surveyed urology residency applicants who interviewed at our institution from 2016 to 2017. Student demographics were collected in addition to forms of urology exposures (clinical and research). Early urology exposure was defined as occurring before the 3rd year of medical school. Early exposures were compared by gender and racial/ethnic groups underrepresented in medicine. RESULTS: During the study period 72 interviewees were invited to participate and 71 completed the survey (response rate 98.6%). The majority of participants were male (54, 76%). Thirteen participants (18%) met the criteria for underrepresented in medicine. Fewer female applicants discovered urology (41% vs 75%, p=0.01), first shadowed a urologist (35% vs 68%, p=0.02), first operated with a urologist (29% vs 60%, p=0.03) and began research (0% vs 49%, p <0.001) before the 3rd year of medical school compared to male applicants. Fewer applicants underrepresented in medicine had shadowed a urologist before the 3rd year of medical school (31% vs 67%, p=0.02). We found no other statistical differences between those underrepresented in medicine and those not underrepresented in medicine in terms of other early urology exposures, medical school urology opportunities or personal exposures. CONCLUSIONS: Disparities in early urology exposures, especially research exposure, exist by gender and less so among applicants underrepresented in medicine. Identifying these disparities may uncover systemic bias within career trajectories and provide targets for earlier interventions in medical school training.

Do Women Work Less Than Men in Urology: Data From the American Urological Association Census.

OBJECTIVE: To further explore the issue of work parity between male and female urologists in the context of demographics, practice characteristics, subspecialty affiliation, and planned retirement. MATERIALS AND METHODS: We analyzed data from the 2014 American Urological Association census, which is a specialty wide survey distributed to the entire urology community in the United States. A total of 2204 census samples were weighted to represent 11,703 urologists who practiced in the United States in 2014. We compared clinical and nonclinical hours worked by gender after adjusting for age, practice setting, fellowship type, and whether or not the urologist performed inpatient operations. RESULTS: Of the 11,703 practicing urologists in the United States, female urologists make up approximately 7.7% of the workforce (n ~ 897). Female practicing urologists were younger (66.4%, <45 years old), had shorter training intervals, and a younger planned retirement age than their male counterparts (63 years vs 68.5 years, P <.001). More women were fellowship-trained in a urologic subspecialty (54.9% vs 34.9%, P <.001) and more were in academic practices (33.2% vs 21.9%, P = .03). After adjusting for age, practice type, subspecialty, and inpatient operations performed, there was no difference in hours worked between women and men (beta-coefficient -2.8, 95% confidence interval -6.4 to 0.7, P = .12). CONCLUSION: Gender does not appear to drive the number of hours urologists work per week. There is work hour parity between women and men practicing urologists in both clinical and nonclinical hours. Women are proportionately more likely to pursue fellowship training and hold academic positions.

Characteristics of Genital Dissatisfaction Among a Nationally Representative Sample of U.S. Women.

BACKGROUND: Female genital self-image is an important aspect of psychosocial and sexual health. The Female Genital Self-Image Scale (FGSIS) is a validated instrument that has been used to characterize women's level of genital dissatisfaction. AIM: In this report, we assess genital dissatisfaction using the FGSIS in a nationally representative sample of U.S. women. METHODS: We conducted a nationally representative survey of non-institutionalized adults aged 18-65 years residing in the United States. The survey included questions about demographics, sexual behavior, and the FGSIS. OUTCOMES: Demographic characteristics were found to significantly correlate to women's perceived genital dissatisfaction. RESULTS: In total, 3,372 women completed the survey and 3,143 (93.2%) completed the FGSIS. The mean age was 46 years, and there was broad representation across the United States in terms of age, education, and location. On bivariate analysis, women's genital dissatisfaction was significantly correlated to their age, race, location, and education. Women who were sexually active were less likely to report genital dissatisfaction than women who were not sexually active (76% vs 62%, respectively, P < .001). The frequency of sexual activity was negatively correlated with genital dissatisfaction (P = .002). Women who reported genital dissatisfaction were less likely than those who reported satisfaction to engage in receptive vaginal sex (83% vs 88%, respectively, P = .03). There were no other significant associations between genital dissatisfaction and types of sexual activity. On multivariate analysis, women were less likely to report genital dissatisfaction if they were older, of black race, had an education level of high school or above, and/or lived in the Northeastern or Midwestern United States. There was no association between genital dissatisfaction and relationship status or gender of sexual partner. CLINICAL TRANSLATION: Female genital dissatisfaction may be related to age, race, education, and geography. CONCLUSIONS: This is the first nationally representative sample of U.S. women focusing on genital and self-image and dissatisfaction. These data may not apply outside the United States. These data may help providers who provide information for women and manage concerns related to genital self-image. Rowen TS, Gaither TW, Shindel AW, et al. Characteristics of Genital Dissatisfaction Among a Nationally Representative Sample of U.S. Women. J Sex Med 2018;15:698-704.

Estimated total costs from non-fatal and fatal bicycle crashes in the USA: 1997-2013.

INTRODUCTION: Emergency department visits and hospital admissions resulting from adult bicycle trauma have increased dramatically. Annual medical costs and work losses of these incidents last were estimated for 2005 and quality-of-life losses for 2000. METHODS: We estimated costs associated with adult bicycle injuries in the USA using 1997-2013 non-fatal incidence data from the National Electronic Injury Surveillance System with cost estimates from the Consumer Product Safety Commission's Injury Cost Model, and 1999-2013 fatal incidence data from the National Vital Statistics System costed by similar methods. RESULTS: Approximately 3.8 million non-fatal adult bicycle injuries were reported during the study period and 9839 deaths. In 2010 dollars, estimated adult bicycle injury costs totalled $24.4 billion in 2013. Estimated injury costs per mile bicycled fell from $2.85 in 2001 to $2.35 in 2009. From 1999 to 2013, total estimated costs were $209 billion due to non-fatal bicycle injuries and $28 billion due to fatal injuries. Inflation-free annual costs in the study period increased by 137% for non-fatal injuries and 23% for fatal injuries. The share of non-fatal costs associated with injuries to riders age 45 and older increased by 1.6% (95% CI 1.4% to 1.9%) annually. The proportion of costs due to incidents that occurred on a street or highway steadily increased by 0.8% (95% CI 0.4% to 1.3%) annually. CONCLUSIONS: Inflation-free costs per case associated with non-fatal bicycle injuries are increasing. The growth in costs is especially associated with rising ridership, riders 45 and older, and street/highway crashes.

Understanding patients' preferences for surgical management of urethral stricture disease.

OBJECTIVES: To understand how prioritization of treatment attributes and treatment choice varies by patient characteristics, we sought to specifically determine how demographic variables affect patient treatment preference. PATIENTS AND METHODS: Male patients with urethral stricture disease participated in a choice-based conjoint (CBC) analysis exercise evaluating six treatment attributes associated with internal urethrotomy and urethroplasty. Demographic and past symptom data were collected. Stratified analysis of demographic variables, including age, education, income, was conducted using a mixed effect logistic regression model to evaluate the coefficient size and confidence intervals between the treatments attribute preferences of each strata. RESULTS: 169 patients completed the CBC exercise and were included in our analysis. Overall success of the procedure is the most important treatment attribute to patients and this persists across strata. Older patients (≥65) express preferences for better success rates and fewer future procedures, whereas younger patients prefer a less invasive approach and are more willing to accept additional procedures if needed. Patients with lower levels of education preferred open reconstruction and had a stronger preference against multiple future procedures, whereas those with higher levels of education preferred endoscopic treatment and had a less strong preference against multiple future procedures. Low-income individuals express statistically significant stronger negative preferences against high copay costs compared to high-income individuals. CONCLUSION: These results can help to inform physicians' counseling about surgical management of urethral stricture disease to better align patient preferences with treatment selection and encourage shared decision making.