Evaluation of the Cancer of Bladder Risk Assessment (COBRA) Score in the Cancer Genome Atlas (TCGA) Bladder Cancer Cohort.

OBJECTIVE: To evaluate the Cancer of the Bladder Risk Assessment (COBRA) score in The Cancer Genome Atlas (TCGA) bladder cancer cohort. Second, to investigate the utility of the COBRA score within each bladder cancer molecular subtype following radical cystectomy (RC) and determine if it can help identify candidates for adjuvant therapies and clinical trials. METHODS: Among the TCGA bladder cancer cohort (n = 412), RC pathology reports were reviewed to calculate COBRA scores. Kaplan-Meier survival curves along with univariable and multivariable Cox proportional hazard models were used to determine the clinical utility of the COBRA score to predict overall survival (OS) within the overall cohort and within each molecular subtype (if n>30 within subtype). RESULTS: In the analytic cohort (n = 273) there was a median follow-up of 18 months. Higher COBRA score was associated with significant increased risk of death in both univariable (HR = 1.52 per point [PP] 95% CI [1.32, 1.75)] and multivariable models (HR = 1.54 PP 95% CI [1.32, 1.79]). This remained true in multivariable models stratified by molecular subtype for basal (HR = 1.37 PP 95% CI [1.07, 1.74]), luminal infiltrated (HR = 1.70 PP 95% CI [1.10, 2.64]), and luminal papillary (HR = 1.62 PP 95% CI [1.28, 2.06]) tumors. CONCLUSION: Our findings validate the COBRA score in the TCGA bladder cancer cohort. This suggests the COBRA score can be used in conjunction with molecular subtyping information to help guide clinical decision-making following RC to improve risk stratification and allow for earlier identification of candidates for adjuvant therapies and clinical trials.

Cost-Benefit Analysis of a Support Program for Nursing Staff.

OBJECTIVES: A peer-support program called Resilience In Stressful Events (RISE) was designed to help hospital staff cope with stressful patient-related events. The aim of this study was to evaluate the impact of the RISE program by conducting an economic evaluation of its cost benefit. METHODS: A Markov model with a 1-year time horizon was developed to compare the cost benefit with and without the RISE program from a provider (hospital) perspective. Nursing staff who used the RISE program between 2015 and 2016 at a 1000-bed, private hospital in the United States were included in the analysis. The cost of running the RISE program, nurse turnover, and nurse time off were modeled. Data on costs were obtained from literature review and hospital data. Probabilities of quitting or taking time off with or without the RISE program were estimated using survey data. Net monetary benefit (NMB) and budget impact of having the RISE program were computed to determine cost benefit to the hospital. RESULTS: Expected model results of the RISE program found a net monetary benefit savings of US $22,576.05 per nurse who initiated a RISE call. These savings were determined to be 99.9% consistent on the basis of a probabilistic sensitivity analysis. The budget impact analysis revealed that a hospital could save US $1.81 million each year because of the RISE program. CONCLUSIONS: The RISE program resulted in substantial cost savings to the hospital. Hospitals should be encouraged by these findings to implement institution-wide support programs for medical staff, based on a high demand for this type of service and the potential for cost savings.

A Nationally Representative Study of Nonindex Hospital Readmissions following Radical Prostatectomy: Implications for Bundled Payment Models.

PURPOSE: Implementing episode based payment models requires a detailed understanding of health care utilization throughout the 90-day postoperative episode. This includes nonindex hospital readmissions, which currently do not exist for patients treated with radical prostatectomy. We compared the causes, costs and predictors of index vs nonindex hospital readmissions after radical prostatectomy. MATERIALS AND METHODS: We identified patients with prostate cancer who underwent radical prostatectomy from 2010 to 2014 in the Nationwide Readmissions Database. Sociodemographic factors, hospital costs and causes of 90-day readmissions were compared between index and nonindex hospital readmissions. Multivariable regression models were used to determine whether nonindex readmissions were more costly than index readmission for several causes of readmission and also to identify predictors of nonindex readmissions. RESULTS: Of the 214,473 patients treated with radical prostatectomy 12,316 (5.7%) experienced a 90-day readmission and 4,283 (30.6%) had a nonindex readmission. Nonindex readmissions were more likely for complications which were cardiovascular specific (16.6% vs 10.3%) and nonradical prostatectomy specific (49.4% vs 32.8%, each p <0.01). On multivariable modeling readmission costs were significantly higher for nonindex vs index readmissions ($10,751 vs $10,113, p <0.01). Cardiovascular and electrolyte related nonindex readmissions ($12,995 vs $10,108, p <0.001, and $4,962 vs $3,179, p=0.01, respectively) were more expensive. Nonindex hospital readmission predictors included minimally invasive radical prostatectomy (OR 1.28, 95% CI 1.03-1.58), radical prostatectomy done at a high volume institution (OR 2.02, 95% CI 1.41-2.89) and residence in a more rural location (less than 50,000 population OR 1.68, 95% CI 1.21-2.35). CONCLUSIONS: In this nationally representative study nonindex hospital readmissions were associated with higher readmission costs, which were driven by differences in a small subset of readmissions. The benefits of undergoing radical prostatectomy at a high volume center should be carefully balanced with the increased odds of nonindex hospital readmissions and higher costs associated with such centers as regionalization continues.

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

OBJECTIVE: To investigate the impact of continent urinary diversion on readmissions and hospital costs in a nationally representative sample of radical cystectomies (RCs) performed in the USA. PATIENTS AND METHODS: The 2010-2014 Nationwide Readmissions Database was queried for patients with a diagnosis of bladder cancer who underwent RC. We identified patients undergoing continent (neobladder or continent cutaneous reservoir) or incontinent (ileal conduit) diversions. Multivariable logistic regression models were used to identify predictors of 90-day readmission, prolonged length of stay, and total hospital costs. RESULTS: Amongst 21 126 patients identified, 19 437 (92.0%) underwent incontinent diversion and 1 689 (8.0%) had a continent diversion created. Continent diversion patients were younger, healthier, and treated at high-volume metropolitan centres. Continent diversions resulted in fewer in-hospital complications (37.3% vs 42.5%, P = 0.02) but led to more 90-day readmissions (46.5% vs 39.6%, P = 0.004). In addition, continent diversion patients were more often readmitted for infectious complications (38.7% vs 29.4%, P = 0.004) and genitourinary complications (18.5% vs 13.0%, P = 0.01). On multivariable logistic regression, patients with a continent diversion were more likely to be readmitted within 90 days (odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.28, 1.88) and have increased hospital costs during initial hospitalisation (OR 1.99, 95% CI: 1.52, 2.61). Continent diversion led to a $4 617 (American dollars) increase in initial hospital costs ($36 640 vs $32 023, P < 0.001), which was maintained at 30 days ($48 621 vs $44 231, P < 0.001) and at 90 days ($56 380 vs $52 820, P < 0.001). CONCLUSION: In a nationally representative sample of RCs performed in the USA, continent urinary diversion led to more frequent readmissions and increased hospital costs. Interventions designed to address specific outpatient issues with continent diversions can potentially lead to a significant decrease in readmissions and associated hospital costs.

Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors.

BACKGROUND: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs. AIM: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS. METHODS: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission. OUTCOME: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions. RESULTS: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS. CLINICAL IMPLICATIONS: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy. STRENGTHS AND LIMITATIONS: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables. CONCLUSIONS: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065.

Erectile Dysfunction Treatment Following Radical Cystoprostatectomy: Analysis of a Nationwide Insurance Claims Database.

INTRODUCTION: To improve care for patients after radical cystoprostatectomy (RCP), focus on survivorship issues such as sexual function needs to increase. Previous studies have demonstrated the burden of erectile dysfunction (ED) after RCP to be as high as 89%. AIM: To determine the rates of ED treatment use (phosphodiesterase type 5 inhibitors, injectable therapies, urethral suppositories, vacuum erection devices, and penile prosthetics) in patients with bladder cancer before and after RCP to better understand current patterns of care. METHODS: Men with bladder cancer undergoing RCP were identified in the MarketScan database (2010-2014). ED treatment use was assessed at baseline (during the 1 year before RCP) and at 6-month intervals (0-6, 7-12, 13-18, 19-24 months) after RCP. Multivariable logistic regression models were used to identify predictors of ED treatment use at 6-month intervals after RCP. OUTCOMES: ED treatment rates and predictors of ED treatment at 0-6, 7-12, 13-18, 19-24 month follow-up after RCP. RESULTS: At baseline, 6.5% of patients (77 of 1,176) used ED treatments. The rates of ED treatment use at 0 to 6, 7 to 12, 13 to 18, and 19 to 24 months after RCP were 15.2%, 12.7%, 8.1%, and 10.1% respectively. Phosphodiesterase type 5 inhibitors were the most commonly used treatment at all time points. In the multivariable model, predictors of ED treatment use at 0 to 6 months after RCP were age younger than 50 years (odds ratio [OR] = 3.17, 95% CI = 1.68-6.01), baseline ED treatment use (OR = 5.75, 95% CI = 3.08-10.72), neoadjuvant chemotherapy (OR = 1.72, 95% CI = 1.13-2.61), and neobladder diversion (OR = 2.40, 95% CI = 1.56-3.70). Baseline ED treatment use continued to be associated with ED treatment use at 6 to 12 months (OR = 5.63, 95% CI = 2.42-13.10) and 13 to 18 months (OR = 8.99, 95% CI = 3.05-26.51) after RCP. CLINICAL IMPLICATIONS: While the burden of ED following RCP is known to be high, overall ED treatment rates are low. These findings suggest either ED treatment is low priority for RCP patients or education about potential ED therapies may not be commonly discussed with patients following RCP. Urologists should consider discussing sexual function more frequently with their RCP patients. STRENGTHS & LIMITATIONS: Strengths include the use of a national claims database, which allows for longitudinal follow-up and detailed information on prescription medications and devices. Limitations include the lack of pathologic and oncologic outcomes data. CONCLUSION: ED treatment use after RCP is quite low. The strongest predictor of ED treatment use after RCP was baseline treatment use. These findings suggest ED treatment is a low priority for patients with RCP or education about potential ED therapies might not be commonly discussed with patients after RCP. Urologists should consider discussing sexual function more frequently with their patients undergoing RCP. Chappadi MR, Kates M, Sopko NA, et al. Erectile Dysfunction Treatment Following Radical Cystoprostatectomy: Analysis of a Nationwide Insurance Claims Database. J Sex Med 2017;14:810-817.

Evaluation of gender-based disparities in time from initial haematuria presentation to upper tract urothelial carcinoma diagnosis: analysis of a nationwide insurance claims database.

OBJECTIVE: To investigate the length of time from initial haematuria presentation to upper tract urothelial carcinoma (UTUC) diagnosis and the effect of gender on this duration. PATIENTS AND METHODS: Patients with haematuria claims in the year prior to UTUC diagnosis were identified from the MarketScan database (2010-2014). Delayed diagnosis was defined as >90 days from haematuria presentation to UTUC diagnosis. Multivariable Poisson regression models were used to determine factors associated with delayed UTUC diagnosis. RESULTS: Among 1 326 patients with UTUC, 469 (35.4%) experienced delayed diagnosis. Men (n = 866) had a longer median interval from haematuria to diagnosis than women (60 vs 49 days; P = 0.04). In the multivariable model, male gender (relative risk [RR] 1.13, 95% confidence interval [CI] 0.95-1.34) was not associated with delayed diagnosis, while urinary tract infection (UTI; RR 1.52, 95% CI 1.32-1.76), nephrolithiasis (RR 1.23, 95% CI 1.06-1.44), new (RR 1.37, 95% CI 1.12-1.66) and recurrent prostate-related diagnoses (RR 1.61, 95% CI 1.23-2.10) were. For men presenting to non-urologists, UTI (RR 1.44, 95% CI 1.22-1.71), nephrolithiasis (RR 1.25 95% CI 1.05-1.49), new (RR 1.41, 95% CI 1.12-1.78) and recurrent prostate-related diagnoses (RR 1.94, 95% CI 1.45-2.58) were associated with delayed diagnosis; however, for men presenting to urologists, nephrolithiasis (RR 1.08 95% CI 0.78-1.49), new (RR 1.15, 95% CI 0.79-1.68) and recurrent prostate-related diagnoses (RR 1.17, 95% CI 0.69-1.97) were not associated with delayed diagnosis, while UTI diagnosis (RR 1.74, 95% CI 1.31-2.31) was still associated with delayed diagnosis. CONCLUSION: A UTUC diagnosis was made >90 days after haematuria presentation in approximately one-third of patients. Men experienced a longer median interval from haematuria to UTUC diagnosis compared with women, but male gender was not an independent predictor of delayed diagnosis. Benign diagnoses during haematuria evaluation were strongly associated with delayed diagnosis, especially among patients initially seen by non-urologists. Future interventions should focus on development of non-invasive techniques to improve clinical risk stratification of patients presenting with haematuria and to educate practitioners, especially non-urologists, with regard to the importance of a thoughtful haematuria evaluation and the common mimickers of UTUC, to help reduce delays in diagnosis.

Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

PURPOSE: We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy. MATERIALS AND METHODS: The 2013 Nationwide Readmissions Database was queried for patients with bladder cancer undergoing cystectomy. Sociodemographic characteristics, hospital costs and causes of readmission were compared among index and nonindex readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission and subsequent readmission. RESULTS: Among 4,991 patients identified 29% (1,447) and 11% (571) experienced an index and nonindex readmission, respectively. Compared to index readmissions, nonindex readmissions were more likely late readmissions (p <0.001) of older patients (p=0.047) who underwent cystectomy at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p <0.001). Compared to index readmissions the percentage of nonindex readmissions for cardiovascular complications was higher (7.6% vs 2.9%, p=0.003), while the percentage of nonindex readmissions for gastrointestinal (6.0% vs 11.0%, p=0.04) and wound (5.3% vs 16.7%, p=0.0001) complications was lower. Predictors of nonindex readmission included longer length of stay (OR 1.02; 95% CI 1.001, 1.04), patient location in less populated areas, nonteaching hospital (OR 0.52; 95% CI 0.31, 0.86) and discharge to facility (OR 2.82; 95% CI 1.75, 4.55) or with home health (OR 1.49; 95% CI 1.05, 2.10). Nonindex readmissions had comparable mean readmission hospital costs ($14,147 vs $15,102, p=0.7), in-hospital mortality (OR 1.11; 95% CI 0.42, 2.87) and subsequent readmission (OR 1.32; 95% CI 0.87, 2.00) to index readmissions. CONCLUSIONS: This nationally representative study of patients undergoing radical cystectomy demonstrated comparable perioperative outcomes and hospital costs between index and nonindex readmitted patients, which supports the continued regionalization of cystectomy care.